Black S Medical Dictionary PDF
Black S Medical Dictionary PDF
Black S Medical Dictionary PDF
viii
Preface
and functions changed. I predict that such reorganisation will continue
throughout the life of this
edition, so readers wishing to check on how the NHS works may need to refer to o
ther sources to be
absolutely sure of remaining up-to-date. Blacks Medical Dictionary is neither a t
extbook 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 patie
nts own doctors are
normally the appropriate source for personal medical advice. The dictionary shou
ld, however, help readers
to decide when it would be wise to seek medical advice and subsequently help the
m to set such advice in
context. Although every effort has been made to ensure accuracy, neither the pub
lishers nor the author can
be held responsible for any consequences if readers use the book for the treatme
nt of themselves or others.
Acknowledgements I am grateful to colleagues who have updated or rewritt
en entries. They include: Dr
Phil Alderson, Professor Michael Baum, Dr Karin Fuchs, Dr Pamela Laurie, Dr Rich
ard Lehman, Mr John
McGarry, Dr Klim McPherson, Mr Michael Paynton, Dr Rob Miller and Professor Simo
n Wessely. Harvey
Marcovitch
Note: The use of small capitals for instance stomach, refers the reader
to the entry of that name
for additional information.
2
Abdomen, Diseases of PANCREAS, DISEASES OF; GALL-BLADDER, DISEASES OF; K
IDNEYS, DISEASES OF; URINARY
BLADDER, DISEASES OF; HERNIA; PERITONITIS; APPENDICITIS; TUMOUR.
A
Various processes that can occur include inflammation, ulceration, infec
tion 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 structure in the abdomen gets inflamed, peritonitis may result. Causes inclu
de injury, inflammation of
the Fallopian tubes (SALPINGITIS), and intestinal disorders such as APPENDICITIS
, CROHNS DISEASE,
DIVERTICULITIS or a perforated PEPTIC ULCER. Disorders of the GALLBLADDER or URI
NARY TRACT may also result
in acute abdominal pain. General symptoms of abdominal disease include:
Pain This is usually ill-defined but can be very
(see ADRENAL GLANDS). The SPLEEN is positioned high up on the left and p
artly behind the stomach. The
great blood vessels and nerves lie on the back wall, and the remainder of the sp
ace is taken up by the
intestines or bowels (see INTESTINE). The large intestine lies in the flanks on
either side in front of the
kidneys, crossing below the stomach from right to left, while the small intestin
e hangs from the back wall
in coils which fill up the spaces between the other organs. Hanging down from th
e stomach in front of the
bowels is the OMENTUM, or apron, containing much fat and helping to protect the
bowels. In pregnancy the
UTERUS, or womb, rises up from the pelvis into the abdomen as it increases in si
ze, lifting the coils of
the small intestine above it. The PELVIS is the part of the abdomen within the b
ony pelvis (see BONE), and
contains the rectum or end part of the intestine, the bladder, and in the male t
he PROSTATE GLAND; in the
female the uterus, OVARIES, and FALLOPIAN TUBES.
unpleasant, and is termed visceral pain. Pain is initially felt near the
mid line of the abdomen.
Generally, abdominal pain felt high up in the mid line originates from the stoma
ch and duodenum. Pain that
is felt around the umbilicus arises from the small intestine, appendix and first
part of the large bowel,
and low mid-line pain comes from the rest of the large bowel. If the diseased or
gan secondarily inflames or
infects the lining of the abdominal wall the PERITONEUM peritonitis occurs and t
he pain becomes more
defined and quite severe, with local tenderness over the site of the diseased or
gan itself. Hence the pain
of appendicitis begins as a vague mid-line pain, and only later moves over to th
e right iliac fossa, when
the inflamed appendix has caused localised peritonitis. PERFORATION of one of th
e hollow organs in the
abdomen for example, a ruptured appendix or a gastric or duodenal ulcer (see STO
MACH, DISEASES OF)
eroding the wall of the gut usually causes peritonitis with resulting severe pai
n. The character of the
pain is also important. It may be constant, as occurs in inflammatory diseases a
nd infections, or colicky
(intermittent) as in intestinal obstruction.
Abdomen, Acute
Swelling The commonest cause of abdomSee ABDOMEN, DISEASES OF.
inal swelling in women is pregnancy. In disease, swelling may be due to
the accumulation of trapped
intestinal contents within the bowel, the presence of free fluid (ascites) withi
n the abdomen, or
enlargement of one or more of the
Position of renal system on rear wall of abdomen.
Abdomen, Diseases of See under STOMACH, DISEASES OF; INTESTINE, DISEASES
OF; DIARRHOEA; LIVER, DISEASES
OF;
Abortion 3
abdominal organs due to benign causes or tumour.
Constipation is
the infrequent or incomplete passage of FAECES; sometimes only flatus ca
n be passed and, rarely, no
bowel movements occur (see main entry for CONSTIPATION). It is often associated
with abdominal swelling. In
intestinal obstruction, the onset of symptoms is usually rapid with complete con
stipation and severe,
colicky pain. In chronic constipation, the symptoms occur more gradually.
Nausea and vomiting may be due to irriAbnormal A structure or process that is not normal (typical, usual or co
nforming to the standard);
differing from the usual condition of the body.
ABO Blood Groups See BLOOD GROUPS.
Abortifacient An abortifacient is a drug which causes artificial ABORTIO
N.
Abortion
tation of the stomach, or to intestinal obstruction when it may be parti
cularly foul and persistent.
There are also important nonabdominal causes, such as in response to severe pain
or motion sickness.
Abortion is defined as the expulsion of a FETUS before it is normally vi
able, usually before 24 weeks
of pregnancy. (There are exceptional cases nowadays in which fetuses as young as
22 weeks gestation have
survived.) (See also PREGNANCY AND LABOUR.)
Diarrhoea is most commonly due to simple
Spontaneous abortion Often called misand self-limiting infection, such as food poisoning, but may also indica
te serious disease, especially
if it is persistent or contains blood (see main entry for DIARRHOEA).
carriage, this may occur at any time before 28 weeks; 85 per cent occur
in the first 12 weeks of
pregnancy. Of all diagnosed pregnancies, 25 per cent end in spontaneous abortion
. Spontaneous abortions
occurring in early pregnancy are almost always associated with chromosomal abnor
malities of the fetus.
Other causes are uterine shape, maternal disorders such as DIABETES MELLITUS, di
seases of the thyroid gland
(see under ENDOCRINE GLANDS), and problems with the immune system (see IMMUNITY)
. Recurrent spontaneous
abortion (that is, three or more) seems to be a particular problem in women who
have an abnormal response
of their immune system to pregnancy. Other factors include being older, having h
ad a lot of babies
4
Abortion
gentle dilatation of the neck of the uterus (cerA vix), and curetting-out the remaining products
of the pregnancy. A few late abortions are associated with the cervix op
ening too early, abnormal
structural abnormalities of the uterus, and possibly infection in the mother. Dr
ugs are often used to
suppress uterine contractions, but evidence-based studies show that these do not
generally improve fetal
salvage. In proven cases of cervical incompetence, the cervix can be closed with
a suture which is removed
at 37 weeks gestation. The evidence for the value of this procedure is uncertain.
Therapeutic abortion In the UK, before an abortion procedure is legally
permitted, two doctors must
agree and sign a form defined under the 1967 Abortion Act that the continuation
of the pregnancy would
involve risk greater than if the pregnancy were terminated of injury to the phys
ical and/or mental
health of the mother or any existing child(ren). Legislation in 1990 modified th
e Act, which had previously
stated that, at the time of the abortion, the pregnancy should not have exceeded
the 24th week. Now, an
abortion may legally be performed if continuing the pregnancy would risk the wom
ans life, or the mental
health of the woman or her existing child(ren) is at risk, or if there is a subs
tantial risk of serious
handicap to the baby. In 95 per cent of therapeutic terminations in the UK the r
eason is risk of injury to
the physical or mental health of the woman. There is no time limit on therapeutic
abortion where the
termination is done to save the mothers life, there is substantial risk of seriou
s fetal handicap, or of
grave permanent injury to the health of the mother. About 190,000 terminations a
re carried out in the UK
each year and only 11.5 per cent are over 20 weeks gestation, with the vast majori
ty of these late
abortions being for severe, latediagnosed, fetal abnormality. The maternal morta
lity from therapeutic
abortion is less than 1 per 100,000 women and, provided that the procedure is pe
rformed skilfully by
experienced doctors before 12 weeks of pregnancy, it is very safe. There is no e
vidence that therapeutic
abortion is associated with any reduction in future fertility, increased rates o
f spontaneous abortion or
preterm birth in subsequent pregnancies.
Methods of abortion All abortions must be carried out in premises licens
ed for doing so or in NHS
hospitals. The method used is either
surgical or medical, with the latter being used more and the former less
as time goes on. Proper
consent must be obtained, signed for and witnessed. Women under 16 years of age
can consent to termination
provided that the doctors obtaining the consent are sure she clearly understands
the procedure and its
implications. Parental consent in the under-16s is not legally required, but cou
nselling doctors have a
duty to record that they have advised young people to inform their parents. Howe
ver, many youngsters do not
do so. The womans partner has no legal say in the decision to terminate her pregn
ancy. A combination of
two drugs, mifepristone and a prostaglandin (or a prostaglandin-like drug, misop
rostol see
PROSTAGLANDINS), may be used to terminate a pregnancy up to 63 days gestation. A
similar regime can be
used between nine and 12 weeks but at this gestation there is a 5 per cent risk
of post-treatment
HAEMORRHAGE. An ultrasound scan is first done to confirm pregnancy and gestation
. The sac containing the
developing placenta and fetus must be in the uterus; the woman must be under 35
years of age if she is a
moderate smoker, but can be over 35 if she is a non-smoker. Reasons for not usin
g this method include women
with diseases of the ADRENAL GLANDS, on long-term CORTICOSTEROIDS, and those who
have a haemorrhagic
disorder or who are on ANTICOAGULANTS. The drugs cannot be used in women with se
vere liver or kidney
disease, and caution is required in those with CHRONIC OBSTRUCTIVE PULMONARY DIS
EASE (COPD), disease of the
cardiovascular system, or prosthetic heart valves (see PROSTHESIS), as well as w
ith those who have had a
CAESAREAN SECTION or an ECTOPIC PREGNANCY in the past or who are being treated f
or HYPERTENSION. Some
clinics use this drug combination for pregnancies older than 12 weeks. In pregna
ncies approaching viability
(20 weeks), pretreatment fetocide (killing of the fetus) with intrauterine drug
therapy may be required.
MEDICAL METHODS
Vacuum curettage is a method used up to 1415 weeks. Some very experienced
gynaecologists will perform
abortions surgically by dilating the cervix and evacuating the uterine contents
up to 22 weeks gestation.
The greater the size of the pregnancy, the higher the risk of haemorrhage and pe
rforation of the uterus. In
the UK, illegal abortion is rare but in other countries this is not the case. Wh
ere illegal abortions are
done, the risks of
SURGICAL METHODS
Absorption 5
infection and perforation are high and death a definite risk. Legal abor
tions are generally safe. In
the USA, partial-birth abortions are spoken of but, in fact, there is no such pr
ocedure recorded in the UK
medical journals.
Abrasion Abrasion means the rubbing-off of the surface of the skin or of
a mucous membrane due to some
mechanical injury. Such injuries, though slight in themselves, are apt to allow
the entrance of
dirt-containing organisms, and so to lead to an ABSCESS or some more severe form
of inflammation.
Treatment The most effective form of treatment consists in the thorough
and immediate cleansing of the
wound with soap and water. An antiseptic such as 1 per cent cetrimide can then b
e applied, and a sterile
dry dressing. Abreaction An emotional release caused by the recall of past unple
asant experiences. This is
normally the result of psychoanalytical treatment in which psychotherapy, certai
n drugs, or hypnosis (see
HYPNOTISM) are used to effect the abreaction. The technique is used in the treat
ment of anxiety, hysteria,
or other neurotic states.
Abruptio Placenta Placental bleeding after the 24th week of pregnancy, w
hich may result in complete or
partial detachment of the placenta from the wall of the womb. The woman may go i
nto shock. The condition is
sometimes associated with raised blood pressure and PRE-ECLAMPSIA. (See also PRE
GNANCY AND LABOUR.)
Abscess A localised collection of pus. A minute abscess is known as a PU
STULE; a diffused production of
pus is known as CELLULITIS or ERYSIPELAS. An abscess may be acute or chronic. An
acute abscess is one which
develops rapidly within the course of a few days or hours. It is characterised b
y a definite set of
symptoms.
Causes The direct cause is various BACTERIA. Sometimes the presence of f
oreign bodies, such as bullets
or splinters, may produce an abscess, but these foreign bodies may remain buried
in the tissues without
causing any trouble provided that they are not contaminated by bacteria or other
micro-organisms. The
micro-organisms most frequently found are staphylococci (see STAPHYLOCOCCUS), an
d, next to these,
streptococci (see STREPTOCOCCUS)
though the latter cause more virulent abscesses. Other abscess-forming o
rganisms are Pseudomonas
pyocyanea and Escherichia coli, which live always in the bowels and under certai
n conditions wander into
the surrounding tissues, producing abscesses. The presence of micro-organisms is
not sufficient in itself
6
Abstract
by multiple villi that increase its surface area.
A (See also DIGESTION; ASSIMILATION.)
Accident and Emergency Medicine
The group of animal parasites which includes Sarcoptes scabiei, the caus
e of the skin disease known as
itch, or SCABIES. This parasite used to be known as Acarus scabiei.
Accident and Emergency Medicine is the specialty responsible for assessi
ng the immediate needs of
acutely ill and injured people. Urgent treatment is provided where necessary; if
required, the patients
admission to an appropriate hospital bed is organised. Every part of the UK has
nominated key hospitals
with the appropriately trained staff and necessary facilities to deal with acute
ly ill or injured patients.
It is well-recognised that prompt treatment in the first hour or so after an acc
ident or after the onset of
an acute illness the so-called golden hour can make the difference between the pat
ients recovery and
serious disability or death. A&E Medicine is a relatively new specialty in the U
K and there are still
inadequate numbers of consultants and trainees, despite an inexorable rise in th
e number of patients
attending A&E departments. With a similar rise in hospital admissions there is o
ften no bed available
immediately for casualties, resulting in backlogs of patients waiting for treatm
ent. A major debate in the
specialty is about the likely need to centralise services by downgrading or clos
ing smaller units, in order
to make the most efficient use of staff. See www.baem.org.uk
Accidental Death
Accommodation
Abstract (1) A dry powder produced by extracting the active principles f
rom a crude drug. Abstracts are
standardised so as to be twice the strength of the crude drug. (2) Summary of sc
ientific paper.
Acanthosis Nigricans Acanthosis nigricans is a darkly pigmented verrucou
s skin change, usually
occurring around the neck and axilla. It may be inherited but is most commonly a
cquired, and is associated
with adenocarcinoma usually of the stomach (see CANCER) and certain hormonal dis
orders such as
POLYCYSTIC OVARY SYNDROME, ADDISONS DISEASE and CUSHINGS SYNDROME.
Acarina The group of arthropod insects that include the parasitic MITES
and TICKS.
Acarus
Accouchement Archaic term for delivery of a baby (see NANCY AND LABOUR).
PREGAccretion Addition to an object of the substance of which it is comprise
d. An example is the growth of
crystals in a fluid, or overgrowth of bone after injury. The term also describes
foreign material
collecting on the surface of a body structure: for example, PLAQUE on teeth.
Acetoacetic Acid An organic acid produced by the LIVER when it is rapidl
y oxidising fatty acids a
metabolic process which occurs, for example, during starvation. The acid produce
d is then converted to
ACETONE, which is excreted.
Acetone Acetone is a volatile, colourless organic compound of the KETONE
group produced by the partial
oxidation of fatty acids. In some abnormal conditions, such as starvation, uncon
trolled diabetes (see
DIABETES MELLITUS) or prolonged vomiting, acetone and other ketones can accumula
te in the blood. Acetone
may then appear in the urine, along with betahydroxybutyric and aceotacic acids,
presaging developing COMA.
Acetylcholine
See ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS.
An acetic-acid ester of the organic base choline, acetylcholine is one o
f the substances which mediates
the transmission of nerve impulses from one nerve to another, or from a nerve to
the organ it acts on, such
as muscles. It acts on both muscarinic receptors (blocked by ATROPINE and respon
sible for ganglionic and
parasympathetic transmission and also for sympathetic innervation of sweat gland
s see under AUTONOMIC
NERVOUS SYSTEM) and nicotinic receptors (responsible for the transmission of ner
ve impulses to muscles and
blocked by curare, thus causing paralysis). Acetylcholine is rapidly destroyed b
y cholinesterase, an ENZYME
present in the blood. ANTICHOLINERGIC drugs such as PHYSOSTIGMINE prolong the ac
tion of acetylcholine.
Acetabulum
Acetylcysteine
8
Achilles Tendon
Tendon A Achilles A thick tendon that joins the calf muscles to the heel
bone (calcaneus) and pulls up
that bone. The tendon is prone to rupture in middle-aged people playing vigorous
sports such as squash or
tennis. Named after the classical Greek hero Achilles, who was reputedly vulnera
ble to his enemies only in
his heel.
Achlorhydria Achlorhydria means an absence of HYDROfrom the STOMACHs secr
etions. If the condition
persists after the administration of HISTAMINE, the person probably has atrophy
of the stomach lining.
Achlorhydria occurs in about 4 per cent of healthy people and in several conditi
ons, including PERNICIOUS
ANAEMIA, carcinoma of the stomach and
CHLORIC ACID
GASTRITIS.
Achondroplasia The commonest form of inherited retarded growth. It is a
dominant hereditary disorder of
endochondral ossification, caused by mutations of fibroblast growth factor recep
tor 3 genes.The long bones
of the arms and legs fail to grow properly, while the trunk and head develop nor
mally. Achondroplasia
affects both sexes and, while many infants are stillborn or die soon after birth
, those who survive have
normal intelligence, a normal expectation of life and good health.
Achromia Loss of colour for example, DEPIGMENTATION of the SKIN or of th
e iris of the EYE.
Aciclovir Aciclovir is an antiviral drug that inhibits DNA synthesis in
cells infected by HERPES
VIRUSES, although it does not eradicate them. It is only effective if started at
the onset of infection;
uses include the systemic treatment of herpes simplex infections of the skin and
mucous membranes
(including genital herpes), as well as of varicella-zoster (chickenpox) pneumoni
a and encephalitis. It is
also used topically in the eye. It is especially valuable for the treatment of h
erpes infections in those
with IMMUNODEFICIENCY and may be required for the prevention of recurrence and f
or prophylaxis indeed, it
may be life-saving. Similar medications include famciclovir and valaciclovir.
Acid Base Balance The balance between the acid and alkaline elements pre
sent in the blood and body
fluids.
The normal hydrogen ion concentration of the is a constant pH 74, and the
lungs and kidneys have a
crucial function in maintaining this figure. Changes in pH value will cause ACID
OSIS or ALKALOSIS. PLASMA
Acromegaly
puberty, and which may persist for many years. It involves plugged pores
(blackheads and whiteheads),
pimples and deeper nodules on the face, neck, trunk and even the upper arms. It
arises from pilosebaceous
glands (relating to hair follicles and associated SEBACEOUS GLANDS). SEBUM produ
ction is increased and
bacterial proliferation causes inflammation with PAPULE and PUSTULE formation. P
lugs of sebum and epidermal
cells form blackheads (comedones); the colour is not due to dirt but to dried oi
l and shed skin cells in
the hairfollicle openings.
Treatment Twice-daily washing with a salicylic-acid cleanser can help re
move the poreblocking debris,
as can daily shampooing. Use only oil-free cosmetics and hide blackheads with a
flesh-tinted acne lotion
containing benzoyl peroxide, acid or sulphur. Never squeeze blackheads, however
tempting; ask a skin
specialist how to do this properly. Other treatments include microdermabrasion,
and the antibiotic lotions
erythromycin and clindamycin may be effective. Tretinoin and adapilene can be us
ed on the skin but are not
permitted in pregnancy and may cause problems such as hypersensitivity to sunlig
ht, so medical advice is
essential. In resistant cases, long-term suppressive oral therapy with one of th
e TETRACYCLINES or with
ERYTHROMYCIN may be necessary. In females a combined oestrogenantiandrogen pill is
an alternative. Severe
resistant acne can be cleared by a 16- to 24week course of oral isotretinoin, bu
t this drug is teratogenic
(see TERATOGENESIS) and can cause many side-effects including depression, so its
use requires specialist
supervision. See www.skincarephysicians.com/acnenet/
9
Acriflavine An aniline derivative, this is an orange-red crystalline pow
der, readily soluble in water,
with strong antiseptic powers.
AcroPrefix meaning extremity or tip.
Acrocyanosis A condition, occurring especially in young women, in which
there is persistent blueness of
hands, feet, nose and ears as a result of slow circulation of blood through the
small vessels of the skin.
Acromegaly
Acoustic
A disorder caused by the increased secretion of growth hormone by an ADE
NOMA of the anterior PITUITARY
GLAND. It results in excessive growth of both the skeletal and the soft tissues.
If it occurs in
adolescence before the bony epiphyses have fused, the result is gigantism; if it
occurs in adult life the
skeletal overgrowth is confined to the hands, feet, cranial sinuses and jaw. Mos
10 Acromion
X-ray techniques, such as gamma knife irradiA ation, have shown promise. Drugs such as BROMOCRIPTINE, capergoline an
d quiangoline, which are
dopamine agonists lower growthhormone levels in acromegaly and are particularly
useful as an adjunct to
radiotherapy. Drugs which inhibit growth-hormone release by competing for its re
ceptors, octeotride and
lanreotride, also have a place in treatment. See www.niddk.nih.gov/health/endo/p
ubs/ acro/acro.htm
www.umm.edu/endocrin/acromegaly.htm
Acromion That part of the scapula, or shoulder blade, forming the tip of
the shoulder and giving its
squareness to the latter. It projects forwards from the scapula, and, with the C
LAVICLE or collar-bone in
front, forms a protective arch of bone over the shoulder-joint.
Acroparaesthesia A disorder occurring predominantly in middleaged women
in which there is numbness and
tingling of the fingers.
ACTH (Adrenocorticotrophic Hormone) ACTH is the commonly used abbreviati
on for CORTICOTROPIN.
Actinomycin D See DACTINOMYCIN.
Actinomycosis A chronic infectious condition caused by an anaerobic micr
o-organism, Actinomyces
israelii, that often occurs as a COMMENSAL on the gums, teeth and tonsils. Commo
nest in adult men, the
sites most affected are the jaw, lungs and intestine, though the disease can occ
ur anywhere. Suppurating
granulomatous tumours develop which discharge an oily, thick pus containing yell
owish (sulphur) granules.
A slowly progressive condition, actinomycosis usually responds to antibiotic dru
gs but improvement may be
slow and surgery is sometimes needed to drain infected sites. Early diagnosis is
important. Treatment is
with antibiotics such as penicillin and tetracyclines. The disease occurs in cat
tle, where it is known as
woody tongue.
Action on Smoking and Health See ASH.
Acupuncture A traditional Chinese method of healing by inserting thin ne
edles into certain areas
beneath
the skin and rotating them. Its rationale is that disease is a manifesta
tion of a disturbance of Yin
and Yang energy in the body, and that acupuncture brings this energy back into b
alance by what is described
as the judicious stimulation or depression of the flow of energy in the various m
eridians. What is still
unclear to western doctors is why needling, which is the essence of acupuncture,
should have the effect it
is claimed to have. One theory is that the technique stimulates deep sensory ner
Addisons Disease 11
such as oxygen-free radicals and PROTEASE damage the alveolar capillary
membranes (see ALVEOLUS). Once
this happens, protein-rich fluid leaks into the alveoli and interstitial spaces.
SURFACTANT is also lost.
This impairs the exchange of oxygen and carbon dioxide in the lungs and gives ri
se to the clinical and
pathological picture of acute respiratory failure. The typical patient with ARDS
has rapidly worsening
hypoxaemia (lack of oxygen in the blood), often requiring mechanical ventilation
. There are all the signs
of respiratory failure (see TACHYPNOEA; TACHYCARDIA; CYANOSIS), although the che
st may be clear apart from
a few crackles. Radiographs show bilateral, patchy, peripheral shadowing. Blood
gases will show a low PaO2
(concentration of oxygen in arterial blood) and usually a high PaCO2 (concentrat
ion of carbon dioxide in
arterial blood). The lungs are stiff they are less effective because of the loss o
f surfactant and the
PULMONARY OEDEMA.
Causes The causes of ARDS may be broadly divided into the following: DIR
ECT INSULT
Viral, bacterial and fungal PNEUMONIA Lung trauma or contusion Inhalatio
n of toxic gases or smoke
ASPIRATION of gastric contents Near-drowning
surfactant through a nebuliser or aerosol may help to improve lung effec
tiveness and reduce oedema.
Some experimental evidence supports the use of free-radical scavengers and ANTIO
XIDANTS, but these are not
commonly used. Other techniques include the inhalation of NITRIC OXIDE (NO) to m
oderate vascular tone, and
prone positioning to improve breathing. In severe cases, extracorporeal gas exch
ange has been advocated as
a supportive measure until the lungs have healed enough for adequate gas exchang
e. (See also RESPIRATORY
DISTRESS SYNDROME; HYALINE MEMBRANE DISEASE; SARS.)
Acyclovir See ACICLOVIR.
Adactyly Absence of the digits.
Adaptation A slowly diminishing reaction of a sense organ to persistent
or repetitive stimulation. For
example, a persistent smell may after a while result in the nose failing to sign
al its presence; the
pressure-sensitive nerve endings in the skin may become accustomed to the presen
ce of clothes on the body;
regular background noise may be screened out by the cochlear nerve that links ea
r and brain.
Addiction See DEPENDENCE.
INDIRECT INSULT
Septic, haemorrhagic and cardiogenic SHOCK METABOLIC DISORDERS such as U
RAEMIA and pancreatitis (see
PANCREAS, DISORDERS OF) Bowel infarction Drug ingestion Massive blood transfusio
n, transfusion reaction
(see TRANSFUSION OF BLOOD), CARDIOPULMONARY BYPASS, disseminated intravascular c
oagulation
Treatment The principles of management are supportive, with treatment of
the underlying condition if
that is possible. Oxygenation is improved by increasing the concentration of oxy
gen breathed in by the
patient, usually with mechanical ventilation of the lungs, often using continuou
s positive airways pressure
(CPAP). Attempts are made to reduce the formation of pulmonary oedema by careful
management of how much
fluid is given to the patient (fluid balance). Infection is treated if it arises
, as are the possible
complications of prolonged ventilation with low lung compliance (e.g. PNEUMOTHOR
AX). There is some evidence
that giving
Addisons Disease The cause of Addisons disease (also called chronic adrena
l insufficiency and
hypocortisolism) is a deficiency of the adrenocortical hormones CORTISOL, ALDOST
ERONE and androgens (see
ANDROGEN) due to destruction of the adrenal cortex (see ADRENAL GLANDS). It occu
rs in about 1 in 25,000 of
the population. In the past, destruction of the adrenal cortex was due to TUBERC
ULOSIS (TB), but nowadays
fewer than 20 per cent of patients have TB while 70 per cent suffer from autoimm
une damage. Rare causes of
Addisons disease include metastases (see METASTASIS) from CARCINOMA, usually of t
he bronchus; granulomata
(see GRANULOMA); and HAEMOCHROMATOSIS. It can also occur as a result of surgery
for cancer of the PITUITARY
GLAND destroying the cells which produce ACTH (ADRENOCORTICOTROPHIC HORMONE) the
hormone which provokes
the adrenal cortex into action.
Symptoms The clinical symptoms appear slowly and depend upon the severit
y of the
A
12 Adduct
underlying disease process. The patient usually
A complains of appetite and weight loss, nausea,
weakness and fatigue. The skin becomes pigmented due to the increased pr
oduction of ACTH. Faintness,
especially on standing, is due to postural HYPOTENSION secondary to aldosterone
deficiency. Women lose
their axillary hair and both sexes are liable to develop mental symptoms such as
DEPRESSION. Acute episodes
Addisonian crises may occur, brought on by infection, injury or other stressful
events; they are caused
by a fall in aldosterone levels, leading to abnormal loss of sodium and water vi
a the kidneys, dehydration,
low blood pressure and confusion. Patients may develop increased tanning of the
skin from extra
pigmentation, with black or blue discoloration of the skin, lips, mouth, rectum
and vagina occurring.
ANOREXIA, nausea and vomiting are common and the sufferer may feel cold.
Diagnosis This depends on demonstrating impaired serum levels of cortiso
l and inability of these levels
to rise after an injection of ACTH.
Treatment consists in replacement of the deficient hormones. HYDROCORTIS
ONE tablets are commonly used;
some patients also require the salt-retaining hormone, fludrocortisone. Treatmen
t enables them to lead a
completely normal life and to enjoy a normal life expectancy. Before surgery, or
if the patient is pregnant
and unable to take tablets, injectable hydrocortisone may be needed. Rarely, tre
ated patients may have a
crisis, perhaps because they have not been taking their medication or have been
vomiting it. Emergency
resuscitation is needed with fluids, salt and sugar. Because of this, all patien
ts should carry a card
detailing their condition and necessary management. Treatment of any complicatin
g infections such as
tuberculosis is essential. Sometimes DIABETES MELLITUS coexists with Addisons dis
ease and must be treated.
Secondary adrenal insufficiency may occur in panhypopituitarism (see PITUITARY G
LAND), in patients treated
with CORTICOSTEROIDS or after such patients have stopped treatment. Adduct To mo
ve a limb or any other part
towards the midline of the body. (Opposite: ABDUCT.)
Adenitis Adenitis means inflammation of a GLAND.
AdenoA prefix denoting relation to a glands.
GLAND
or
Adenocarcinoma A malignant growth of glandular tissue. This tissue is wi
despread throughout the bodys
organs and the tumours may occur, for example, in the STOMACH, OVARIES and UTERU
S. Adenocarcinomas may be
subdivided into those that arise from mucous or serous secreting glandular tissu
e.
Adenoids See NOSE, DISORDERS OF.
Adenolipoma A non-malignant tumour arising from the EPITHELIUM and made
up of ADIPOSE TISSUE and
glandular tissues (see GLAND).
Adenoma A growth or cyst arising from the EPITHELIUM, a lining layer of
cells on the inside of organs.
Although usually benign, adenomas can, as they enlarge, press on adjacent tissue
such as nerves or, in the
case of an adenoma of the PITUITARY GLAND, on brain tissue, causing symptoms. Wh
ere adenomas arise in
ENDOCRINE GLANDS, such as the adrenals, pancreas, pituitary and thyroid, they ca
n provoke excessive
production of the hormone normally produced by the gland. If an adenoma is causi
ng or is likely to cause
symptoms it is usually surgically removed (see also TUMOUR).
Adenomatosis A condition in which multiple glandular overgrowths occur.
Adenosine Triphosphate (ATP) A compound comprising the chemical substanc
es adenine, ribose and
phosphates. The chemical bonds of the phosphates contain energy needed for cell
METABOLISM that occurs when
muscle cells contract. This energy is made available when ATP breaks up to form
other chemical groupings
adenosine diphosphate (ADP) and adenosine monophosphate (AMP). The energy needed
for recombining AMP and
ADP to form ATP is produced by the breakdown of carbohydrates or other constitue
ncies of food.
Adenoviruses Viruses (see VIRUS) containing double-stranded DNA; these c
ause around 5 per cent of
clinically recognised respiratory illnesses. Of the 40
Adrenal Glands 13
or so known types, only a few have been properly studied to establish ho
w they produce disease.
Adenoviruses cause fever and inflammation of the respiratory tract and mucous me
mbranes of the eyes
symptoms resembling those of the common cold. They also cause ENTERITIS, haemorr
hagic CYSTITIS and
lifethreatening infections in newborn babies. Infections are generally benign an
d selflimiting, and
treatment is symptomatic and supportive, although the elderly and people with ch
ronic chest conditions may
develop secondary infections which require antibiotic treatment.
The term is also used to describe an ingredient added to a VACCINE to bo
ost the immune systems
production of antibodies, thus enhancing the vaccines effectiveness in promoting
immunity.
ADHD
Adolescence
See ATTENTION DEFICIT DISORDER (HYPERACTIVITY SYNDROME).
See PUBERTY.
Adhesion
See CHILD ADOPTION.
The abnormal union of two normally separate tissues. Adhesion may occur
after inflammation or surgery;
the result is often a fibrous band between the adjacent tissues. Examples are ad
hesions between joint
surfaces which reduce mobility of a joint or, after operation, between loops of
intestine, where the
fibrous band may cause obstruction. Movement of the heart may be restricted by a
dhesions between the organ
and its membranous cover, the pericardial sac.
Adipose Tissue Adipose tissue, or fat, is a loose variety of fibrous tis
sue in the meshes of which lie
cells, each of which is distended by several small drops, or one large drop, of
fat. This tissue replaces
fibrous tissue when the amount of food taken is in excess of the bodily requirem
ents. Adipose tissue occurs
as a layer beneath the skin and also around several internal organs. (See DIET;
FAT; OBESITY.)
Adiposis Dolorosa Also known as Dercums disease. A condition in which pai
nful masses of fat develop
under the skin more common in women than in men.
Adiposity See OBESITY.
Adjuvant Any substance given in concert with another to boost its activi
ty. For instance, a CYTOTOXIC
drug used to reinforce radiotherapy or surgery in the treatment of cancer is des
cribed as adjuvant therapy.
14 Adrenaline
pressure and blood volume. Others are conA cerned in carbohydrate metabolism, whilst
others again are concerned with sex physiology. HYDROCORTISONE is the mo
st important hormone of the
adrenal cortex, controlling as it does the bodys use of carbohydrates, fats and p
roteins. It also helps to
suppress inflammatory reactions and has an influence on the immune system.
Adrenaline Adrenaline is the secretion of the adrenal medulla (see ADREN
AL GLANDS). Its effect is
similar to stimulation of the SYMPATHETIC NERVOUS SYSTEM as occurs when a person
is excited, shocked or
frightened. In the United States Pharmacopoeia it is known as epinephrine. It is
also prepared
synthetically. Among its important effects are raising of the blood pressure, in
creasing the amount of
glucose in the blood, and constricting the smaller blood vessels. Adrenaline has
an important use when
injected intramuscularly or intravenously in the treatment of ANAPHYLAXIS. Many
patients prone to this
condition are prescribed a preassembled adrenaline-containing syringe and needle
(Min-i-Jet, Epipen) and
are taught how to self-administer in an emergency. Adrenaline may be applied dir
ectly to wounds, on gauze
or lint, to check haemorrhage; injected along with some local anaesthetic it per
mits painless, bloodless
operations to be performed on the eye, nose, etc. Nowadays it is rarely, if ever
, used hypodermically and
is no longer given to treat ASTHMA. In severe cardiac arrest, adrenaline (1 in 1
0,000) by central
intravenous injection is recommended. It can be given through an endotracheal tu
be as part of neonatal
resuscitation.
Adrenergic Receptors The sites in the body on which ADRENALINE and compa
rable stimulants of the
SYMPATHETIC NERVOUS SYSTEM act. Drugs which have an adrenaline-like action are d
escribed as being
adrenergic. There are five different types of adrenergic receptors, known as alp
ha1, alpha2, beta1, beta2
and beta3 respectively. Stimulation of alpha receptors leads to constriction of
the bronchi, constriction
of the blood vessels with consequent rise in blood pressure, and dilatation of t
he pupils of the eyes.
Stimulation of beta1 receptors quickens the rate and output of the heart, while
stimulation of beta2
receptors dilates the bronchi. Beta3 receptors are now known to mediate so-calle
d non-shivering
thermogenesis, a way of producing heat from
specialised fat cells that is particularly relevant to the human infant.
For long it had been realised
that in certain cases of ASTHMA, adrenaline had not the usual beneficial effect
of dilating the bronchi
during an attack; rather it made the asthma worse. This was due to its acting on
both the alpha and beta
Aerotitis 15
Adrenogenital Syndrome An inherited condition, the adrenogenital syndrom
e also known as congenital
adrenal hyperplasia is an uncommon disorder affecting about 1 baby in 7,500. The
condition is present
from birth and causes various ENZYME defects as well as blocking the production
of HYDROCORTISONE and
ALDOSTERONE by the ADRENAL GLANDS. In girls the syndrome often produces VIRILISA
TION of the genital tract,
often with gross enlargement of the clitoris and fusion of the labia so that the
genitalia may be mistaken
for a malformed penis. The metabolism of salt and water may be disturbed, causin
g dehydration, low blood
pressure and weight loss; this can produce collapse at a few days or weeks of ag
e. Enlargement of the
adrenal glands occurs and the affected individual may also develop excessive pig
mentation in the skin. When
virilisation is noted at birth, great care must be taken to determine genetic se
x by karyotyping: parents
should be reassured as to the babys sex (never in between). Blood levels of adrenal
hormones are
measured to obtain a precise diagnosis. Traditionally, doctors have advised pare
nts to choose their
childs gender on the basis of discussing the likely condition of the genitalia af
ter puberty. Thus, where
the phallus is likely to be inadequate as a male organ, it may be preferred to r
ear the child as female.
Surgery is usually advised in the first two years to deal with clitoromegaly but
parent/ patient pressure
groups, especially in the US, have declared it wrong to consider surgery until t
he children are competent
to make their own decision. Other treatment requires replacement of the missing
hormones which, if started
early, may lead to normal sexual development. There is still controversy surroun
ding the ethics of gender
reassignment. See www.baps.org.uk
Advance Statements about Medical Treatment See LIVING WILL.
Adverse Reactions to Drugs When a new drug is introduced, it has usually
been studied only in
relatively few patients typically 1,500. If n patients have been studied, and no
serious effects
observed, there is still a chance of a serious adverse effect occurring in the g
eneral population as
frequently as 3/n (1:500). Adverse effects can be divided into types. First, tho
se which are closely
related to the concentration of the drug and accord with what is known of its PHARMACOLOGY
. These so-called type A
(augmented pharmacological) effects are distinguished from type B (bizarre) effe
cts which are
unpredictable, usually rare, and often severe. ANAPHYLAXIS is the most obvious o
f these; other examples
include bone-marrow suppression with CO-TRIMOXAZOLE; hepatic failure (see HEPATI
TIS) with SODIUM VALPROATE;
and PULMONARY FIBROSIS with AMIODARONE. A more comprehensive classification incl
udes reactions type C
16 Aetiology
A Aetiology That part of medical science dealing with the causes of dise
ase.
Afferent An adjective to describe nerves, blood vessels or lymphatic ves
sels that conduct their
electrical charge or contents inwards to the brain, spinal cord or relevant orga
n. (Opposite: EFFERENT.)
Afibrinogenaemia A condition in which the blood will not clot because FI
BRIN is absent. It is
characterised by haemorrhage. There are two forms: (a) a congenital form, and (b
) an acquired form. The
latter may be associated with advanced liver disease, or may occur as a complica
tion of labour. Treatment
consists of the intravenous injection of fibrinogen, and blood transfusion. (See
also COAGULATION.)
Afterbirth See PLACENTA.
Afterpains Pains similar to but feebler than those of labour, occurring
in the two or three days
following childbirth. (See PREGNANCY AND LABOUR.)
Causes are generally the presence of a blood clot or retained piece of P
LACENTA which the womb (see
UTERUS) is attempting to expel. Agammaglobulinaemia An inherited condition found
in male infants, in which
there is no GAMMA-GLOBULIN in the blood. These children are particularly suscept
ible to infections, as they
are unable to form ANTIBODIES to any infecting micro-organism. Acquired agammagl
obulinaemia is a rare
disorder occurring in both sexes in their 20s and 40s, characterised by recurren
t bacterial infections. The
cause is a disturbance in the working of the immune system. (See IMMUNITY.)
homeostatic mechanisms; environment and lifestyle also affect the ageing
process. The effects of ageing
include: cessation of MENSTRUATION in females; wrinkling of the skin due to a lo
ss of elastic tissue;
failing memory (especially short term) and a reduced ability to learn new skills
, along with slowed
responses changes caused by the loss of or less efficient working of nerve cells
; the senses become less
acute; the lungs become less efficient, as does heart muscle, both causing a fal
l in exercise tolerance;
arteries harden, resulting in a rise in blood pressure and poor blood circulatio
n; joints are less mobile,
bones beome more brittle (OSTEOPOROSIS) and muscle bulk and strength are reduced
; the lens of the EYE
becomes less elastic, resulting in poorer sight, and it may also become opaque (
CATARACT). In developed
countries people are living longer, in part because infant and child mortality r
ates have dropped
dramatically over the past 100 years or so. Improved standards of living and mor
e effective health care
have also contributed to greater longevity: the proportion of people over 65 yea
rs of age has greatly
increased, and that of the over-75s is still rising. The 2001 census found 336,0
AI 17
The blood serum of the animal, known now as anti-typhoid serum, is issue
d to laboratories for use when
bacilli are found in the excretions of a patient who is possibly suffering from
typhoid fever. The bacilli
are exposed to the action of a drop of the serum; if the serum shows the power o
f agglutinating these
bacteria, this forms evidence that the bacteria in question are typhoid bacilli.
The reaction may also be
carried out in the contrary manner: that is to say, the serum from the blood of
a patient who may be
suffering from typhoid fever, but in whom the diagnosis is still doubtful, is ad
ded to a drop of fluid
containing typhoid bacilli; if these are agglutinated into clumps by the patients
serum, the patient is
then known to be suffering from typhoid fever. If they do not agglutinate, the s
ymptoms are due to some
other condition. This reaction for typhoid fever is known as the Widal reaction.
Comparable agglutination
reactions, using an appropriate serum, are used in the diagnosis of a number of
diseases, including
glandular fever (when it is known as the PaulBunnell reaction), typhus fever (wh
en it is known as the
Weil-Felix reaction), undulant fever, and Weils disease. (For more information ab
out these diseases, see
under separate entries.)
Agglutinogen An ANTIGEN that stimulates production of an agglutinin an a
ntibody that causes
AGGLUTINATION or clumping of bacteria, blood cells or other antigenic particles.
In the case of blood
cells, this should not be confused with the clumping that happens in blood COAGU
LATION, which is a
different process.
Aggression A general term that covers a range of hostile behaviour, some
of which may extend beyond
normal social behaviour. Some physical diseases cause aggressive outbursts: temp
oral lobe EPILEPSY and
hypoglycaemia (see DIABETES MELLITUS) are examples. Certain mental disorders suc
h as antisocial
personality disorders, alcohol or drug abuse, and SCHIZOPHRENIA may be associate
d with aggression. Male
sex hormones (see under ANDROGEN) appear to be linked to aggressive behaviour, a
nd aggression is more
common among adolescents and young adults than other sections of the population.
Agnosia The condition in which, in certain diseases of the brain, the pa
tient loses the ability to
recognise the character of objects through the senses touch, taste, sight, heari
ng.
Agonist (1) A muscle which contracts and causes a movement. Contraction
of an agonist is complemented
by relaxation of its antagonist (see below). (2) A drug that acts through recept
ors on the surface of the
cell or within the cell and provokes a biological response. As the body contains
natural agonists that
combine with cell receptors, any occupation of these cell receptors by drug molecu
to preve
prevents
is a dru
which ac
muscle a
18 AIDS/HIV
A AIDS/HIV Acquired Immune Deficiency Syndrome (AIDS) is the clinical ma
nifestation of infection with
Human Immunodeficiency Virus (HIV). HIV belongs to the retroviruses, which in tu
rn belong to the
lentiviruses (characterised by slow onset of disease). There are two main HIV st
rains: HIV-1, by far the
commonest; and HIV-2, which is prevalent in Western Africa (including Ivory Coas
t, Gambia, Mali, Nigeria
and Sierra Leone). HIV attacks the human immune system (see IMMUNITY) so that th
e infected person becomes
susceptible to opportunistic infections, such as TUBERCULOSIS, PNEUMONIA, DIARRH
OEA, MENINGITIS and tumours
such as KAPOSIS SARCOMA. AIDS is thus the disease syndrome associated with advanc
ed HIV infection. Both
HIV-1 and HIV-2 are predominantly sexually transmitted and both are associated w
ith secondary opportunistic
infections. However, HIV-2 seems to result in slower damage to the immune system
. HIV-1 is known to mutate
rapidly and has given rise to other subtypes. HIV is thought to have occurred in
humans in the 1950s, but
whether or not it infected humans from another primate species is uncertain. It
became widespread in the
1970s but its latency in causing symptoms meant that the epidemic was not notice
d until the following
decade. Although it is a sexually transmitted disease, it can also be transmitte
d by intravenous drug use
(through sharing an infected needle), blood transfusions with infected blood (he
nce the importance of
effective national blood-screening programmes), organ donation, and occupational
ly (see health-care
workers, below). Babies born of HIV-positive mothers can be infected before or d
uring birth, or through
breast feeding. Although HIV is most likely to occur in blood, semen or vaginal
fluid, it has been found in
saliva and tears (but not sweat); however, there is no evidence that the virus c
an be transmitted from
these two body fluids. There is also no evidence that HIV can be transmitted by
biting insects (such as
mosquitoes). HIV does not survive well in the environment and is rapidly destroy
ed through drying.
were newly infected with HIV, and that 3 million adults and children die
d. In Africa in 2003, 3.4
million people were newly infected and 2.3 million died, with more than 28 milli
on carrying the virus.
HIV/AIDS was the leading cause of death in sub-Saharan Africa where over half of
the infections were in
women and 90 per cent of cases resulted from heterosexual sex. In some southern
African countries, one in
three pregnant women had HIV. In Asia and the Pacific there were 1.2 million new
infections and 435,000
deaths. The area with the fastest-growing epidemic is Eastern Europe, especially
the Russian Federation
where in 2002 around a million people had HIV and there were an estimated 250,00
0 new infections, with
intravenous drug use a key contributor to this figure. Seventy-five per cent of
cases occurred in men, with
male-to-male sexual transmission an important cause of infection, though heteros
AIDS/HIV
enormous rate 109) and over the course of several years the body is unab
le to generate sufficient new
cells to keep pace. This leads to progressive destruction of the bodys immune cap
abilities, evidenced
clinically by the development of opportunistic infection and unusual tumours.
Monitoring of clinical progression It is possible to measure the number
of viral particles present in
the plasma. This gives an accurate guide to the likely progression rate, which w
ill be slow in those
individuals with fewer than 10,000 particles per ml of plasma but progressively
more rapid above this
figure. The main clinical monitoring of the immune system is through the numbers
of CD4 lymphocytes in the
blood. The normal count is around 850 cells per ml and, without treatment, event
ual progression to AIDS is
likely in those individuals whose CD4 count falls below 500 per ml. Opportunisti
c infections occur most
frequently when the count falls below 200 per ml: most such infections are treat
able, and death is only
likely when the CD4 count falls below 50 cells per ml when infection is develope
d with organisms that are
difficult to treat because of their low intrinsic virulence. Simple, cheap and h
ighly accurate tests are
available to detect HIV antibodies in the serum. These normally occur within thr
ee months of infection and
remain the cornerstone of the diagnosis.
Clinical features Most infected individuals have a viral illness some th
ree weeks after contact with
HIV. The clinical features are often non-specific and remain undiagnosed but inc
lude a fine red rash, large
lymph nodes, an influenza-like illness, cerebral involvement and sometimes the d
evelopment of opportunistic
infections. The antibody test may be negative at this stage but there are usuall
y high levels of virus
particles in the blood. The antibody test is virtually always positive within th
ree months of infection.
HIV infection is often subsequently asymptomatic for a period of ten years or mo
re, although in most
patients progressive immune destruction is occurring during this time and a vari
ety of minor opportunistic
infections such as HERPES ZOSTER or oral thrush (see CANDIDA) do occur. In addit
ion, generalised
LYMPHADENOPATHY is present in a third of patients and some suffer from severe ma
laise, weight loss, night
sweats, mild fever, ANAEMIA or easy bruising due to THROMBOCYTOPENIA. The presen
tation of opportunistic
infection is highly variable but usually involves either the
19
CENTRAL NERVOUS SYSTEM, the gastrointestinal tract or the LUNGS. Patient
s may present with a sudden
onset of a neurological deficit or EPILEPSY due to a sudden onset of a STROKE-li
ke
syndrome, or epilepsy due to a space-occupying lesion in the brain most
commonly TOXOPLASMOSIS. In
late disease, HIV infection of the central nervous system itself may produce pro
gressive memory loss,
impaired concentration and mental slowness called AIDS DEMENTIA. A wide variety
of opportunistic PROTOZOA
or viruses produces DYSPHAGIA, DIARRHOEA and wasting. In the respiratory system
the commonest opportunistic
infection associated with AIDS, pneumonia, produces severe shortness of breath a
nd sometimes CYANOSIS,
usually with a striking lack of clinical signs in the chest. In very late HIV in
fection, when the CD4 count
has fallen below 50 cells per ml, infection with CYTOMEGALOVIRUS may produce pro
gressive retinal necrosis
(see EYE, DISORDERS OF) which will lead to blindness if untreated, as well as a
variety of gastrointestinal
symptoms. At this stage, infection with atypical mycobacteria is also common, pr
oducing severe anaemia,
wasting and fevers. The commonest tumour associated with HIV is Kaposis sarcoma w
hich produces purplish
skin lesions. This and nonHodgkins lymphoma (see LYMPHOMA), which is a hundred ti
mes more frequent among
HIVpositive individuals than in the general population, are likely to be associa
ted with or caused by
opportunistic viral infections.
Prevention There is, as yet, no vaccine to prevent HIV infection. Vaccin
e development has been hampered
by the large number of new HIV strains generated through frequent mutation and r
ecombination. because HIV
can be transmitted as free virus and in infected cells. because HIV infects help
er T-cells the very cells
involved in the immune response. There are, however, numerous research programme
s underway to develop
vaccines that are either prophylactic or therapeutic. Vaccinedevelopment strateg
ies have included:
recombinant-vector vaccines, in which a live bacterium or virus is genetically m
odified to carry one or
more of the HIV genes; subunit vaccines, consisting of small regions of the HIV
genome designed to induce
an immune response without infection; modified live HIV, which has had its disea
se-promoting genes removed;
and DNA vaccines small loops of DNA (plasmids) containing viral genes that make
the host cells produce
non-infectious viral
A
20 AIDS/HIV
proteins which, in turn, trigger an immune
A response and prime the immune system against
future infection with real virus. In the absence of an effective vaccine
, preventing exposure remains
the chief strategy in reducing the spread of HIV. Used properly, condoms are an
extremely effective method
of preventing exposure to HIV during sexual intercourse and remain the most impo
rtant public-health
approach to countering the further acceleration of the AIDS epidemic. The spermi
cide nonoxynol-9, which is
often included with condoms, is known to kill HIV in vitro; however, its effecti
veness in preventing HIV
infection during intercourse is not known. Public-health strategies must be focu
sed on avoiding high-risk
behaviour and, particularly in developing countries, empowering women to have mo
re control over their
lives, both economically and socially. In many of the poorer regions of the worl
d, women are economically
dependent on men and refusing sex, or insisting on condom use, even when they kn
ow their partners are HIV
positive, is not a straightforward option. Poverty also forces many women into t
he sex industry where they
are at greater risk of infection. Cultural problems in gaining acceptance for un
iversal condom-use by men
in some developing countries suggests that other preventive strategies should al
so be considered.
Microbicides used as vaginal sprays or chemical condoms have the potential to give
women more direct
control over their exposure risk, and research is underway to develop suitable p
roducts. Epidemiological
studies suggest that male circumcision may offer some protection against HIV inf
ection, although more
research is needed before this can be an established publichealth strategy. Glob
ally, about 70 per cent of
infected men have acquired the virus through unprotected vaginal sex; in these m
en, infection is likely to
have occurred through the penis with the mucosal epithelia of the inner surface
of the foreskin and the
frenulum considered the most likely sites for infection. It is suggested that in
circumcised men, the glans
may become keratinised and thus less likely to facilitate infection. Circumcisio
n may also reduce the risk
of lesions caused by other sexually transmitted disease.
Treatment AIDS/HIV treatment can be categorised as specific therapies fo
r the individual opportunistic
infections which ultimately cause death and highly active antiretroviral therapy
(HAART) designed to
reduce viral load
and replication. HAART is also the most effective way of preventing oppo
rtunistic infections, and has
had a significant impact in delaying the onset of AIDS in HIV-positive individua
ls in developed countries.
Four classes of drugs are currently in use. Nucleoside analogues, including ZIDO
VUDINE and DIDANOSINE,
interfere with the activity of the unique enzyme of the retrovirus reverse trans
criptase which is essential
for replication. Nucleotide analogues, such as tenofovir, act in the same way bu
t require no intracellular
activation. Non-nucleoside reverse transcriptase inhibitors, such as nevirapine
and EFAVIRENZ, act by a
different mechanism on the same enzyme. The most potent single agents against HI
V are the protease
inhibitors, such as lopinavir, which render a unique viral enzyme ineffective. T
hese drugs are used in a
variety of combinations in an attempt to reduce the plasma HIV viral load to bel
ow detectable limits, which
is achieved in approximately 90 per cent of patients who have not previously rec
eived therapy. This usually
also produces a profound rise in CD4 count. It is likely, however, that such tre
atments need to be lifelong
and since they are associated with toxicities, long-term adherence is difficult.
Thus the optimum time
for treatment intervention remains controversial, with some clinicians believing
that this should be
governed by the viral load rising above 10,000 copies, and others that it should
primarily be designed to
prevent the development of opportunistic infections thus, that initiation of the
rapy should be guided
more by the CD4 count. It should be noted that the drug regimens have been devis
ed for infection with
HIV-1; it is not known how effective they are at treating infection with HIV-2.
HIV and pregnancy An HIV-positive woman can transmit the virus to her fe
tus, with the risk of infection
being particularly high during parturition; however, the risk of perinatal HIV t
ransmission can be reduced
by antiviral drug therapy. In the UK, HIV testing is available to all women as p
art of antenatal care. The
benefits of antenatal HIV testing in countries where antiviral drugs are not ava
ilable are questionable. An
HIV-positive woman might be advised not to breast feed because of the risks of t
ransmitting HIV via
breastmilk, but there may be a greater risk associated with not breast feeding a
t all. Babies in many poor
communities are thought to be at high risk of infectious diseases and malnutriti
on if they are not breast
fed and
Air Passages
may thus be at greater overall risk of death during infancy.
Counselling Confidential counselling is an essential part of AIDS manage
ment, both in terms of
supporting the psychological wellbeing of the individual and in dealing with iss
ues such as family
relations, sexual partners and implications for employment (e.g. for health-care
workers). Counsellors must
be particularly sensitive to culture and lifestyle issues. Counselling is essent
ial both before an HIV test
is taken and when the results are revealed.
the number of blood samples taken from a patient, safer-needle devices (
such as needles that self-blunt
after use) and needleless drug administration are all thought to reduce the risk
of exposure to HIV and
other blood-borne viruses. Although there have been numerous cases of health-car
e workers developing HIV
through occupational exposure, there is little evidence of health-care workers p
assing HIV to their
patients through normal medical procedures.
Air The general constituents of air are:
Health-care workers Health-care workers may be at risk of occupational e
xposure to HIV, either through
undertaking invasive procedures or through accidental exposure to infected blood
from a contaminated needle
(needlestick injury). Needlestick injuries are frequent in health care as many a
s 600,000 to 800,000 are
thought to occur annually in the United States. Transmission is much more likely
where the worker has been
exposed to HIV through a needlestick injury or deep cut with a contaminated inst
rument than through
exposure of mucous membranes to contaminated blood or body fluids. However, even
where exposure occurs
through a needlestick injury, the risk of seroconversion is much lower than with
a similar exposure to
hepatitis C or hepatitis B. A percutaneous exposure to HIV-infected blood in a h
ealth-care setting is
thought to carry a risk of about one infection per 300 injuries (one in 1,000 fo
r mucous-membrane
exposure), compared with one in 30 for hepatitis C, and one in three for hepatit
is B (when the source
patient is e-antigen positive). In the event of an injury, health-care workers a
re advised to report the
incident immediately where, depending on a risk assessment, they may be offered
post-exposure prophylaxis
(PEP). They should also wash the contaminated area with soap and water (but with
out scrubbing) and, if
appropriate, encourage bleeding at the site of injury. PEP, using a combination
of antiretroviral drugs (in
a similar regimen to HAART see above), is thought to greatly reduce the chances
of seroconversion; it
should be commenced as soon as possible, preferably within one or two hours of t
he injury. Although PEP is
available, safe systems of work are considered to offer the greatest protection.
Double-gloving (latex
gloves remove much of the blood from the surface of the needle during a needlest
ick), correct use of sharps
containers (for used needles and instruments), avoiding the resheathing of used
needles, reduction in
21
Oxygen Nitrogen Argon Carbon dioxide
per cent 2094 7809 094 003
Besides these, there are always ozone, minerals and organic matter prese
nt in small and variable
amounts, and more or less water vapour according to the weather. In the air of t
owns, sulphurous acid and
sulphuretted hydrogen are important impurities derived from combustion. After ai
r has been respired once,
the oxygen falls by about 4 per cent and the carbonic acid rises to about 4 per
cent, while organic matter
and water vapour are greatly increased and the air rises in temperature. The cau
se of the discomfort felt
in badly ventilated rooms and crowded halls is associated with the increase in t
he temperature and moisture
of the air, but a high percentage of carbon dioxide may be present without causi
ng any noticeable
discomfort or appreciable quickening of the respiration. A combination of hot we
ather and emissions from
vehicles and fossil-fuel combustion produces pollutants linked to a rise in the
incidence of ASTHMA and
other cardiorespiratory conditions. Falling levels of ozone in the upper atmosph
ere are also believed to
contribute to global warming because ozone screens the earth from most of the su
ns harmful ultraviolet
radiation.
Air Embolism A bubble of air in a blood vessel that affects the flow of
blood from the heart. Air may
enter the circulation after injury, infusions into the venous circulation, or su
rgery. The victim suffers
breathlessness, chest discomfort, and acute heart failure.
Air Passages These are the nose, pharynx or throat (the large cavity beh
ind the nose and mouth),
larynx,
A
22 Air-Sickness
trachea or windpipe, and bronchi or bronchial
A tubes. On entering the nose, the air passes through a high narrow pass
age on each side, the outer
wall of which has three projections (the nasal conchae). It then passes down int
o the pharynx where the
food and air passages meet and cross. The larynx lies in front of the lower part
of the pharynx and is the
organ where the voice is produced (see VOICE AND SPEECH) by aid of the vocal cor
ds. The opening between the
cords is called the glottis, and shortly after passing this the air reaches the
trachea or windpipe. The
windpipe leads into the chest and divides above the heart into two bronchi, one
of which goes to each lung,
in which it splits into finer and finer tubes (see LUNGS). The larynx is enclose
d in two strong cartilages:
the thyroid (of which the most projecting part, the Adams apple, is a prominent p
oint on the front of the
neck), and the cricoid (which can be felt as a hard ring about an inch below the
thyroid). Beneath this,
the trachea which is stiffened by rings of cartilage so that it is never closed,
no matter what position
the body is in can be traced down until it disappears behind the breastbone.
Air-Sickness This condition is very similar to sea-sickness. (See MOTION
(TRAVEL) SICKNESS.)
Akinesia Loss or impairment of voluntary movement, or immobility. It is
characteristically seen in
PARKINSONISM.
Alastrim Alastrim, or variola minor, is a form of SMALLwhich differs fro
m ordinary smallpox in being
milder and having a low mortality. POX
Albendazole A drug adjunct to surgery in the treatment of hydatid cysts
(see under CYSTS) caused by
Taenia echinococcus, a small tapeworm (see TAENIASIS). If surgery is not possibl
e, albendazole can be used
on its own. The drug is also used to treat STRONGYLOIDIASIS.
Albinism A group of inherited disorders characterised by absence of or d
ecrease in MELANIN in the skin,
hair and eyes. The skin is pink, the hair white or pale yellow, and the iris of
the eye translucent.
Nystagmus (see under EYE, DISORDERS OF), PHOTOPHOBIA, SQUINT and poor eyesight a
re common. Photoprotection
of both skin and
eyes is essential. In the tropics, light-induced skin cancer may develop
early.
Albumins Albumins are water-soluble proteins which enter into the compos
ition of all the tissues of the
body. Albumins are generally divided according to their source of origin, as mus
clealbumin, milk-albumin,
blood- or serumalbumin, egg-albumin, vegetable-albumin, etc. These differ both i
n chemical reactions and
Alcohol Dependence 23
intake, binge drinking, and dependence (alcoholism). The first pattern usu
ally leads to mainly
physical problems such as gastritis, peptic ulcer, liver disease, heart disease
and impotence. The second
is most common among young men and usually leads to mainly social and occupation
al problems getting into
fights, jeopardising personal relationships, overspending on alcohol at weekends
, and missing days off work
because of hangovers. The third pattern alcohol dependence is the most serious,
and can severely
disrupt health and social stability. Many researchers consider alcohol dependenc
e to be an illness that
runs in families, with a genetic component which is probably passed on as a vuln
erable personality. But it
is hard to disentangle genetic, environmental and social factors in such familie
s. In the UK there are
estimated to be around a million people suffering from alcohol dependence and a
similar number who have
difficulty controlling their consumption (together about 1:30 of the population)
. Alcohol causes tolerance
and both physical and psychological dependence (see DEPENDENCE for definitions).
Dependent drinkers
classically drink early in the morning to relieve overnight withdrawal symptoms.
These symptoms include
anxiety, restlessness, nausea and vomiting, and tremor. Sudden withdrawal from r
egular heavy drinking can
lead to lifethreatening delirium tremens (DTs), with severe tremor, hallucinatio
ns (often visual seeing
spiders and monsters, rather than the pink elephants of romantic myth), and CONV
ULSIONS. This must be
treated urgently with sedative drugs, preferably by intravenous drip. Similar sy
mptoms, plus severe
INCOORDINATION and double-vision, can occur in WERNICKES ENCEPHALOPATHY, a seriou
s neurological condition
due to lack of the B vitamin thiamine (whose absorption from the stomach is mark
edly reduced by alcohol).
If not treated urgently with injections of thiamine and other vitamins, this can
lead to an irreversible
form of brain damage called Korsakoffs psychosis, with severe amnesia. Finally, p
rolonged alcohol misuse
can cause a form of dementia. In addition to these severe neurological disorders
, the wide range of
life-threatening problems caused by heavy drinking includes HEPATITIS, liver CIR
RHOSIS, pancreatitis (see
PANCREAS, DISEASES OF), gastrointestinal haemorrhage, suicide and FETAL ALCOHOL
SYNDROME; pregnant women
should not drink alcohol as this syndrome may occur with more than a glass
of wine or half-pint of beer a day. The social effects of alcohol misuse
such as marital breakdown,
family violence and severe debt can be equally devastating. Treatment of alcohol
-related problems is only
moderately successful. First, many of the physical problems are treated in the s
hort term by doctors who
fail to spot, or never ask about, heavy drinking. Second, attempts at treating a
lcohol dependence by
detoxification or drying out (substituting a tranquillising drug for alcohol and w
ithdrawing it gradually
over about a week) are not always followed-up by adequate support at home, so th
at drinking starts again.
Home support by community alcohol teams comprising doctors, nurses, social worke
rs and, when appropriate,
probation officers is a recent development that may have better results. Many dr
inkers find the voluntary
organisation Alcoholics Anonymous (AA) and its related groups for relatives (AlAnon) and teenagers
(Alateen) helpful because total abstinence from alcohol is encouraged by intensi
ve psychological and social
support from fellow ex-drinkers. Useful contacts are: Alcoholics Anonymous; Al-A
non Family Groups UK and
Eire (including Alateen); Alcohol Concern; Alcohol Focus Scotland; and Alcohol a
nd Substance Misuse. 1
standard drink = 1 unit = pint of beer = 1 measure of spirits = 1 glass of sherr
y or vermouth = 1 glass
of wine
Limits within which alcohol is believed not to cause long-term health ri
sks:
Women up to 2 units a day, 14 a week (Pregnant women should avoid alcoho
l completely. If this is too
difficult, 1 unit a day seems to be safe for the baby.) Women absorb alcohol mor
e quickly than men.
Men up to 3 units a day, 21 a week Alcohol Dependence Alcohol dependence
, or alcoholism, is described
under ALCOHOL but a summary of the symptoms may be helpful in spotting the disor
der. Behavioural symptoms
vary but include furtiveness; aggression; inappropriately generous gestures; per
sonality changes
(selfishness, jealousy, irritability and outbursts of anger); empty promises to
stop drinking; poor
appetite; scruffy appearance; and long periods of drunkenness.
A
24 Alcuronium
A Alcuronium Alcuronium is a drug which relaxes voluntary muscles. Given
by injection during ANAESto
relax a patient undergoing surgery, the drug may delay the restart of spontaneou
s breathing. THESIA
Aldosterone Aldosterone is a hormone secreted by the adrenal cortex (see
ADRENAL GLANDS). It plays an
important part in maintaining the electrolyte balance of the body by promoting t
he reabsorption of sodium
and the secretion of potassium by the renal tubules. It is thus of primary impor
tance in controlling the
volume of the body fluids.
Alexia Alexia is another name for WORD (See also APHASIA; DYSLEXIA.)
BLINDNESS.
Alfacalcidol Alfacalcidol is a synthetic form (or analogue) of vitamin D
. (See APPENDIX 5: VITAMINS.)
Alglucerase A drug used under specialist supervision for the rare heredi
tary disorder, GAUCHERS
DISEASE.
Algorithm A set of instructions performed in a logical sequence to solve
a problem. Algorithms are used
increasingly in emergency situations, for example by ambulance controllers or by
organisations such as NHS
Direct. Each answer to a question leads on down a decision tree to the next ques
tion, eventually resulting
in a recommended action or response.
Alimentary Canal See GASTROINTESTINAL TRACT.
Alkali A substance which neutralises an acid to form a salt, and turns l
itmus and other vegetable dyes
blue. Alkalis are generally oxides or carbonates of metals.
Alkaloids Substances found commonly in various plants. They are natural
nitrogenous organic bases and
combine with acids to form crystalline salts. Among alkaloids, morphine was disc
overed in 1805, strychnine
in 1818, quinine and caffeine in 1820, nicotine in 1829, and atropine in 1833. O
nly a few alkaloids occur
in the animal kingdom, the outstanding example being ADRENALINE, which is formed
in the medulla of
the suprarenal, or adrenal, gland. Alkaloids are often used for medicina
l purposes. The name of an
alkaloid ends in ine (in Latin, ina).
Neutral principals are crystalline substances with actions similar to th
ose of alkaloids but having a
neutral reaction. The name of a neutral principal ends in in, e.g. digitalin, aloi
n. The following are
the more important alkaloids, with their source plants: Aconite, from Monkshood.
Atropine, from Belladonna
(juice of Deadly Nightshade). Cocaine, from Coca leaves. Hyoscine, from Henbane.
Allergy
blood cells); and adverse effects on reproductive function, including TE
RATOGENESIS. Indeed, cytotoxic
drugs must not be given in pregnancy, especially during the first three months.
Prolonged use of alkylating
drugs, especially when accompanying radiotherapy, is also associated with a sign
ficant rise in the
incidence of acute non-lymphocytic LEUKAEMIA. Among the dozen or so alkylating d
rugs in use are
CYCLOPHOSPHAMIDE, CHLORAMBUCIL, MELPHALAN, BUSULFAN and THIOTEPA. (See also CHEM
OTHERAPY.)
Allantoin Prepared synthetically, this powder, which occurs naturally in
comfrey root, has been used as
an ADJUVANT in the treatment of skin ulcers. It has been thought to stimulate th
e formation of the surface
epithelial layer of skin, but its therapeutic value is now more dubious.
Allantois A vascular structure which, very early in the life of an EMBRY
O, grows out from its hind-gut.
The end becomes attached to the wall of the womb (see UTERUS); it spreads out, b
ecomes stalked, and later
develops into the PLACENTA and umbilical cord, which forms the only connection b
etween mother and embryo.
Allele An allele, or allelomorph, is a gene (see GENES) which may exist
in one or more forms, only one
of which can occur in a given chromosome (see CHROMOSOMES). Two alleles of a giv
en gene are at the same
relative positions on a pair of homologous (similarly structured) chromosomes. I
f the two alleles are
identical, the subject is homozygous for the gene namely, the genes will exert a
unanimous influence on a
particular characteristic. If the alleles are different, with one having a domin
ant and the other a
recessive influence, the subject is heterozygous.
Allergen Any substance usually a protein which, taken into the body, mak
es the body hypersensitive
or allergic to it. Thus, in hay fever, the allergen is pollen. (See ALLERGY.)
Allergic Rhinitis See HAY FEVER.
Allergy A term generally used to describe an adverse reaction by the bod
y to any substance ingested by
the affected individual. Strictly, allergy refers to any reactions incited by an
abnormal
25
immunological response to an ALLERGEN, and susceptibility has a strong g
enetic component. Most allergic
disorders are linked to ATOPY, the predisposition to generate the allergic antib
ody immunoglobulin E (IgE)
to common environmental agents (see ANTIBODIES; IMMUNOGLOBULINS). Because IgE is
able to sensitise MAST
CELLS (which play a part in inflammatory and allergic reactions) anywhere in the
body, atopic individuals
often have disease in more than one organ. Since the allergic disorder HAY FEVER
26 Allocheiria
A
of the principal environmental Identification factors underlying the inc
rease in incidence, to enable
preventive measures to be planned.
Safe and effective immunotherapy to prevent and reverse allergic disease
. that target the protein
reactions Treatments activated by antigens. Identification of how IgE is produce
d in the
Treatment depends on the cause. Specific antifungal drugs cure tinea cap
itis. Correction of thyroid or
iron deficiency may be dramatic. Male baldness may be modified slightly by longterm use of minoxidil
lotion, or improved permanently by various types of hair-follicle grafting of tr
ansplants from the
occipital scalp. Female balding may be amenable to antiandrogen/oestrogen regime
ns, but severe forms
require a wig.
Alopecia Areata Alopecia areata is a common form of reversible hair loss
which may be patchy, total on
the scalp, eyebrows or eyelashes, or universal on the body. The onset is sudden
at any age and the affected
scalp-skin looks normal. The hair follicles remain intact but switched off and usu
ally hair growth
recovers spontaneously. No consistently effective treatment is available but inj
ections of CORTICOSTEROIDS,
given with a spray gun into the scalp, may be useful. The regrown hair may be wh
ite at first but
pigmentation recovers later.
Alpha Adrenergic Blockers Also called adrenoceptor-blocking agents or al
pha blockers, these drugs stop
the stimulation of alpha-adrenergic receptors at the nerve endings of the SYMPAT
HETIC NERVOUS SYSTEM by
HORMONES with ADRENALINE-like characteristics. The drugs dilate the arteries, ca
using a fall in blood
pressure, so they are used to treat HYPERTENSION and also benign enlargement of
the PROSTATE GLAND.
Examples of this group of drugs are doxazosin, indoramin, phentolamine and prazo
sin. The drugs should be
used with caution as some may cause a severe drop in blood pressure when first t
aken.
Alpha-Feto Protein A protein produced in the gut and liver of the FETUS.
Abnormality in the fetus, such
as neural tube defect, may result in raised levels of alphafeto protein in the m
aternal blood. In DOWNS
(DOWN) SYNDROME, levels may be abnormally low. In either case, screening of the
pregnancy should be carried
out, including AMNIOCENTESIS to check the amount of alpha-feto protein in the am
niotic fluid. The protein
may also be produced in some abnormal tissues in
Alveolitis 27
the adult in patients with liver cancer, for example.
ALTE This is an abbreviation for acute life-threatening event. It applies
to infants, usually under
one year of age, who suddenly and unexpectedly become pale or blue and appear to
stop breathing. They
generally recover spontaneously, although a parent or bystander often administer
s mouth-to-mouth
resuscitation. By the time the baby reaches hospital he or she is usually well.
Investigations show that
the most common cause of ALTE is GASTRO-OESOPHAGEAL REFLUX, causing stomach acid
to be regurgitated into
the throat and provoking reflex closure of the GLOTTIS. Other causes may be brie
f epileptic seizures,
identified by ELECTROENCEPHALOGRAPHY (EEG); a heart ARRHYTHMIA; or a respiratory
infection. In many cases
the cause remains unknown, even though the events may be repeated, and the large
majority of babies grow
out of the condition. Much controversy surrounds the suggestion confirmed by hidd
en video-recording in
hospitals that a small minority of these babies have been subjected to repeated
brief deliberate
suffocation (see under MUNCHAUSENS SYNDROME). Treatment is that of the underlying
cause, if discovered.
Parents may also be offered an APNOEA monitor, a device attached to the child es
pecially when asleep
which sounds an alarm if breathing stops for more than 20 seconds.
Alternative Medicine See COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM).
Altitude Sickness This condition, also known as mountain sickness, occur
s in mountain climbers or
hikers who have climbed too quickly to heights above 3,000 metres, thus failing
to allow their bodies to
acclimatise to altitude. The lower atmospheric pressure and shortage of oxygen r
esult in hyperventilation
deep, quick breathing and this reduces the amount of carbon dioxide in the blood
. Nausea, anxiety and
exhaustion are presenting symptoms, and seriously affected individuals may be ac
utely breathless because of
pulmonary oedema (excess fluid in the lungs). Gradual climbing over two or three
days should prevent
mountain sickness. In serious cases the individual must be brought down to hospi
tal urgently. Most attacks,
however, are mild.
Aluminium A light metallic element. It occurs in bauxite and other miner
als and its compounds are found
in low concentration in the body. Their function, if any, is unknown but they ar
e believed to be harmful.
Aluminium hydroxide is, however, a safe, slow-acting substance that is widely us
ed in the treatment of
indigestion, gastric ulcers (see STOMACH, DISEASES OF) and oesophagitis (see OES
OPHAGUS, DISEASES OF),
acting as an antacid (see ANTACIDS). Other ingested sources of aluminium include
cooking utensils, kitchen
foil and some cooking and food additives. Most aluminium is excreted; the rest i
s deposited in the brain,
liver, lungs and thyroid gland. Prolonged use of aluminium-based antacids can ca
use loss of appetite,
tiredness and weakness. It has been suggested that ALZHEIMERS DISEASE is more com
mon in areas with water
which contains a high concentration of the element, but this issue is controvers
ial.
Alveolitis Inflammation of the alveoli (see ALVEOLUS) of the lungs cause
d by an allergic reaction. When
the inflammation is caused by infection it is called PNEUMONIA, and when by a ch
emical or physical agent it
is called pneumonitis. It may be associated with systemic sclerosis or RHEUMATOI
D ARTHRITIS.
Extrinsic allergic alveolitis is the condition induced by the lungs beco
ming allergic (see ALLERGY) to
various factors or substances. It includes BAGASSOSIS, FARMERS LUNG and BUDGERIGA
R-FANCIERS LUNG, and is
characterised by the onset of shortness of breath, tightness of the chest, cough
and fever. The onset may
be sudden or gradual. Treatment consists of removal of the affected individual f
rom the offending material
to which he or she has become allergic. CORTICOSTEROIDS give temporary relief.
Fibrosing alveolitis In this disease there is diffuse FIBROSIS of the wa
lls of the alveoli of the
lungs. This causes loss of lung volume with both forced expiratory volume and vi
tal capacity affected, but
the ratio between them remaining normal. The patient complains of cough and prog
ressive DYSPNOEA. Typically
the patient will be cyanosed (blue see CYANOSIS), clubbed (see CLUBBING), and ha
ve crackles in the midand lower-lung fields. Blood gases will reveal HYPOXIA and, in early disease, hy
pocapnia (deficiency of
carbon dioxide in the blood due to hyperventilation). There is an associA
28 Alveolus
ation with
RHEUMATOID ARTHRITIS
(about
A one-eighth of cases), systemic lupus erythematosus (see under LUPUS), and systemic SCLEROSIS. Certain drugs for examp
le, bleomycin, busulphan and
hexamethonium may also cause this condition, as may high concentrations of oxyge
n, and inhalation of
CADMIUM fumes.
Alveolus (1) The minute divisions of glands and the air sacs of the lung
s. (2) The sockets of the teeth
in the jawbone.
Alzheimers Disease Alzheimers disease is a progressive degenerating proces
s of neural tissue
affecting mainly the frontal and temporal lobes of the BRAIN in middle and late
life. There is probably a
genetic component to Alzheimers disease, but earlyonset Alzheimers is linked to ce
rtain mutations, or
changes, in three particular GENES. Examination of affected brains shows senile p
laques containing an
amyloid-like material distributed throughout an atrophied cortex (see AMYLOID PL
AQUES). Many remaining
neurons, or nerve cells, show changes in their NEUROFIBRILS which thicken and tw
ist into neurofibrillary
tangles. First symptoms are psychological with insidious impairment of recent mem
ory and disorientation in
time and space. This becomes increasingly associated with difficulties in judgem
ent, comprehension and
abstract reasoning. After very few years, progressive neurological deterioration
produces poor gait,
immobility and death. When assessment has found no other organic cause for an af
fected individuals
symptoms, treatment is primarily palliative. The essential part of treatment is
the provision of
appropriate nursing and social care, with strong support being given to the rela
tives or other carers for
whom looking after sufferers is a prolonged and onerous burden. Proper diet and
exercise are helpful, as is
keeping the individual occupied. If possible, sufferers should stay in familiar
surroundings with day-care
and short-stay institutional facilities a useful way of maintaining them at home
for as long as possible.
TRANQUILLISERS can help control difficult behaviour and sleeplessness but should
be used with care.
Recently drugs such as DONEPEZIL and RIVASTIGMINE, which retard the breakdown of
ACETYLCHOLINE, may check
but not cure this distressing condition. About 40 per cent of those with DEMENTI
A improve. Research is in
progress to transplant healthy
nerve cells (developed from stem cells) into the brain tissue of patient
s with Alzheimers disease with
the aim of improving brain function. The rising proportion of elderly people in
the population is resulting
in a rising incidence of Alzheimers, which is rare before the age of 60 but incre
ases steadily thereafter
so that 30 per cent of people over the age of 84 are affected.
Amantadine A drug used to treat certain virus infections which is also o
f value in the prevention of
some forms of influenza. It is also used to treat PARKINSONISM.
Amaurosis Fugax Sudden transitory impairment, or loss, of vision. It usu
ally affects only one eye, and
is commonly due to circulatory failure. In its simplest form it occurs in normal
people on rising suddenly
from the sitting or recumbent position, when it is due to the effects of gravity
. It also occurs in
migraine. A not uncommon cause, particularly in elderly people, is transient ocu
lar ISCHAEMIA, resulting
from blockage of the circulation to the retina (see EYE) by emboli (see EMBOLISM
) from the common carotid
artery or the heart. Treatment in this last group of cases consists of control o
f the blood pressure if
this is raised, as it often is in such cases; and the administration of drugs th
at reduce the stickiness of
blood platelets, such as aspirin. In some instances, removal of the part of the
carotid artery from which
the emboli are coming may be indicated.
Ambivalence The psychological state in which a person concurrently hates
and loves the same object or
person.
Amblyopia Defective vision for which no recognisable cause exists in any
part of the eye. It may be due
to such causes as defective development or excessive use of tobacco or alcohol.
The most important form is
that associated with SQUINT, or gross difference in refraction between the two e
yes. It has been estimated
that in Britain around 5 per cent of young adults have amblyopia due to this cau
se.
Amelia This is absence of the limbs, usually a congenital defect.
Aminocaproic Acid
29
Amenorrhoea
Amentia
Absence of MENSTRUATION at the time of life at which it should normally
occur. If menstruation has
never occurred, the amenorrhoea is termed primary; secondary amenorrhoea is defi
ned as menstruation ceasing
after a normal cycle has been experienced for a number of years. A few patients
with primary amenorrhoea
have an abnormality of their CHROMOSOMES or malformation of the genital tract su
ch as absecence of the
UTERUS (see TURNERS SYNDROME). A gynaecological examination will rarely disclose
an IMPERFORATE HYMEN in a
young girl who may also complain of regular cycles of pain like period pains. Th
ere are many causes of
secondary amenorrhoea and management requires dealing with the primary cause. Th
e commonest cause is
pregnancy. Disorders of the HYPOTHALAMUS and related psychological factors such
as anorexia nervosa (see
EATING DISORDERS) also cause amenorrhoea, as can poor nutrition and loss of weig
ht by extreme dieting. It
is common in ballet dancers and athletes who exercise a great deal, but can also
be triggered by serious
illnesses such as tuberculosis or malaria. Excess secretion of prolactin, either
due to a micro-adenoma
(see ADENOMA) of the PITUITARY GLAND or to various prescription drugs will produ
ce amenorrhoea, and
sometimes GALACTORRHOEA as well. Malfunction of other parts of the pituitary gla
nd will cause failure to
produce GONADOTROPHINS, thus causing ovarian failure with consequent amenorrhea.
In CUSHINGS SYNDROME,
amenorrhoea is caused by excessive production of cortisol. Similarly, androgenpr
oduction abnormalities are
found in the common POLYCYSTIC OVARY SYNDROME. These conditions also have abnorm
alities of the
insulin/glucose control mechanisms. Taking the contraceptive pill is not now con
sidered to provoke
secondary amenorrhoea but OBESITY and HYPOTHYROIDISM are potential causes. When
the cause is weight loss,
restoring body weight may alone restore menstruation. Otherwise, measuring gonad
otrophic hormone levels
will help show whether amenorrhoea is due to primary ovarian failure or secondar
y to pituitary disease.
Women with raised concentrations of serum gonadotrophic hormones have primary ov
arian failure. When
amenorrhoea is due to limited pituitary failure, treatment with CLOMIPHENE may s
olve the problem.
Amentia is the failure of the intellectual faculties to develop normally
.
Amethocaine An effective local anaesthetic for topical application. Rapi
dly absorbed from mucous
membranes, it should never be applied to inflamed, traumatised or highly vascula
r surfaces nor used when
30 Aminoglutethimide
respiratory tract resulting from a deficiency in
A the bodys immunological defence mechanisms (see IMMUNITY).
Aminoglutethimide A drug that inhibits the synthesis of adrenal CORTICOS
TEROIDS. It is proving to be of
value in the treatment of cancer of the breast in post-menopausal women.
Aminoglycosides A group of antibiotics usually reserved for use in patie
nts with severe infections.
They are effective against a wide range of BACTERIA including some gram-positive
and many gram-negative
organisms (see GRAMS STAIN). Aminoglycosides must be used cautiously because they
can damage the inner ear
thus affecting hearing and the kidneys. Examples of this group are AMIKACIN and
GENTAMICIN (effective
against Pseudomonas aeuriginosa), NEOMYCIN (used only for topical administration
for skin infections), and
STREPTOMYCIN (effective in combination with other drugs against Mycobacterium tu
berculosis).
Aminophylline A combination of theophylline and ethylenediamine. It is u
sed intravenously in the
treatment of acute severe ASTHMA, or as an oral preparation in the treatment of
chronic asthma.
Amiodarone (in the form of amiodarone hydrochloride) is a drug used to t
reat ARRHYTHMIA of the HEART
and initiated only under supervision in hospital or by an appropriate specialist
. Given by mouth or
intravenous infusion, amiodarone can help to control paroxysmal supraventricular
, nodal and ventricular
TACHYCARDIA as well as FIBRILLATION of the auricles and ventricles of the heart.
It may take some time to
achieve control, and several weeks to be eliminated from the body when treatment
is stopped. The drug has a
range of potentially serious sideeffects.
Amitriptyline See ANTIDEPRESSANT DRUGS.
olution
pungent
in the
ammonia
form it
5 per cent).
Amnion Amnion is the tough fibrous membrane which lines the cavity of th
e womb (UTERUS) during
pregnancy, and contains between 05 and 1 litre (12 pints) of fluid in which the EM
BRYO floats. It is
formed from the ovum (egg) along with the embryo, and in labour the part of it a
t the mouth of the womb
forms the bag of waters. (See PREGNANCY AND LABOUR.) When a child is born with a CA
UL, the caul is a
piece of amnion.
Amnioscopy The insertion of a viewing instrument (amnioscope) through th
e abdominal wall into the
pregnant UTERUS to examine the inside of the amniotic sac (see AMNION). The grow
ing FETUS can be viewed
directly and its condition and sex assessed without disturbing the pregnancy. Th
e amniotic sac may also be
viewed late in pregnancy through the cervix or neck of the womb using an instrum
ent called the fetoscope.
Amniotic Fluid The clear fluid contained within the AMNION that
s the FETUS in the womb and
protects it from external pressure. The fluid, comprising mainly water,
ced by the amnion and is
regularly circulated, being swallowed by the fetus and excreted through
eys back into the amniotic
sac. By the 35th week of pregnancy there is about 1 litre of fluid, but
ls to 0.5 litres at term.
The amniotic sac normally ruptures in early labour, releasing the fluid
surround
is produ
the kidn
this fal
or waters.
Amputation 31
protoplasm that changes its shape as the protozoon progresses or absorbs
nourishment. Several varieties
are found under different conditions within the human body. One variety, Entamoe
ba coli, is found in the
large intestine of humans without any associated disease; another, Entamoeba gin
givalis, is found in the
sockets of the teeth and associated with PYORRHOEA. Entamoeba histolytica is the
causative organism of
amoebic dysentery (see DYSENTERY); Acanthamoeba and Naegleria fowleri cause the
infection of the brain
known as MENINGOENCEPHALITIS. Entamoeba histolytica may also cause meningoenceph
alitis. Other forms are
found in the genital organs.
Amoebiasis See DYSENTERY.
Amoxicillin See PENICILLIN; ANTIBIOTICS.
Amphetamines
Ampoule A small glass container having one end drawn out into a point ca
pable of being sealed so as to
preserve its contents sterile. It is used for containing solutions for hypodermi
c injection.
Ampulla of Vater The dilated section of the common BILE DUCT when it is
joined by the duct from the
PANCREAS.
Amputation Severance of a limb, or part of a limb, from the 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
variety of reasons. In the young, severe injury is the most common cause, when d
amage to the limb is so
extensive as to make it non-viable or functionally useless. In the elderly, ampu
tation is more often the
result of vascular insufficiency, resulting in gangrene or intractable pain.
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, produc
ing a sense of well-being
and confidence and seemingly increasing the capacity for mental work. They are,
however, drugs of
DEPENDENCE and their medical use is now strictly limited for example, to the tre
atment of NARCOLEPSY.
Because amphetamines inhibit appetite, they rapidly achieved a reputatio
n for slimming purposes.
However, they should not be used for this purpose; their dangers far outweigh th
eir 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 give
32 Amsacrine
Sarcoma (see
CANCER)
of bone, muscle or conA nective tissues in a limb is another reason for amputation. The aim is
to restore the patient to full
mobility with a prosthetic (artificial) limb, which requires both a well-fitting
PROSTHESIS and a
well-healed surgical wound. If this is not possible, the aim is to leave the pat
ient with a limb stump that
is still useful for balancing, sitting and transferring. Common types of lower-l
imb amputation are shown in
the illustration. The Symes amputation can be walked upon without requiring a pr
osthesis. The below-knee
amputation preserves normal flexion of the knee, and virtually normal walking ca
n be achieved with a
well-fitting artificial limb. Learning to walk is more difficult following an ab
ove-knee amputation, but
some highly motivated patients can manage well. After any amputation it is not u
nusual for the patient to
experience the sensation that the limb is still present: this is called a PHANTOM
LIMB and the sensation
may persist for a long time.
Amsacrine See under CYTOTOXIC.
Amylase An ENZYME in pancreatic juice which facilitates the conversion o
f starch to maltose. (See
PANCREAS.)
Amyl Nitrite A volatile, oily liquid prepared by the action of nitric an
d nitrous acids on amyl
alcohol. It was used for many years to treat angina but has been superseded by o
ther nitrate drugs such as
glyceril trinitrate. The substance is misused by drug abusers to produce a high an
d is referred to as
poppers.
Amyloidosis A rare condition in which deposits of complex protein, known
as amyloid, are found in
various parts of the body. It is a degenerative condition resulting from various
causes such as chronic
infection, including tuberculosis and rheumatoid arthritis.
Amyloid Plaques Characteristic waxy deposits of amyloid found in primary
AMYLOIDOSIS, the cause of
which is unknown.
Amylose The name applied to any carbohydrate of the starch group.
Amyotrophy Loss of muscle bulk and strength caused by a disorder of the
nerve that supplies the muscle.
The loss is progressive and characterises chronic NEUROPATHY. Patients with DIAB
ETES MELLITUS and MOTOR
NEURONE DISEASE (MND) often suffer from amyotrophy as well as spasticity (see SP
ASTIC) of muscles.
Anaemia
The anabolic steroids in therapeutic use include nandrolone and stanozol
ol.
from the gastrointestinal tract. The Bleeding best example here is anaem
ia due to bleeding
Anabolism Production by the body of complex molecules like fat and prote
ins from simpler substances
taken in the diet.
Anaemia The condition characterised by inadequate red blood cells and/or
HAEMOGLOBIN in the BLOOD. It
is considered to exist if haemoglobin levels are below 13 grams per 100 ml in ma
les and below 12 grams per
100 ml in adult nonpregnant women. No simple classification of anaemia can be wh
olly accurate, but the most
useful method is to divide anaemias into: (a) microcytic hypochromic or iron def
iciency anaemia; (b)
megaloblastic hyperchromic anaemia; (c) aplastic anaemia; (d) haemolytic anaemia
; (e) inherited anaemias
(see below). In Britain, anaemia is much more common among women than men. Thus,
around 10 per cent of
girls have anaemia at the age of 15, whilst in adult life the incidence is over
30 per cent between the
ages of 30 and 40, around 20 per cent at 50, and around 30 per cent at 70. Among
men the incidence is under
5 per cent until the age of 50; it then rises to 20 per cent at the age of 70. N
inety per cent of all cases
of anaemia in Britain are microcytic, 7 per cent are macrocytic, and 3 per cent
are haemolytic or aplastic.
Inherited anaemias include sickle-cell anaemia and THALASSAEMIA.
Microcytic
hypochromic
anaemia
corresponds to a large extent with what used to be known as secondary ana
emia. It takes its name from
the characteristic changes in the blood.
Causes
LOSS OF BLOOD
a result of trauma. This is perhaps the As simplest example of all, when
, as a result of
te severe anaemia.
Childbirth. A considerable amount of blood is always lost at childbirth; if this
is severe, or if the woman
was anaemic during pregnancy, a severe degree of anaemia may develop.
33
34 Anaemia
giddiness, and loses consciousness if he or she
A tries to stand or sit up. The breathing is rapid and distressed, the p
ulse is rapid and the blood
pressure is low. In chronic cases the tongue is often sore (GLOSSITIS), and the
nails of the fingers may be
brittle and concave instead of convex (koilonychia). In some cases, particularly
in women, the
Plummer-Vinson syndrome is present: this consists of difficulty in swallowing an
d may be accompanied by
huskiness; in these cases glossitis is also present. There may be slight enlarge
ment of the SPLEEN, and
there is usually some diminution in gastric acidity. The characteristic change i
s a diminution in both the
haemoglobin and the red cell content of the blood. There is a relatively greater
fall in the haemoglobin
than in the red cell count. If the blood is examined under a microscope, the red
cells are seen to be paler
and smaller than normal. These small red cells are known as microcytes.
CHANGES IN THE BLOOD
Treatment consists primarily of giving sufficient iron by mouth to resto
re, and then maintain, a normal
blood picture. The main iron preparation now used is ferrous sulphate, 200 mg, t
hrice daily after meals.
When the blood picture has become normal, the dosage is gradually reduced. A pre
paration of iron is
available which can be given intravenously, but this is only used in cases which
do not respond to iron
given by mouth, or in cases in which it is essential to obtain a quick response.
If, of course, there is
haemorrhage, this must be arrested, and if the loss of blood has been severe it
may be necessary to give a
blood transfusion (see TRANSFUSION Transfusion of blood). Care must be taken to
ensure that the patient
is having an adequate diet. If there is any underlying metabolic, oncological, t
oxic or infective
condition, this, of course, must be adequately treated after appropriate investi
gations. Megaloblastic
hyperchromic anaemia There are various forms of anaemia of this type, such as th
ose due to nutritional
deficiencies, but the most important is that known as pernicious anaemia. PERNIC
IOUS ANAEMIA An autoimmune
disease in which sensitised lymphocytes (see LYMPHOCYTE) destroy the PARIETAL ce
lls of the stomach. These
cells normally produce INTRINSIC FACTOR, the carrier protein for vitamin B12 (se
e APPENDIX 5: VITAMINS)
that permits its absorption in the terminal part of the ILEUM. Lack of the factor prevents vita
min B12 absorption and this
causes macrocytic (or megaloblastic) anaemia. The disorder can affect men and wo
men, usually those over the
age of 40; onset is insidious so it may be well advanced before medical advice i
s sought. The skin and
MUCOSA become pale, the tongue is smooth and atrophic and is accompanied by CHEI
LOSIS. Peripheral
Anaesthesia 35
blood cells. This may be the result of undue fragility of the red blood
cells, when the condition is
known as congenital haemolytic anaemia, or of acholuric JAUNDICE.
Sickle-cell anaemia A form of anaemia characteristically found in people
of African descent, so-called
because of the sickle shape of the red blood cells. It is caused by the presence
of the abnormal
HAEMOGLOBIN, haemoglobin S, due to AMINO ACID substitutions in their polypeptide
chains, reflecting a
genetic mutation. Deoxygenation of haemoglobin S leads to sickling, which increa
ses the blood viscosity and
tends to obstruct flow, thereby increasing the sickling of other cells. THROMBOS
IS and areas of tissue
INFARCTION may follow, causing severe pain, swelling and tenderness. The resulti
ng sickle cells are more
fragile than normal red blood cells, and have a shorter life span, hence the ana
emia. Advice is obtainable
from the Sickle Cell Society.
Anaerobe The term applied to bacteria having the power to live without a
ir. Such organisms are found
growing freely, deep in the soil as, for example, the tetanus bacillus.
Anaesthesia The loss or absence of sensation or feeling. Commonly used t
o describe a reversible process
which allows operations and painful or unpleasant procedures to be performed wit
hout distress to the
patient. The speciality of anaesthesia broadly covers its provision for SURGERY,
intensive therapy
(intensive care), chronic pain management, acute pain management and obstetric a
nalgesia. Anaesthetists in
Britain are trained specialists with a medical degree, but in many countries som
e anaesthetists may be
nurse practitioners working under the supervision of a medical anaesthetist. The
anaesthetist will assess
the patients fitness for anaesthesia, choose and perform the appropriate type of
anaesthetic while
monitoring and caring for the patients well-being, and, after the anaesthetic, su
pervise recovery and the
provision of post-operative pain relief. Anaesthesia may be broadly divided into
general and local
anaesthesia. Quite commonly the two are combined to allow continued relief of pa
in at the operation site
after the patient awakens.
General anaesthesia is most often produced by using a combination of dru
gs to induce
a state of reversible UNCONSCIOUSNESS. Balanced anaesthesia uses a combina
tion of drugs to provide
unconsciousness, analgesia, and a greater or lesser degree of muscle relaxation.
A general anaesthetic
comprises induction, maintenance and recovery. Historically, anaesthesia has bee
n divided into four stages
(see below), but these are only clearly seen during induction and maintenance of
anaesthesia using
inhalational agents alone. (1) Onset of induction to unconsciousness (2) Stage o
36 Anaesthesia
A
Patient under general anaesthesia (top). Use of a mask to deliver anaest
hetic gases (bottom left).
Delivering anaesthetic gases direct to the lungs (bottom right).
most rapid induction and recovery though on a worldwide basis halothane,
ether and chloroform are
still widely used. Despite several theories, the mode of action of these agents
is not fully understood.
Their efficacy is related to how well they dissolve into the LIPID substances in
nerve cells, and it is
thought that they act at more than one site within brain cells probably at the c
ell membrane. By whatever
method, they reversibly depress the conduction of impulses within the CENTRAL NE
RVOUS SYSTEM and thereby
produce unconsciousness. At the end of surgery any muscle relaxant still in the
patients body is reversed,
the volatile agent is turned off and the patient breathes oxygen or oxygen-enric
hed air. This is the
reversal or recovery phase of anaesthesia. Once the anaesthetist is sati
sfied with the degree of
recovery, patients are transferred to a recovery area within the operating-theat
re complex where they are
cared for by specialist staff, under the supervision of an anaesthetist, until t
hey are ready to return to
the ward. (See also ARTIFICIAL VENTILATION OF THE LUNGS.)
Local anaesthetics are drugs which reversibly block the conduction of im
pulses in nerves. They
therefore produce anaesthesia (and muscle relaxation) only in those areas of the
body served by the
nerve(s) affected by these drugs. Many drugs have some local anaesthetic action
but the drugs used
specifically for this purpose are all amide or ester derivatives of aromatic
Analgesics 37
acids. Variations in the basic structure produce drugs with different sp
eeds of onset, duration of
action and preferential SENSORY rather than MOTOR blockade (stopping the activit
y in the sensory or motor
nerves respectively). The use of local rather than general anaesthesia will depe
nd on the type of surgery
and in some cases the unsuitability of the patient for general anaesthesia. It i
s also used to supplement
general anaesthesia, relieve pain in labour (see under PREGNANCY AND LABOUR) and
in the treatment of pain
in persons not undergoing surgery. Several commonly used techniques are listed b
elow: An area of
anaesthetised skin or tissue is produced by injecting local anaesthetic around i
t. This technique is used
for removing small superficial lesions or anaesthetising surgical incisions. LOC
AL INFILTRATION
Local anaesthetic is injected close to a nerve or nerve plexus, often us
ing a peripheral nerve
stimulator to identify the correct point. The anaesthetic diffuses into the nerv
e, blocking it and
producing anaesthesia in the area supplied by it.
NERVE BLOCKS
Small volumes of local anaesthetic are injected into the cerebrospinal f
luid through a small-bore
needle which has been inserted through the tissues of the back and the dura mate
r (the outer membrane
surrounding the spinal cord). A dense motor and sensory blockade is produced in
the lower half of the body.
How high up in the body it reaches is dependent on the volume and dose of anaest
hetic, the patients
position and individual variation. If the block is too high, then respiratory-mu
scle paralysis and
therefore respiratory arrest may occur. HYPOTENSION (low blood pressure) may occ
ur because of peripheral
vasodilation caused by sympatheticnerve blockade. Occasionally spinal anaesthesi
a is complicated by a
headache, perhaps caused by continuing leakage of cerebrospinal fluid from the d
ural puncture point. SPINAL
ANAESTHESIA
EPIDURAL ANAESTHESIA Spinal nerves are blocked in the epidural space wit
h local anaesthetic injected
through a fine plastic tube (catheter) which is introduced into the space using
a special needle (Tuohy
needle). It can be used as a continuous technique either by intermittent injecti
ons, an infusion or by
patient-controlled pump. This makes it ideal for surgery in the lower part of th
e body, the relief of pain
in labour and for post-operative analgesia. Complications include hypotension, spinal headache (less than 1:100), poor
efficacy, nerve damage
(1:12,000) and spinal-cord compression from CLOT or ABSCESS (extremely rare).
Analeptic A restorative medicine, or one which acts as a stimulant of th
38 Analysis
often used by individuals attempting suicide.
A Even if there are no immediate symptoms, individuals suspected of havi
ng taken an overdose should be
sent to hospital urgently for treatment. The NSAIDs (including aspirin) inhibit
prostaglandin synthesis.
Prostaglandins are released by tissues that are inflamed, and may cause pain at
peripheral pain sensors or
sensitise nerve endings to painful stimuli: by inhibiting their production, pain
and inflammation are
reduced. NSAIDs are particularly effective for pain produced by inflammation for
example, ARTHRITIS.
Side-effects include gastrointestinal bleeding (caused by mucosal erosions parti
cularly in the stomach),
inhibition of platelet aggregation (see PLATELETS), and potential for renal (kid
ney) damage. Severe pain is
often treated with opioid drugs. The original drugs were naturally occurring pla
nt ALKALOIDS (e.g.
MORPHINE), whilst newer drugs are man-made. They mimic the action of naturally o
ccurring compounds
(ENDORPHINS and ENCEPHALIN) which are found within the brain and spinal cord, an
d act on receptors to
reduce the transmission of painful stimuli within the central nervous system (an
d possibly peripherally).
They tend to produce side-effects of euphoria, respiratory depression, vomiting,
constipation and itching.
Chronic use or abuse of these drugs may give rise to addiction.
Analysis Analysis means a separation into component parts by determinati
on of the chemical constituents
of a substance. The process of analysis is carried out by various means, for exa
mple: chromatographic
analysis by means of the adsorption column; colorimetric analysis by means of va
rious colour tests;
densimetric analysis by estimation of the specific gravity; gasometric analysis
by estimation of the
different gases given off in some process; polariscope analysis by means of the
polariscope; and volumetric
analysis by measuring volumes of liquids. Analysis is also sometimes used as an
abbreviation for
PSYCHOANALYSIS.
Anaphylactoid Purpura See HENOCH-SCHNLEIN PURPURA.
Anaphylaxis An immediate (and potentially health- or lifethreatening) hy
persensitivity reaction
produced by the bodys immunoglobulin E (IgE) antibodies to a foreign substance (a
ntigen); the affected
tissues release histamine which causes
local or systemic attack. An example is the pain, swelling, eruption, fe
ver and sometimes collapse that
may occur after a wasp sting or ingestion of peanut in a particularly sensitive
person. Some people may
suffer from anaphylaxis as a result of allergy to other foods or substances such
as animal hair or plant
leaves. On rare occasions a person may be so sensitive that anaphylaxis may lead
to profound SHOCK and
collapse which, unless the affected person receives urgent medical attention, in
cluding injection of
ADRENALINE, may cause death. (See also ALLERGY; IMMUNITY.)
Anaplasia The state in which a body cell loses its distinctive character
s and takes on a more primitive
form; it occurs, for example, in cancer, when cells proliferate rapidly.
Anastomosis Direct intercommunication of the branches of two or more vei
ns or arteries without any
intervening network of capillary vessels. The term also describes the surgical j
oining of two hollow blood
vessels, nerves or organs such as intestines to form an intercommunication.
Anatomy The science which deals with the structure of the bodies of men
and animals. Brief descriptions
of the anatomy of each important organ are given under the headings of the vario
us organs. It is studied by
dissection of bodies bequeathed for the purpose, or of the bodies of those who d
ie in hospitals and similar
institutions, unclaimed by relatives.
Ancrod An ENZYME present in the venom of the Malayan pit viper, which de
stroys the FIBRINOGEN in blood
and thereby prevents the blood from clotting. In other words it is an anticoagul
ant (see ANTICOAGULANTS).
Ancylostomiasis A parasitic infection caused by the nematodes Ancylostom
a duodenale and Necator
americanus, resulting in hookworm disease. These infections are exceedingly comm
on in tropical and
developing countries, millions of people being affected. Classically, A. duodena
le occurred in the Far
East, Mediterranean littoral, and Middle East, and N. americanus in tropical Afr
ica, Central and South
America, and the Far East; however, in recent years, geographical separation of
the two human species is
less distinct. In areas where standards of hygiene and sanita-
Aneurysm 39
tion are unsatisfactory, larvae (embryos) enter via intact skin, usually
the feet. Ground itch
occasionally occurs as larvae enter the body. They then undergo a complex life-c
ycle, migrating through the
lungs, trachea, and pharynx. Adult worms are 513 (mean 12) mm in length; their no
rmal habitat is the small
INTESTINE especially the jejunum where they adhere to the mucosa by hooks, thus
causing seepage of
blood into the lumen. A wormpair produces large numbers of eggs, which are excre
ted in faeces; when
deposited on moist soil they remain viable for many weeks or months. Clinical ma
nifestations include
microcytic hypochromic ANAEMIA, hypoalbuminaemia (low serum protein) and, in a s
evere case, OEDEMA. A
chronic infection in childhood can give rise to physical, mental and sexual reta
rdation. Treatment is with
one of the benzimidazole compounds, usually mebendazole or albendazole; however,
in developing countries,
cheaper preparations are used, including tetrachloroethylene, bephenium hydroxyn
aphthoate, and pyrantel
embonate. Anaemia usually responds to iron supplements; blood transfusion is rar
ely indicated.
Ancylostoma braziliensis A nematode infection of dogs, which in humans c
auses local disease (larva
migrans) only, generally on the soles of the feet. It is usually acquired by wal
king on beaches
contaminated with dog faeces in places such as the Caribbean.
Androgen The general term for any one of a group of HORMONES which gover
n the development of the sexual
organs and the secondary sexual characteristics of the male. TESTOSTERONE, the a
ndrogenic hormone formed in
the interstitial cells of the testis (see TESTICLE), controls the development an
d maintenance of the male
sex organs and secondary sex characteristics. In small doses it increases the nu
mber of spermatozoa (see
SPERMATOZOON) produced, but in large doses it inhibits the gonadotrophic activit
y of the anterior PITUITARY
GLAND and suppresses the formation of the spermatozoa. It is both androgenic and
anabolic in action. The
anabolic effect includes the ability to stimulate protein synthesis and to dimin
ish the catabolism of amino
acids, and this is associated with retention of nitrogen, potassium, phosphorus
and calcium. Doses in
excess of 10 mg daily to the female may produce VIRILISM. Unconjugated testoster
one is rarely used
clinically because its derivatives have a more powerful and prolonged effect, an
d because testosterone itself requires implantation into the subcutaneous fat using a
trocar and cannula for maximum
therapeutic benefit. Testosterone propionate is prepared in an oily solution, as
it is insoluble in water;
it is effective for three days and is therefore administered intramuscularly twi
ce weekly. Testosterone
phenyl-propionate is a long-acting microcrystalline preparation which, when give
n by intramuscular or
40 Angina
the blood vessels originating from the aorta: the
A outcome is an INFARCTION in the organs supplied by the affected vessel
(s). Aneurysms may also form in
the arteries at the base of the brain, usually due to an inherited defect of the
arterial wall. Aneurysms
generally arise in the elderly, with men affected more commonly than women. The
most common cause is
degenerative atheromatous disease, but other rarer causes include trauma, inheri
ted conditions such as
MARFANS SYNDROME, or acquired conditions such as SYPHILIS or POLYARTERITIS NODOSA
. Once formed, the
pressure of the circulating blood within the aneurysm causes it to increase in s
ize. At first, there may be
no symptoms or signs, but as the aneurysm enlarges it becomes detectable as a sw
elling which pulsates with
each heartbeat. It may also cause pain due to pressure on local nerves or bones.
Rupture of the aneurysm
may occur at any time, but is much more likely when the aneurysm is large. Ruptu
re is usually a surgical
emergency, because the bleeding is arterial and therefore considerable amounts o
f blood may be lost very
rapidly, leading to collapse, shock and even death. Rupture of an aneurysm in th
e circle of Willis causes
subarachnoid haemorrhage, a lifethreatening event. Rupture of an aneurysm in the
abdominal aorta is also
life-threatening.
Treatment Treatment is usually surgical. Once an aneurysm has formed, th
e tendency is for it to enlarge
progressively regardless of any
medical therapy. The surgery is often demanding and is therefore usually
undertaken only when the
aneurysm is large and the risk of rupture is therefore increased. The patients ge
neral fitness for surgery
is also an important consideration. The surgery usually involves either bypassin
g or replacing the affected
part of the artery using a conduit made either of vein or of a man-made fibre wh
ich has been woven or
knitted into a tube. Routine X-ray scanning of the abdominal aorta is a valuable
preventive procedure,
enabling cold surgery to be performed on identified aneurysms.
Angina A feeling of constriction or suffocation often accompanied by pai
n (see ANGINA PECTORIS).
Angina Pectoris Pain in the centre of the chest. Usually, exercise somet
imes acute anxiety brings
it on and pain may be severe and felt also in the arms and the jaw. The conditio
n, which is aggravated by
cold weather, is the result of the hearts demand for blood being greater than tha
t which the coronary
arteries can provide. This failure is most often due to narrowing of the coronar
y arteries by ATHEROMA;
rarely, it may be caused by congenital defects in the arteries rendering them in
capable of carrying
sufficient blood to meet increased demands from the body. Angina may be relieved
Ankle 41
drug treatment does not work, surgery on the coronary arteries such as a
ngioplasty or bypass grafts may
be necessary. People who suffer from angina pectoris need advice on their lifest
yle, and in particular on
diet, exercise and avoidance of smoking or excessive alcohol consumption. They m
ay have high blood
pressure, which will also require medical treatment (see HEART, DISEASES OF; HYP
ERTENSION).
Angiocardiography Radiography of the heart after injection into it of a
radio-opaque substance.
Angiography Radiography of blood vessels made visible by injecting into
them a radio-opaque substance.
In the case of arteries this is known as arteriography; the corresponding term f
or veins being venography
or phlebography. This procedure demonstrates whether there is any narrowing or b
allooning of the lumen of
the vessel, changes usually caused by disease or injury.
Angioma A TUMOUR NAEVUS.)
composed of blood vessels. (See
ANGIOTENSIN-CONVERTING INHIBITORS.)
ENZYME
(ACE)
Angiotensin-Converting Enzyme (ACE) Inhibitors The ENZYME that converts
angiotensin I to angiotensin II
(see ANGIOTENSIN) is called angiotensin-converting enzyme. Angiotensin II contro
ls the blood pressure and
is the most potent endogenous pressor substance produced in the body; angiotensi
n I has no such pressor
activity. Inhibition of the enzyme that converts angiotensin I to angiotensin II
will thus have marked
effects on lowering the blood pressure, and ACE inhibitors have a valuable role
in treating heart failure
when thiazides and beta blockers cannot be used or fail to work, especially afte
r myocardial infarction
(see HEART, DISEASES OF). Captopril was the first ACE inhibitor to be synthesise
d: it reduces peripheral
resistance by causing arteriolar dilatation and thus lowers blood pressure. Othe
r drugs such as enalapril,
lisinopril, cilazapril, quinapril and ramipril have since been developed. Some k
idney disorders increase
the production of angiotensin II and so cause HYPERTENSION.
Angitis
Angio-Oedema URTICARIA.
Angitis (or angiitis) means inflammation of a vessel such as a blood ves
sel, lymph vessel, or bile
duct.
Angioplasty
ngstrm Unit
A method of treating blockage or narrowing of a blood vessel by recanali
sing the vessel that is,
inserting a balloon into the constriction to reopen it. The technique is used to
treat a narrowed artery in
the heart or a limb. About 65 per cent of patients treated benefit, but when sym
ptoms persist or recur the
procedure may be repeated. There is a small risk of damage to the vessel or valv
e. New procedures under
development include the use of lasers, cutting drills and suction to remove the
deposits of ATHEROMA
blocking the arteries.
Called after the Swedish physicist, this is a measurement of length and
equals 1/10,000 of a
micrometre, or one-hundred-millionth of a centimetre. It is represented by the s
ymbol and is used to give
the length of electromagnetic waves.
Angiotensin
See GLYCOGEN.
Also called angioneurotic oedema;
see under
Angiotensin is a peptide that occurs in two forms: I and II. The former
results from the action of the
ENZYME, RENIN on alpha globulin (a protein) produced by the liver and passed int
o the blood. During passage
of the blood through the lungs, angiotensin I is converted into an active form,
angiotensin II, by an
enzyme. This active form constricts the blood vessels and stimulates the release
of two hormones
VASOPRESSIN and ALDOSTERONE which raise the blood pressure. (See also
Anhidrosis Anhidrosis is an abnormal diminution in the secretion of swea
t. This may be caused by
disease or by a congenital defect.
Animal Starch Anisocytosis This means inequality in the size of erythroc
ytes (red blood cells); it
occurs in many forms but is prominent in megaloblastic ANAEMIA.
Ankle The joint between the leg bones (TIBIA and FIBULA) above, and the
TALUS (the Roman dicebone)
below. It is a very strong joint with powerful ligaments binding the bones toget
her
A
42 Ankylosing Spondylitis
at either side, and bony projections from the leg
A bones, which form large bosses on either side,
called the outer and inner malleoli, extending about 12 mm (half an inch
) below the actual joint. Two
common injuries near the ankle are a sprain, on the inner side, consisting of te
aring of the internal
ligament; and fracture of the fibula (Potts fracture) on the outer side. (See als
o JOINTS, DISEASES OF.)
Anoxia That state in which the body tissues have an inadequate supply of
OXYGEN. This may be because
the blood in the lungs does not receive enough oxygen, or because there is not e
nough blood to receive the
oxygen, or because the blood stagnates in the body.
Antabuse
Ankylosing Spondylitis
See DISULFIRAM.
See SPINE AND SPINAL CORD, DISEASES AND INJURIES OF.
Antacids
Ankylosis The condition of a joint in which the movements are restricted
by fibrous bands, or by
malformation, or by actual union of the bones. (See JOINTS, DISEASES OF.)
Ankylostoma See ANCYLOSTOMIASIS.
Anodynes Any drug or treatment that eases pain. These may range from opi
um the oldest and most
powerful anodyne but a highly addictive substance through ANALGESICS, to warmth
and massage.
Anopheles The generic name of a widely distributed group of mosquitoes,
certain species of which
transmit to humans the parasitic protozoa Plasmodium, the agent that causes MALA
RIA. Anopheles maculipennis
and A. bifurcatus are both found in England and can both transmit the malaria pa
rasite.
Anorexia Loss of APPETITE.
Anorexia Nervosa
Drugs traditionally used to treat gastrointestinal disorders, including
peptic ulcer. They neutralise
the hydrochloric acid secreted in the stomachs digestive juices and relieve pain
and the discomfort of
DYSPEPSIA (indigestion). A large number of proprietary preparations are on sale
to the public and most
contain compounds of aluminium or magnesium or a mixture of the two. Other agent
s include activated
dimethicone an antifoaming agent aimed at relieving flatulence; alginates, which
Anthrax 43
child-to-be are carefully assessed, and any problem or potential problem
s dealt with. Most antenatal
care deals with normal pregnancies and is supervised by general practitioners an
d midwives in primary-care
clinics. If any serious problems are identified, the mother can be referred to s
pecialists clinics in
hospitals. (See PREGNANCY AND LABOUR.)
Antepartum An adjective describing an event before labour starts in preg
nancy (see PREGNANCY AND
LABOUR).
Anterior An adjective that describes or relates to the front part of the
body, limbs, or organs.
Anterior Tibial Syndrome See under MUSCLES, DISORDERS OF
Compression syndrome.
Anteversion The term applied to the forward tilting of an organ, especia
lly of the UTERUS.
Anthelmintics Substances which cause the death or expulsion of parasitic
worms such as hook, tape and
threadworms (see TAENIA; ENTEROBIASIS).
Anthracosis The change which takes place in the lungs and bronchial glan
ds of coal-miners, and others,
who inhale coal-dust constantly. The lungs are amazingly efficient in coping wit
h this problem; during a
working lifetime a coal-miner may inhale around 5,000 grams of dust, but at POST
-MORTEM EXAMINATION it is
rare to find more than about 40 grams in the lungs. The affected tissues change
in colour from greyish pink
to jet black, owing to loading with minute carbon particles. (See PNEUMOCONIOSIS
.)
Anthracyclines that destroy tumour cells: examples include aclarubicin,
daunorubicin, doxorubicin,
epirubicin and idarubicin.
ANTIBIOTICS
Anthrax A serious disease occurring in sheep and cattle, and in those wh
o tend them or handle the
bones, skins and fleeces even long after removal of the latter from the animals.
It is sometimes referred
to as malignant pustule, wool-sorters disease, splenic fever of animals, or murra
in. It is now a rare
condition in the United
Kingdom. The cause is a bacillus (B. anthracis) which grows in long chai
ns and produces spores of great
vitality. These spores retain their life for years, in dried skins and fleeces;
they are not destroyed by
boiling, freezing, 5 per cent carbolic lotion, or, like many bacilli, by the gas
Antidepressant Drugs 45
Anticoagulants
Anticoagulants are drugs which inhibit COAGULATION of the blood. They ar
e used to prevent and treat
abnormal clotting of the blood, to treat THROMBOSIS, and sometimes to prevent or
treat STROKE or TRANSIENT
ISCHAEMIC ATTACKS OR EPISODES (TIA, TIE). Anticoagulant drugs are also prescribe
d preventively in major
surgery to stop abnormal clotting from occurring; HAEMODIALYSIS is another proce
dure during which these
drugs are used. Anticoagulants are also prescribed to prevent thrombi (clots) fo
rming on prosthetic heart
valves after heart surgery. The drugs are much more effective in the treatment a
nd prevention of venous
clotting for example, deep vein thrombosis (DVT), see under VEINS, DISEASES OF t
han in preventing
thrombosis formation in arteries with their fastflowing blood in which thrombi c
ontain little fibrin
(against which the anticoagulants work) and many PLATELETS. The main anticoagula
nts now in use are the
natural agent HEPARIN (a quick-acting variety and a low-molecular-weight long-ac
ting type); synthetic oral
anticoagulants such as WARFARIN and the less-often-used acenocoumarol and PHENIN
DIONE; and antiplatelet
compounds such as ASPIRIN, clopidogrel dipyridamole and ticlopidines. Fondaparin
ux is an extract of heparin
which can be given once daily by injection; ximelagatran, an inhibitor of thromb
in, is being trialled as
the first new oral anticoagulant since heparin. Patients taking anticoagulants n
eed careful medical
monitoring and they should carry an Anticoagulant Card with instructions about t
he use of whatever drug
they may be receiving essential information should the individual require treatm
ent for other medical
conditions as well as for thrombosis.
Anticonvulsants
Drugs that reduce or prevent the severity of an epileptic convulsion or
seizure (see EPILEPSY). The
nature of the fit, and the patients reaction to it, influences the type of antico
nvulsant used.
Anticonvulsants inhibit the high level of electrical activity in the brain that
causes the fit. Among
regularly used anticonvulsants are carbamazepine, sodium valproate, clonazopam,
lamotrigine, gabapentin,
vigabatrin, and topiramate. Older drugs such as phenytoin and primidone remain u
seful in some patients.
Intravenous anticonvulsants, such as diazepam, are used for rapid control of epi
leptic status.
Antidepressant Drugs
These widely used drugs include a range of different preparations which
relieve DEPRESSION. All the
antidepressants available at the time of writing are more or less equally effect
ive. In studies where
patients agree to take either antidepressants or identical dummy PLACEBO pills (
46 Antidiarrhoeal Treatments
They are stimulants, rather than sedatives, and
A are particularly helpful for people who are physically and mentally slowed by depression. They work well but have one bi
g disadvantage a dangerous
interaction with certain foods and other drugs, causing a sudden and very danger
ous increase in blood
pressure. People taking them must carry an information card explaining the risk
and listing the things that
they should avoid. Because of this risk, MAOIs are not used much now, except whe
n other treatments have
failed. A new MAOI, moclobemide, which is less likely to interact and so cause h
igh blood pressure, is now
available. LITHIUM CARBONATE is a powerful antidepressant used for intractable d
epression. It should be
used under specialist supervision as the gap between an effective dose and a tox
ic one is narrow. St Johns
Wort is a popular herbal remedy which may be effective, but which is handicapped
by differences of strength
between different preparations or batches. It can interact with a number of conv
entional drugs and so needs
to be used cautiously and with advice. In general, antidepressants work by resto
ring the balance of
chemicals in the brain. Improved sleep and reduced anxiety are usually the first
signs of improvement,
particularly among people taking the more sedative tricyclic drugs. Improvement
in other symptoms follow,
with the mood starting to lift after about two weeks of treatment. Most people f
eel well by three months,
although a few residual symptoms, such as slowness in the mornings, may take lon
ger to clear up. People
taking antidepressants usually want to stop them as soon as they feel better; ho
wever, the risk of relapse
is high for up to a year and most doctors recommend continuing the drugs for aro
und 46 months after
recovery, with gradual reduction of the dose after that. Withdrawal reactions ma
y occur including nausea,
vomiting, headache, giddiness, panic or anxiety and restlessness. The drugs shou
ld be withdrawn gradually
over about a month or longer (up to six months in those who have been on mainten
ance treatment). A wide
range of antidepressant drugs is described in the British National Formulary. Ex
amples include: Tricyclics:
amitryptyline, imipramine, doxepin. MAOIs: phenelzine, isocarboxazid. SSRIs: cit
alopram, fluoxetine,
paraxtene. (Antidepressant drugs not in these three
groups include flupenthixol, mertazapine and venlafaxine.)
Antidiarrhoeal Treatments Initial treatment of acute DIARRHOEA is to pre
vent or correct the loss of
fluid and ELECTROLYTES from the body. This is a priority especially in infants a
nd elderly people.
Rehydration can be achieved orally or, in severe cases, by urgent admission to h
ospital for the replacement
of fluid and electrolytes. For adults with acute diarrhoea, short-term symptomat
ic treatment can be
achieved with antimotility drugs such as codeine phosphate, co-phenotrope or lop
eramide hydrochloride.
Adsorbent drugs, for example, KAOLIN, should not be used in acute diarrhoea, but
bulkforming drugs
ispaghula or methylcellulose can help to control the consistency of faeces in pa
tients with ileostomies
and colostomies (see ILEOSTOMY; COLOSTOMY), or those with diarrhoea caused by DI
VERTICULAR DISEASE.
Irritable bowel syndrome, malabsorption syndrom, ulcerative colitis, Crohns disea
se and diverticular
disease are often accompanied by diarrhoea; for more information on these condit
ions, see under separate
entries. ANTIBIOTICS may sometimes cause diarrhoea and this side-effect should b
e borne in mind when the
cause of the condition is being investigated.
Antidiuretic Hormone (ADH) See VASOPRESSIN.
Antidotes An antidote is a therapeutic substance used to counteract the
toxic action(s) of a specific
substance. Very few substances have an antidote.
Antiemetic A drug that counteracts nausea and sickness. Some antihistami
nes and anticholinergics have
an antiemetic effect. They are used to combat motion sickness or nausea and vomi
ting brought on by other
drugs in particular, drugs used in ANAESTHESIA and anticancer agents and by RADI
OTHERAPY.
Antigen Whenever the body identifies a substance entering it as foreign
or potentially dangerous, the
immune system (see IMMUNITY) produces an an antibody (see ANTIBODIES) to combat
it. Antigens are normally
proteins, but simple substances for instance, metals may become antigenic by com
bining with and
changing the
Antiperistalsis 47
bodys own proteins. Such a product is called a hapten.
Antihelminthic See ANTHELMINTICS.
Antihistamine Drugs Antihistamine drugs antagonise the action of HISTAMI
NE and are therefore of value
in the treatment of certain allergic conditions (see ALLERGY). They may be divid
ed into those with a
central action (e.g. flupheniramine and cyclizine) and those such as loratidine
and terfenadine with almost
no central action. Antihistamines are also of some value in the treatment of vas
omotor RHINITIS (see also
under NOSE, DISORDERS OF); they reduce rhinorrhoea and sneezing but are usually
less effective in relieving
nasal congestion. All antihistamines are useful in the treatment of URTICARIA an
d certain allergic skin
rashes, insect bites and stings, as well as in the treatment of drug allergies.
Chlorpheniramine or
promethazine injections are useful in the emergency treatment of angio-oedema (s
ee under URTICARIA) and
ANAPHYLAXIS.
There is little evidence that any one antihistamine is superior to anoth
er, and patients vary
considerably in their response to them. The antihistamines differ in their durat
ion of action and in the
incidence of side-effects such as drowsiness. Most are short-acting, but some (s
uch as promethazine) work
for up to 12 hours. They all cause sedation but promethazine, trimeprazine and d
imenhydrinate tend to be
more sedating while chlorpheniramine and cyclizine are less so, as are astemizol
e, oxatomide and
terfenadine. Patients should be warned that their ability to drive or operate ma
chinery may be impaired
when taking these drugs, and that the effects of ALCOHOL may be increased.
Antihypertensive Drugs A group of drugs used to treat high blood pressur
e (HYPERTENSION). Untreated
hypertension leads to STROKE, heart attacks and heart failure. The high incidenc
e of hypertension in
western countries has led to intensive research to discover antihypertensive dru
gs, and many have been
marketed. The drugs may work by reducing the power of the heartbeat, by dilating
the blood vessels or by
increasing the excretion of salts and water in the urine (diuresis). Antihyperte
nsive treatment has greatly
improved the prognosis of patients with high blood pressure by cutting the frequ
ency of heart and renal
failure (see KIDNEYS, DISEASES OF), stroke, and
coronary thrombosis (see HEART, DISEASES OF). Drugs used for treatment c
an be classified as follows:
diuretics; vasodilator antihypertensives; centrally acting antihypertensives; ad
renergic neurone-blocking
drugs; alpha-adrenoreceptorblocking drugs; drugs affecting the reninangiotensin
system; ganglion-blocking
drugs; and tyrosine hydroxylase inhibitors. The drugs prescribed depend on many
factors, including the type
48 Antipsychotic Drugs
A
upwards, instead of in the proper direction. (See PERISTALSIS.)
Antipsychotic Drugs See NEUROLEPTICS.
Antipyretics Measures used to reduce temperature in FEVER. Varieties inc
lude cold-sponging, wet-packs,
baths and diaphoretic (sweat-reducing) drugs such as QUININE, salicylates and AS
PIRIN.
Antiseptics Antiseptics prevent the growth of diseasecausing micro-organ
isms without damaging living
tissues. Among chemicals used are boric acid, carbolic acid, hydrogen peroxide a
nd products based on coal
tar, such as cresol. Chlorhexidines, iodine, formaldehyde, flavines, alcohol and
hexachlorophane are also
used. Antiseptics are applied to prevent infection for example, in preparing the
skin before operation.
They are also used externally to treat infected wounds.
Antispasmodics These are antimuscarinic drugs (see ANTIMUSwhich have the
property of relaxing smooth
muscle. Along with other antimuscarinic drugs, antispasmodics may be helpful sup
portive treatment for
patients with nonulcer DYSPEPSIA, IRRITABLE BOWEL SYNDROME (IBS) and DIVERTICULA
R DISEASE. Examples of
antispasmodic drugs are ATROPINE sulphate, dicyclomine bromide and propantheline
(a synthetic
antimuscarinic drug used as a treatment adjunct in gastrointestinal disorders an
d also for controlling
urinary frequency), bromide, alverine, mebervine and peppermint oil. With the ar
rival of more powerful and
specific antisecretory drugs, such as the histamine H2-receptor antagonists exam
ples are CIMETIDINE and
RANITIDINE the use of antispasmodics has declined. CARINE)
Antitoxin Any one of various preparations that contain ANTIBODIES which
combine and neutralise the
effects of a particular toxin (see TOXINS) released into the bloodstream by BACT
ERIA. Examples are the
toxins produced by DIPHTHERIA and TETANUS. Antitoxins are produced from the bloo
d of humans or animals that
have been exposed to a particular toxin whether by INFECTION or by INOCULATION a
nd thus have produced
antibodies against it. They are usually given by intramuscular injection.
Antivenom A therapeutic substance used to counteract the toxic action(s)
of a specific animal toxin
(see TOXINS) or venom. They are normally sterilised, proteinaceous globulins (se
e GLOBULIN) extracted from
the SERUM of animals, usually horses, immunised against the specific toxin/ veno
m. Most are given by
intravenous or intramuscular injection and are most effective when given shortly
after the bite or sting
has occurred. Some antivenoms may be effective against the venoms of several clo
sely related animal
species.
Apex 49
during the day. Prescription of these drugs is widespread but physical a
nd psychological DEPENDENCE
occurs as well as TOLERANCE to their effects, especially among those with person
ality disorders or who
abuse drugs and alcohol. This is particularly true of the BARBITURATES which are
now limited in their use,
but also applies to the BENZODIAZEPINES, the most commonly used anxiolytics and
hypnotics. Withdrawal
syndromes may occur if drug treatment is stopped too abruptly; hypnotic sedative
s and anxiolytics should
therefore not be prescribed indiscriminately, but reserved for short courses. Am
ong the anxiolytics are the
widely used benzodiazepines, the rarely used barbiturates, and the occasionally
prescribed drugs such as
BUSPIRONE and beta blockers like OXPRENOLOL (see BETA-ADRENOCEPTORBLOCKING DRUGS
).
Aorta The large vessel which opens out of the left ventricle of the HEAR
T and carries blood to all of
the body. It is about 45 cm (1 feet) long and 25 cm (1 inch) wide. Like other arte
ries it possesses three
coats, of which the middle one is much the thickest. This consists partly of mus
cle fibre, but is mainly
composed of an elastic substance called elastin. The aorta passes first to the r
ight, and lies nearest the
surface behind the end of the second right rib-cartilage; then it curves backwar
ds and to the left, passes
down behind the left lung close to the backbone, and through an opening in the d
iaphragm into the abdomen.
There it divides, at the level of the navel, into the two common iliac arteries,
which carry blood to the
lower limbs. Its branches, in order, are: two coronary arteries to the heart wal
l; the brachiocephalic,
left common carotid, and left subclavian arteries to the head, neck and upper li
mbs; several small branches
to the oesophagus, bronchi, and other organs of the chest; nine pairs of interco
stal arteries which run
around the body between the ribs; one pair of subcostal arteries which is in ser
ies with the intercostal
arteries; four (or five) lumbar arteries to the muscles of the loins; coeliac tr
unk to the stomach, liver
and pancreas; two mesenteric arteries to the bowels; and suprarenal, renal and t
esticular arteries to the
suprarenal body, kidney, and testicle on each side. From the termination of the
aorta rises a small branch,
the median sacral artery, which runs down into the pelvis. In the female the ova
rian arteries replace the
testicular. The chief diseases of the aorta are ATHEROMA
and
ANEURYSM. (See ARTERIES, DISEASES OF; COARCTATION OF THE AORTA.)
Aortic Incompetence See also REGURGITATION. This is the back flow of blo
od through the AORTIC VALVE of
the HEART into the left ventricle, caused by an incompetent valve. The failure t
o close may be caused by a
congenital defect or by damage from disease. The defect may be cured by surgical
50 Apex Beat
Beat A Apex This is the beat of the
Aplasia
of the HEART, which can be felt through the skin to the left of the brea
stbone between the fifth and
sixth ribs. APEX
Apgar Score A method of assessing at birth whether or not a baby require
s resuscitation. The newborn is
routinely assessed at 1 minute of age and again at 5 minutes, and a value of 0,
1 or 2 given to each of
five signs: colour, heart rate, muscle tone, respiratory (or breathing) effort,
and the response to
stimulation. A total score of 7 or more indicates that the newborn child is in e
xcellent condition. An
Apgar score of 5 or less at 15 or 20 minutes predicates an increased risk of sub
sequent CEREBRAL PALSY.
Aphakia Absence of the lens of the EYE.
Aphasia Inability to speak caused by disease in or injury to the cerebra
l cortex in the left half of
the BRAIN (in a right-handed person), affecting the generation and content of sp
eech as well as the
understanding of language; often accompanied by problems with reading and writin
g (see DYSPHASIA).
Comprehension and expression of language occur in two zones of the cerebral cort
ex (the outer layer of the
main part of the brain). They are known as Wernickes area (comprehension) and Bro
cas area (speech
formulation).
The complete or partial failure of tissue or an organ to develop.
Apnoea A general term meaning the cessation of breathing. Apnoea is a me
dical emergency: death soon
follows if breathing is not quickly restored (see APPENDIX 1: BASIC FIRST AID).
Apnoea may be caused by an
obstruction to the airway, for example by the tongue during general ANAESTHESIA,
or by a disturbance of the
mechanisms that control breathing. Rapid heavy breathing reduces the blood level
s of carbon dioxide and can
lead to a brief period of apnoea. Neonatal apnoeic attacks may represent a serio
us emergency, being caused
by prematurity, milk aspiration, heart failure, infection, HYPOXIA, HYPOGLYCAEMI
A or HYPOCALCAEMIA. If
stimulation of the baby does not immediately restore breathing, then bag-and-mas
k ventilation should be
used.
ApoApo- is a prefix implying separation or derivation from.
Apodia Absence of the foot.
Aponeurosis Aponeurosis is the term applied to the white fibrous membran
e which serves as an investment
for the muscles and which covers the skull beneath the scalp.
Aphonia
Apoplexy
Loss of voice, usually sudden. Commonly caused by emotional stress with
no detectable physical
abnormality in the LARYNX. Damage or disease of the larynx usually results in dy
sphonia (partial voice
loss). Where no physical cause can be identified, reassurance and, if the voice
does not quickly return,
PSYCHOTHERAPY are the treatment.
See STROKE.
Aphthous Ulcer Single or multiple (and often recurrent) transiently pain
ful ulcers in the oral mucous
membrane that are usually self-limiting. The cause is unknown and treatment is s
ymptomatic.
Apicectomy Apicectomy is the minor operation carried out to try to save
a tooth which has an ABSCESS on
it or which does not respond to root treatment. In this, the abscess and the APE
X of the tooth are removed.
Apoptosis This is a genetically controlled type of cell death. There is
an orchestrated collapse of a
cell (see CELLS), typified by destruction of the cells membrane; shrinkage of the
cell with condensation
of CHROMATIN; and fragmentation of DNA. The dead cell is then engulfed by adjace
nt cells. This process
occurs without evidence of the inflammation normally associated with a cells dest
ruction by infection or
disease. Apoptosis, first identified in 1972, is involved in biological activiti
es including embryonic
development, ageing and many diseases. Its importance to the bodys many physiolog
ical and pathological
processes has only fairly recently been understood, and research into apoptosis
is proceeding apace. In
adults, around 10 billion cells die each day a figure which balances the number
of cells
Appetite 51
arising from the bodys stem-cell populations (see STEM CELL). Thus, the b
odys normal HOMEOSTASIS is
regulated by apoptosis. As a person ages, apoptopic responses to cell DNA damage
may be less effectively
controlled and so result in more widespread cell destruction, which could be a f
actor in the onset of
degenerative diseases. If, however, apoptopic responses become less sensitive, t
his might contribute to the
uncontrolled multiplication of cells that is typical of cancers. Many diseases a
re now associated with
changed cell survival: AIDS (see AIDS/HIV); ALZHEIMERS DISEASE and PARKINSONISM;
ischaemic damage after
coronary thrombosis (see HEART, DISEASES OF) and STROKE; thyroid diseases (see T
HYROID GLAND, DISEASES OF);
and AUTOIMMUNE DISORDERS. Some cancers, autoimmune disorders and viral infection
s are associated with
reduced or inhibited apoptosis. Anticancer drugs, GAMMA RAYS and ULTRAVIOLET RAY
S (UVR) initiate apoptosis.
Other drugs for example, NONSTEROIDAL (NSAIDS)
ANTI-INFLAMMATORY
DRUGS
alter the process of apoptosis. Research is in train to harness new know
ledge about apoptosis for the
development of new treatments and modifications of existing ones for serious dis
orders such as cancer and
degenerative nervous diseases.
Appendicectomy Appendicectomy, or appendectomy, is the operation for the
removal of the vermiform
appendix in the ABDOMEN (see APPENDICITIS).
Appendicitis This is an inflammatory condition of the APPENDIX, and is a
common surgical emergency,
affecting mainly adolescents and young adults. It is usually due to a combinatio
n of obstruction and
infection of the appendix, and has a variable clinical course ranging from episo
des of mild self-limiting
abdominal pain to life-threatening illness. Abdominal pain beginning in the cent
re of the abdomen but which
later shifts position to the right iliac fossa is the classic symptom. The patie
nt usually has accompanying
fever and sometimes nausea, vomiting, loss of appetite, diarrhoea, or even const
ipation. The precise
symptoms vary with the exact location of the appendix within the abdomen. In som
e individuals the appendix
may grumble with repeated mild attacks which resolve spontaneously. In an acute at
tack, the inflammatory
process begins first in the wall of the appendix but, if the disease progresses,
the appendix can become
secondarily infected and pus may form within it. The blood supply
may become compromised and the wall become gangrenous. Eventually the ap
pendix may rupture, giving rise
to a localised abscess in the abdomen or, more rarely, free pus within the abdom
en which causes generalised
cerebrum.
Apyrexia Absence of FEVER.
Arachnodactyly Arachnodactyly, or MARFANS SYNDROME, is a congenital condi
tion characterised by extreme
length and slenderness of the fingers and toes and, to a lesser extent, of the l
imbs and trunk; laxity of
the ligaments; and dislocation of the lens of the eye. The antero-posterior diam
eter of the skull is
abnormally long, and the jaw is prominent. There may also be abnormalities of th
e heart.
Arachnoid Membrane One of the membranes covering the brain and spinal co
rd (see BRAIN). Arachnoiditis
is the name applied to inflammation of this membrane.
Arboviruses A heterogenous group of around 500 viruses, which are transm
itted to humans by ARTHROPODS.
Grouped in four families, they include the viruses of DENGUE and YELLOW FEVER wh
ich are transmitted by
mosquitoes.
Arc Eye Damage to the corneal surface of the EYE caused by ultraviolet l
ight from arc welding. A
painful condition, it usually heals if the eyes are covered with pads for a day
or two. It can be prevented
by the proper use of protective goggles. A similar condition occurs in snow-blin
dness or when someone fails
to protect the eyes when using suntan lamps.
Arcus Senilis See under EYE, DISORDERS OF.
Arenaviruses A group of viruses, so-called because under the electron mi
croscope they have a
sand-sprinkled (Latin, arenosus) appearance. Among the diseases in humans for wh
ich they are responsible
are LASSA FEVER in West Africa, Argentinian haemorrhagic fever (mortality rate 31
5 per cent), a similar
disease in Bolivia (mortality rate 18 per cent), and lymphocytic choriomeningiti
s, in which deaths are
uncommon.
Arteries 53
Areola Areola literally means a small space, and is the term applied to
the red or dusky ring around
the nipple, or around an inflamed part. Increase in the duskiness of the areola
on the breast is an
important early sign of pregnancy.
Argyll Robertson Pupil A condition (described originally by Dr Argyll Ro
bertson) in which the pupils
contract when the eyes converge on a near object, but fail to contract when a br
ight light falls on the
eye. It is found in several diseases, especially in locomotor ataxia and neurosy
philis, an advanced
manifestation of SYPHILIS.
Argyria Argyria, or argyriosis, means the effect produced by taking silv
er salts over a long period,
and consists of a deep duskiness of the skin, especially of the exposed parts.
Aromatase Inhibitors A group of drugs that stop the action of the ENZYME
, aromatase. This enzyme
converts androgens (see ANDROGEN) to OESTROGENS. If this conversion is inhibited
, the concentrations of
oestrogens in the body are reduced so these drugs operate against tumours, such
as breast cancer, that
depend on oestrogen for their growth. Aromatase inhibitors include anastrazole a
nd formestane, and they are
usually prescribed as second-line treatment after TAMOXIFEN, the prime drug trea
tment for breast cancer.
inhibiting the action of many enzymes (see and also disrupts oxidative p
hosphorylation by substituting
for PHOSPHORUS. Clinical effects of acute poisoning range from severe gastrointe
stinal effects to renal
impairment or failure characterised by OLIGURIA, HAEMATURIA, PROTEINURIA and ren
al tubular necrosis. SHOCK,
COMA and CONVULSIONS are reported, as are JAUNDICE and peripheral NEUROPATHY. Ch
ronic exposures are harder
to diagnose as effects are non-specific: they include gastrointestinal disturban
ces, hyperpigmentation and
HYPERKERATOSIS of skin, localised OEDEMA, ALOPECIA, neuropathy, PARAESTHESIA, HE
PATOMEGALY and jaundice.
Management is largely supportive, particularly ensuring adequate renal function.
Concentrations of arsenic
in urine and blood can be measured and therapy instituted if needed. Several CHE
LATING AGENTS are
effective: these include DMPS (2, 3-dimercapto-1-propanesulphonate), penicillami
ne and dimercaprol; DMPS is
now agent of choice. ENZYME)
Artefact See ARTIFACT.
Arteries
Arrhythmia means any variation from the normal regular rhythm of the hea
rtbeat. The condition is
produced by some affection interfering with the mechanism which controls the bea
ting of the heart, and
includes the following disorders: sinus arrhythmia, atrial fibrillation, atrial
54 Arteries, Diseases of
A
which unite across the palm of the hand in arches that give branches to
the fingers; (3) the two common
iliacs, in which the aorta ends, each of which divides into the internal iliac t
o the organs in the pelvis,
and the external iliac to the lower limb, continued by the femoral in the thigh,
and the popliteal behind
the knee, dividing into the anterior and posterior tibial arteries to the front
and back of the leg. The
latter passes behind the inner ankle to the sole of the foot, where it forms arc
hes similar to those in the
hand, and supplies the foot and toes by plantar branches.
Structure The arteries are highly elastic, dilating at each heartbeat as
blood is driven into them, and
forcing it on by their resiliency (see PULSE). Every artery has three coats: (a)
the outer or adventitia,
consisting of ordinary strong fibrous tissue; (b) the middle or media, consistin
g of muscular fibres
supported by elastic fibres, which in some of the larger arteries form distinct
membranes; and (c) the
inner or intima, consisting of a layer of yellow elastic tissue on whose inner s
urface rests a layer of
smooth plate-like endothelial cells, over which flows the blood. In the larger a
rteries the muscle of the
middle coat is largely replaced by elastic fibres, which render the artery still
more expansile and
elastic. When an artery is cut across, the muscular coat instantly shrinks, draw
ing the cut end within the
fibrous sheath that surrounds the artery, and bunching it up, so that a very sma
ll hole is left to be
closed by blood-clot. (See HAEMORRHAGE.)
Arteries, Diseases of ARTERIES are the blood vessels that convey blood a
way from the heart to the
tissues. The commonest cause of arterial disease is a degenerative condition kno
wn as atherosclerosis. Less
commonly, inflammation of the arteries occurs; this inflammation is known as art
eritis and occurs in a
variety of conditions.
arteries cause limb ischaemia (localised bloodlessness). Risk factors pr
edisposing individuals to
atherosclerosis include age, male gender, raised plasma cholesterol concentratio
n, high blood pressure,
smoking, a family history of atherosclerosis, diabetes and obesity.
Arteritis occurs in a variety of conditions that produce inflammation in
the arteries. Examples include
syphilis now rare in Britain which produces inflammation of the aorta with subse
quent dilatation
(aneurysm formation) and risk of rupture; giant cell arteritis (temporal arterit
is), a condition usually
affecting the elderly, which involves the cranial arteries and leads to headache
, tenderness over the
temporal arteries and the risk of sudden blindness; Takayasus syndrome, predomina
ntly affecting young
females, which involves the aortic arch and its major branches, leading to the a
bsence of pulse in affected
vessels; and polyarteritis nodosa, a condition causing multiple small nodules to
form on the smaller
arteries. General symptoms such as fever, malaise, weakness, anorexia and weight
loss are accompanied by
local manifestations of ischaemia (bloodlessness) in different parts of the body
.
Arteriography See ANGIOGRAPHY.
Arteriole A small artery (see ARTERIES).
Arterio-Venous Aneurysm An abnormal communication between an artery and
a vein. It is usually the
result of an injury, such as a stab or a gunshot wound, which involves both a ne
ighbouring artery and vein.
Arteritis Arteritis means inflammation of an artery (see ARTERIES, DISEA
SES OF).
Atherosclerosis is due to the deposition of
Arthralgia
into the walls of arteries. The process starts in childhood with the dev
elopment of fatty streaks
lining the arteries. In adulthood these progress, scarring and calcifying to for
m irregular narrowings
within the arteries and eventually leading to blockage of the vessel. The conseq
uence of the narrowing or
blockage depends on which vessels are involved diseased cerebral vessels cause s
trokes; coronary vessels
cause angina and heart attacks; renal vessels cause renal failure; and periphera
l
Pain in a joint in which there is no swelling or other indication of ART
HRITIS.
CHOLESTEROL
Arthritis Arthritis refers to any condition of joints of the limbs or sp
ine associated with
inflammatory or structural change. It is distinguished from ARTHRALGIA which sim
ply implies joint pain with
or without any inflammatory or structural change. The two main categories of art
hritis are osteoarthritis,
in which the primary change is
Artifact (Artefact) 55
thought of as mechanical failure of articular cartilage; and rheumatoid
arthritis, in which the primary
problem is a chronic inflammation of the synovial lining of joints, tendon sheat
hs and bursae. Other, less
common forms of inflammatory arthritis include psoriatic arthritis, Reiters syndr
ome, colitic arthritis
and Behets syndrome. Spondarthritis refers to an inflammatory arthritis with invol
vement of the spine and
is often associated with the HLA B27 tissue type. (See OSTEOARTHRITIS; RHEUMATOI
D ARTHRITIS; RHEUMATIC
FEVER.)
Arthrodesis An operation for fixating the bones in a diseased joint in a
given position so that the
joint cannot be moved. It is usually done if pain and deformity in a diseased jo
int caused, for instance,
by RHEUMATOID ARTHRITIS are so bad that they cannot be relieved by drugs, PHYSIO
THERAPY, splinting or
ARTHROPLASTY.
Arthropathy
organisms, such as scorpions, mites, ticks, spiders and centipedes (see
also ARBOVIRUSES).
Arthroscope An endoscopic instrument (see ENDOSCOPE) that enables the op
erator to see inside a joint
cavity and, if necessary, take a biopsy or carry out an operation.
Arthroscopy Inspection of the interior of a joint (usually the knee) to
diagnose any disorder there.
The instrument used is a type of ENDOSCOPE called an ARTHROSCOPE. The knee is of
ten affected by conditions
that are not easy to diagnose and are not revealed by X-ray examination. Surgery
can be performed using
arthroscopy and this reduces the time a patient has to be in hospital.
Arthrotomy Surgical exploration of a joint to examine the contents or to
drain PUS in SEPTIC ARTHRITIS.
A term applied to any form of joint disease.
Articular
Arthroplasty
Articular means anything connected with a joint: for example, articular
rheumatism.
The use of metal or plastic components to replace a joint or part of a j
oint. Arthroplasty was first
used in the 1930s to replace diseased hip-joints and has been routinely used sin
ce the 1960s, enabling
thousands of people, especially the older generation, to resume normal life free
from pain and disability.
Replacement of other joints for instance, knees, fingers, shoulders and elbows h
as now become routine.
(See JOINTS, DISEASES OF and diagram.)
56 Artificial Insemination
Insemination A Artificial In this method of fertilisation, SEMEN is coll
ected either by the husband
(AIH) or by a donor (AID) through masturbation and introduced into the cervix (n
eck of the womb) by means
of an instrument around the time of OVULATION.
AIH is thought to be particularly useful for men with retrograde ejacula
tion or erectile IMPOTENCE. AID
may be considered when the partners sperm count is either very low or zero. Insem
ination can be made with
fresh or frozen semen. Donors should be tested for sexually transmitted diseases
and their identity remain
unknown to the infertile couple. The pregnancy rate over six months is 5060 per c
ent. Artificial
insemination is usually done at specially staffed centres with facilities to sto
re semen and provide the
individuals involved with appropriate counselling. Success rates are up to 70 pe
r cent with fresh semen
(used over a six-month period) and over 50 per cent with frozen semen.
Artificial Intelligence (AI) The design and study of computer systems th
at have properties resembling
human intelligence, such as natural language, problem-solving, and analysis of n
ovel situations.
Artificial Joints See ARTHROPLASTY.
Artificial Kidney See DIALYSIS.
Artificial Limbs and Other Parts See PROSTHESIS.
Artificial Respiration See APPENDIX 1: BASIC FIRST AID.
Artificial Ventilation of the Lungs When we breathe in, the outward move
ment of the chest increases the
volume of the lungs and the pressure in them falls below that of the outside wor
ld. Therefore, air is drawn
in automatically. When we breathe out, some air exits because of the normal elas
tic recoil of the lungs,
but we also force air out by using the muscles of the chest and the DIAPHRAGM. R
eplicating this
artificially involves using a device to produce intermittent positive or negativ
e pressure ventilation as
described below.
Intermittent positive pressure (IPP) The simplest form of intermittent p
ositivepressure ventilation is mouth-to-mouth resuscitation (see APPENDIX 1: BA
SIC FIRST AID) where an
individual blows his or her own expired gases into the lungs of a non-breathing
person via the mouth or
nose. Similarly gas may be blown into the lungs via a face mask (or down an endo
tracheal tube) and a
self-inflating bag or an anaesthetic circuit containing a bag which is inflated
by the flow of fresh gas
from an anaesthetic machine, gas cylinder, or piped supply. In all these example
s expiration is passive.
Ascites 57
Artificial ventilation is not without its hazards. The use of positive p
ressure raises the mean
intrathoracic pressure. This can decrease venous return to the heart and cause a
fall in CARDIAC OUTPUT and
blood pressure. Positivepressure ventilation may also cause PNEUMOTHORAX, but th
is is rare. While patients
are ventilated, they are unable to breathe and so accidental disconnection from
the ventilator may cause
HYPOXIA and death.
Negative-pressure ventilation is seldom used nowadays. The chest or whol
e body, apart from the head, is
placed inside an airtight box. A vacuum lowers the pressure within the box, caus
ing the chest to expand.
Air is drawn into the lungs through the mouth and nose. At the end of inspiratio
n the vacuum is stopped,
the pressure in the box returns to atmospheric, and the patient exhales passivel
y. This is the principle of
the iron lung which saved many lives during the polio epidemics of the 1950s. Thes
e machines are
cumbersome and make access to the patient difficult. In addition, complex manipu
lation of ventilation is
impossible.
Jet ventilation is a relatively modern form of ventilation which utilise
s very small tidal volumes (see
LUNGS) from a high-pressure source at high frequencies (20200/min). First develop
ed by physiologists to
produce low stable intrathoracic pressures whilst studying CAROTID BODY reflexes
, it is sometimes now used
in intensive-therapy units for patients who do not achieve adequate gas exchange
with conventional
ventilation. Its advantages are lower intrathoracic pressures (and therefore les
s risk of pneumothorax and
impaired venous return) and better gas mixing within the lungs.
scribed. About 900 people a year in the UK claim compensation, and 600 o
f these for mesothelioma; most
patients with asbestosis now being diagnosed have it as a consequence of industr
ial practices used before
1970. The use of asbestos is now strictly controlled and, when blue asbestos is
found in old buildings,
skilled workmen are employed to dispose of it.
Ascariasis Ascariasis is the disease produced by infestation with the ro
undworm Ascaris lumbricoides,
also known as the maw-worm. Superficially it resembles a large earthworm: the ma
le measures about 17 cm (7
inches) and the female 23 cm (9 inches) in length. Ascariasis is a dirt disease,
most prevalent where
sanitation and cleanliness are lacking, particularly in the tropics and subtropi
cs. Consumption of food
contaminated by the ova (eggs), especially salad vegetables, is the commonest ca
use of infection. In
children, infection is commonly acquired by crawling or playing on contaminated
earth, and then sucking
their fingers. After a complicated life-cycle in the body the adult worms end up
in the intestines, whence
they may be passed in the stools. A light infection may cause no symptoms. A hea
vy infection may lead to
colic, or even obstruction of the gut. Occasionally a worm may wander into the s
tomach and be vomited up.
Treatment Mebendazole is the drug of choice in the UK, being given as a
single dose. It should be
combined with hygienic measures to break the cycle of autoinfection. All members
of the family require
treatment. Other ANTHELMINTICS include piperazine and pyrantel.
Arytenoid
Ascaricides
The name applied to two cartilages in the
Drugs used to treat ASCARIASIS, a disease caused by an infestation with
the parasitic worm Ascaris
lumbricoides. LEVAMISOLE, MEBENDAZOLE and PIPERAZINE are all effective against t
his parasite.
LARYNX.
Asbestosis A form of PNEUMOCONIOSIS, in which widespread fine scarring o
ccurs in the LUNGS, leading to
severe breathing disability. The main hazard, however, is the risk of cancer (ME
SOTHELIOMA) of the lung or
PLEURA, or sometimes of the ovary (see OVARIES). It is caused by the inhalation
of mainly blue or brown
asbestos dust, either during mining or quarrying, or in one of the many industri
es in which it is used
for example, as an insulating material, in the making of paper, cardboard and br
ake linings. A person
suffering from asbestosis is entitled to compensation, as the disease is legally
proAscaris A worldwide genus of parasitic nematode worms (see ASCARIASIS).
Ascites An accumulation of fluid in the abdomen. The causes include hear
t failure, CANCER, cirrhosis of
the liver (see under LIVER, DISEASES OF), and infections. Treatment is directed
at the underlying cause(s);
if the amount of fluid is causing discomfort, it should be drained off.
A
58 Ascorbic Acid
Acid A Ascorbic Ascorbic acid, or vitamin C (see
APPENDIX 5:
VITAMINS),
is a simple sugar found in living tissues its highest concentrations bei
ng in the adrenal cortex (see
ADRENAL GLANDS) and the eye. Stress and CORTICOTROPIN lead to a loss of ascorbic
acid from the adrenal
cortex. Fresh fruit and vegetables, particularly blackcurrants, citrus fruits, b
erries and green
vegetables, are the richest dietary sources; it may also be synthetically prepar
ed. Ascorbic acid is easily
eliminated from the diet by traditional methods of cooking, being very soluble i
n water and easily
destroyed by heat, alkalis, traces of copper or by an oxidase released by damage
to plant tissues.
Deficiency may lead to SCURVY, traditionally associated with sailors, among elde
rly people living alone or
in poor communities living at subsistence level. It has been claimed that large
doses (12 g daily) will
prevent the common cold, but few large controlled trials have been carried out a
nd it is inadvisable for
people to dose themselves with large quantities of ascorbic acid, which may resu
lt in the formation of
oxalate stones in the urinary tract. (See also VITAMIN.)
Asepsis A technique to produce a germ-free environment to protect patien
ts from infection. It is used
for any procedure that might introduce infection into the body and is essential
for all surgery even
minor procedures. Asepsis is achieved by ensuring that all people who come into
contact with the patient
scrub their hands and wear sterilised gowns with disposable masks and gloves. Op
erating-theatre air and
equipment must also be clean. An aseptic technique is also necessary when caring
for patients whose immune
system (see IMMUNITY) is suppressed: one example is LEUKAEMIA, the treatment of
which affects the immune
system. Asepsis is aimed at preventing infection; antisepsis is the use of chemi
cals to destroy germs
already on the body or in a wound (see ANTISEPTICS).
ASH ASH, or Action on Smoking and Health, is a charity founded by the Ro
yal College of Physicians in
1971 and supported by the Department of Health. It gathers information about the
dangers of smoking, which
it disseminates to the public. It also commissions surveys on public attitudes t
o smoking and helps people
to give up the habit. ASH has contributed substantially to the cut in the number
of smokers: six out of ten
adults are now non-smokers, and
an increasing number of public places are becoming smoke-free. The chari
ty has a small headquarters in
London from which further information may be obtained, with other national and r
egional branches in
Aspirin Poisoning
Asphyxia Asphyxia means literally absence of pulse, but is the name give
n to the whole series of
symptoms which follow stoppage of breathing and of the hearts action. Drowning is
one cause, but
obstruction of the AIR PASSAGES may occur as the result of a foreign body or in
some diseases, such as
CROUP, DIPHTHERIA, swelling of the throat due to wounds or inflammation, ASTHMA
(to a partial extent),
tumours in the chest (causing slow asphyxia), and the external conditions of suf
focation and strangling.
Placing the head in a plastic bag results in asphyxia, and poisonous gases also
cause asphyxia: for
example, CARBON MONOXIDE (CO) gas, which may be given off by a stove or charcoal
brazier in a badly
ventilated room, can kill people during sleep. Several gases, such as sulphurous
acid (from burning
sulphur), ammonia, and chlorine (from bleachingpowder), cause involuntary closur
e of the entrance to the
larynx, and thus prevent breathing. Other gases, such as nitrous oxide (or laugh
ing-gas), chloroform, and
ether, in poisonous quantity, stop the breathing by paralysing the respiration c
entre in the brain.
Symptoms In most cases, death from asphyxia is due to insufficiency of o
xygen supplied to the blood.
The first signs are rapid pulse and gasping for breath. Next comes a rise in the
blood pressure, causing
throbbing in the head, with lividity or blueness of the skin, due to failure of
aeration of the blood,
followed by still greater struggles for breath and by general CONVULSIONS. The h
eart becomes overdistended
and gradually weaker, a paralytic stage sets in, and all struggling and breathin
g slowly cease. When
asphyxia is due to charcoal fumes, coal-gas, and other narcotic influences, ther
e is no convulsive stage,
and death ensues gently and may occur in the course of sleep.
Treatment So long as the heart continues to beat, recovery may be looked
for with prompt treatment. The
one essential of treatment is to get the impure blood aerated by artificial resp
iration. Besides this, the
feeble circulation can be helped by various methods. (See APPENDIX 1: BASIC FIRS
T AID Choking;
Cardiac/respiratory arrest.) Aspiration Aspiration means the withdrawal of fluid
or gases from the natural
cavities of the body or from cavities produced by disease. It may be performed f
or curative purposes;
alternatively, a
59
small amount of fluid may be drawn off for diagnosis of its nature or or
igin. An instrument called an
aspirator is used to remove blood and fluid from a surgical-operation site for e
xample, the abdomen or
the mouth (in dentistry). PLEURISY with effusion is a condition requiring aspira
tion, and a litre or more
of fluid may be drawn off by an aspirator or a large syringe and needle. Chronic
60 Assisted Conception
Conception A Assisted (Further information about the subject and the ter
ms used can be found at http://
www.hfea.gov.uk/glossary) This technique is used when normal methods of attempte
d CONCEPTION or ARTIFICIAL
INSEMINATION with healthy SEMEN have failed. In the UK, assisted-conception proc
edures are governed by the
Human Fertilisation & Embryology Act 1990, which set up the Human Fertilisation
& Embryology Authority
(HFEA).
Human Fertilisation & Embryology Act 1990 UK legislation was prompted by
the report on in vitro
fertilisation produced by a government-appointed committee chaired by Baroness W
arnock. This followed the
birth, in 1978, of the first test-tube baby. This Act allows regulation monitoring
of all treatment
centres to ensure that they carry out treatment and research responsibly. It cov
ers any fertilisation that
uses donated eggs or sperm (called gametes) for example, donor insemination or e
mbryos (see EMBRYO) grown
outside the human body (known as licensed treatment). The Act also covers resear
ch on human embryos with
especial emphasis on foolproof labelling and immaculate data collection.
Human Fertilisation & Embryology Authority (HFEA) Set up by the UK gover
nment following the Warnock
report, the Authoritys 221 members inspect and license centres carrying out ferti
lisation treatments using
donated eggs and sperm. It publishes a code of practice advising centres on how
to conduct their activities
and maintains a register of information on donors, patients and all treatments.
It also reviews routinely
progress and research in fertility treatment and the attempted development of hu
man CLONING. Cloning to
produce viable embryos (reproductive cloning) is forbidden, but limited licensin
g of the technique is
allowed in specialist centres to enable them to produce cells for medical treatm
ent (therapeutic cloning).
In vitro fertilisation (IVF) In this technique, the female partner recei
ves drugs to enhance OVULATION.
Just before the eggs are released from the ovary (see OVARIES), several ripe egg
s are collected under
ULTRASOUND guidance or through a LAPAROSCOPE. The eggs are incubated with the pr
epared sperm. About 40
hours later, once the eggs are fertilised, two eggs (three in special circumstan
ces) are transferred into
the mothers UTERUS via the cervix
(neck of the womb). Pregnancy should then proceed normally. About one in
five IVF pregnancies results
in the birth of a child. The success rate is lower in women over 40.
Indications In women with severely damaged FALLOPIAN TUBES, IVF offers t
he only chance of pregnancy.
The method is also used in couples with unexplained infertility or with male-fac
tor infertility (where
sperms are abnormal or their count low). Women who have had an early or surgical
Asthma 61
Asthenia A traditional term meaning lack of strength.
Asthenopia Asthenopia means a sense of weakness in the eyes, coming on w
hen they are used. As a rule it
is due to long-sightedness, slight inflammation, or weakness of the muscles that
move the eyes. (See
VISION.)
Asthma Asthma is a common disorder of breathing characterised by widespr
ead narrowing of smaller
airways within the lung. In the UK the prevalence among children in the 512 age g
roup is around 10 per
cent, with up to twice the number of boys affected as girls. Among adults, howev
er, the sex incidence
becomes about equal. The main symptom is shortness of breath. A major feature of
asthma is the
reversibility of the airway-narrowing and, consequently, of the breathlessness.
This variability in the
obstruction may occur spontaneously or in response to treatment.
Cause Asthma runs in families, so that parents with asthma have a strong
risk of having children with
asthma, or with other atopic (see ATOPY) illnesses such as HAY FEVER or eczema (
see DERMATITIS). There is
therefore a great deal of interest in the genetic basis of the condition. Severa
l GENES seem to be
associated with the condition of atopy, in which subjects have a predisposition
to form ANTIBODIES of the
IgE class against allergens (see ALLERGEN) they encounter especially inhaled all
ergens. The allergic
response in the lining of the airway leads to an inflammatory reaction. Many cel
ls are involved in this
inflammatory process, including lymphocytes, eosinophils, neutrophils and mast c
ells. The cells are
attracted and controlled by a complex system of inflammatory mediators. The infl
amed airway-wall produced
in this process is then sensitive to further allergic stimuli or to non-specific
challenges such as dust,
smoke or drying from the increased respiration during exercise. Recognition of t
his inflammation has
concentrated attention on anti-inflammatory aspects of treatment. Continued infl
ammation with poor control
of asthma can result in permanent damage to the airway-wall such that reversibil
ity is reduced and
airway-narrowing becomes permanent. Appropriate anti-inflammatory therapy may he
lp to prevent this damage.
Many allergens can be important triggers of asthma. House-dust mite, grass polle
n and
animal dander are the commonest problems. Occupational factors such as g
rain dusts, hardmetals fumes
and chemicals in the plastic and paint industry are important in some adults. Vi
ral infections are another
common trigger, especially in young children. The prevalence of asthma appears t
o be on the increase in
most countries. Several factors have been linked to this increase; most importan
t may be the vulnerability
of the immature immune system (see IMMUNITY) in infants. High exposure to allerg
62 Astigmatism
characterised by obstruction of the airflow
A persisting over several months.
Treatment The first important consideration in the treatment of asthma i
s avoidance of precipitating
factors. When this is a specific animal or occupational exposure, this may be po
ssible; it is however more
difficult for house-dust mite or pollens. Exercise-induced asthma should be trea
ted adequately rather than
avoiding exercise. Desensitisation injections using small quantities of specific
allergens are used widely
in some countries, but rarely in the UK as they are considered to have limited v
alue since most asthma is
precipitated by many stimuli and controlled adequately with simple treatment. Th
ere are two groups of main
drugs for the treatment of asthma. The first are the bronchodilators which relax
the smooth muscle in the
wall of the airways, increase their diameter and relieve breathlessness. The mos
t useful agents are the
beta adrenergic agonists (see ADRENERGIC RECEPTORS) such as salbutamol and terbu
taline. They are best given
by inhalation into the airways since this reduces the general sideeffects from o
ral use. These drugs are
usually given to reverse airway-narrowing or to prevent its onset on exercise. H
owever, longer-acting
inhaled beta agonists such as salmeterol and formoterol or the theophyllines giv
en in tablet form can be
used regularly as prevention. The beta agonists can cause TREMOR and PALPITATION
in some patients. The
second group of drugs are the antiinflammatory agents that act to reduce inflamm
ation of the airway. The
main agents in this group are the CORTICOSTEROIDS. They must be taken regularly,
even when symptoms are
absent. Given by inhalation they have few sideeffects. In acute attacks, short c
ourses of oral steroids are
used; in very severe disease regular oral steroids may be needed. Other drugs ha
ve a role in suppressing
inflammation: sodium cromoglycate has been available for some years and is gener
ally less effective than
inhaled steroids. Newer agents directed at specific steps in the inflammatory pa
thway, such as leukotriene
receptor-antagonists, are alternative agents. Treatment guidelines have been pro
duced by various national
and international bodies, such as the British Thoracic Society. Most have set ou
t treatment in steps
according to severity, with objectives for asthma control based on symptoms and
peak flow. Patients should
have a management plan that sets out their regular treatment and their appropria
te response to changes in
their condition.
Advice and support for research into asthma is provided by the National
Asthma Campaign. See
www.brit-thoracic.org.uk
Prognosis Asthma is diagnosed in 1520 per cent of all pre-school children
in the developed world. Yet
by the age of 15 it is estimated that fewer than 5 per cent still have symptoms.
A study in 2003 reported
on a follow-up of persons born in 19723 who developed asthma and still had proble
ms at the age of nine. By
the time these persons were aged 26, 27 per cent were still having problems; aro
und half of that number had
never been free from the illness and the other half had apparently lost it for a
few years but it had
returned.
Astigmatism An error of refraction in the EYE due to the cornea (the cle
ar membrane in front of the
eye) being unequally curved in different directions, so that rays of light in di
fferent meridians cannot be
brought to a focus together on the retina. The curvature, instead of being globu
lar, is eggshaped, longer
in one axis than the other. The condition causes objects to seem distorted and o
ut of place, a ball for
instance looking like an egg, a circle like an ellipse. The condition is remedie
d by suitable spectacles of
which one surface forms part of a cylinder. A hard contact lens may be fitted to
achieve an evenly curved
surface. Astigmatism may be caused by any disease that affects the shape of the
cornea for example, a
meibomian cyst (a swollen sebaceous gland in the eyelid) may press on the cornea
and distort it.
Astroviruses Small round viruses (see VIRUS) with no distinctive feature
s, which have been isolated
from the stools of infants with gastroenteritis (see DIARRHOEA). Most adults hav
e antibodies against these
viruses; this suggests that infection is common. There is no treatment.
Asymptomatic The lack of any symptoms of disease, whether or not a disea
se is present.
Asynergia The absence of harmonious and coordinated movements between mu
scles having opposite actions
for example, the flexors and extensors of a joint. Asynergia is a sign of diseas
e of the nervous system.
Asystole Arrest of the action of the heart.
At-Risk Register 63
Atavism
Athrombia
The principle of inheritance of disease or bodily characters from grandp
arents or remoter ancestors,
the parents not having been affected by these.
An inherited disorder in which there is a defect of blood-clotting cause
d by a deficiency in the
formation of thrombin (see COAGULATION).
Ataxia
The
Loss of coordination, though the power necessary to make the movements i
s still present. Thus an ataxic
person may have a good grip in each hand but be unable to do any fine movements
with the fingers; or, if
the ataxia be in the legs, the person throws these about a great deal in walking
while still being able to
lift the legs and take steps quite well. This is due to a sensory defect or to d
isease of the cerebellum.
(See FRIEDREICHS ATAXIA; LOCOMOTOR ATAXIA.)
Atelectasis Collapse of a part of the lung, or failure of the lung to ex
pand at birth.
Atenolol One
of several BETA-ADRENOCEPTORBLOCKING DRUGS used in the treatment of high
blood pressure, ANGINA and
ARRHYTHMIA. One
of its practical advantages is that only one dose a day need be taken. A
tenolol, being a betablocking
drug, may precipitate ASTHMA an effect that may be dangerous. Among the side-eff
ects are fatigue and
disturbed sleep.
Atheroma Degenerative changes in the inner and middle coats of arteries.
(See ARTERIES, DISEASES OF.)
Atherosclerosis A form of arteriosclerosis, in which there is fatty dege
neration of the middle coat of
the arterial wall. (See ARTERIES, DISEASES OF.)
Athetosis Athetosis is the name for slow, involuntary writhing and repea
ted movements of the face,
tongue, hands and feet, caused by disease of the brain. It is usually a manifest
ation of CEREBRAL PALSY.
Drugs used to treat PARKINSONISM can also cause athetosis.
Athletes Foot A somewhat loose term applied to a skin eruption on the foo
t, usually between the toes.
It is commonly due to RINGWORM, but may be due to other infections or merely exc
essive sweating of the
feet. It usually responds to careful foot hygiene and the use of antifungal powd
er.
Atlas first
cervical
vertebra.
(See
SPINAL
COLUMN.)
Atony Absence of tone or vigour in muscles and other organs.
Atopy Atopy, meaning out of
erised amongst other features
by a familial tendency. It is due
o produce large amounts
of reagin ANTIBODIES which stick to
NTIGEN is inhaled,
HISTAMINE is released from the mast
ASTHMA and HAY FEVER (see
also ALLERGY). It is estimated that
atopy. (See also
DERMATITIS.)
64 Atrium
A Atrium (Plural: atria.) Atrium is the name now given to the two upper
cavities of the HEART. These
used to be known as the auricles of the heart. The term is also applied to the p
art of the ear immediately
internal to the drum of the ear.
Atrophy Atrophy occurs when normal tissue, an organ or even the whole bo
dy wastes because the
constituent cells die. Undernourishment, disease, injury, lack of use or AGEING
may cause atrophy. Muscular
atrophy occurs in certain neurological diseases such as POLIOMYELITIS or MUSCULA
R DYSTROPHY. The ovary (see
OVARIES) atrophies at the MENOPAUSE. (See also MUSCLES, DISORDERS OF.)
Atropine Atropine is the active principle of belladonna, the juice of th
e deadly nightshade. Because of
its action in dilating the pupils, it was at one time used as a cosmetic to give
the eyes a full, lustrous
appearance. Atropine acts by antagonising the action of the PARASYMPATHETIC NERV
OUS SYSTEM. It temporarily
impairs vision by paralysing accommodative power (see ACCOMMODATION). It inhibit
s the action of some of the
nerves in the AUTONOMIC NERVOUS SYSTEM. The drug relaxes smooth muscle. It has t
he effect of checking the
activity of almost all the glands of the body, including the sweat glands of the
SKIN and the SALIVARY
GLANDS in the mouth. It relieves spasm by paralysing nerves in the muscle of the
intestine, bile ducts,
bladder, stomach, etc. It has the power, in moderate doses, of markedly increasi
ng the rate of the
heartbeat, though by very large doses the heart, along with all other muscles, i
s paralysed and stopped.
Uses In eye troubles, atropine drops are used to dilate the pupil for mo
re thorough examination of the
interior of the eye, or to draw the iris away from wounds and ulcers on the cent
re of the eye. They also
soothe the pain caused by light falling on an inflamed eye, and are further used
to paralyse the ciliary
muscle and so prevent accommodative changes in the eye while the eye is being ex
amined with the
OPHTHALMOSCOPE. Given by injection, atropine is used before general ANAESTHESIA
to reduce secretions in the
bronchial tree. The drug can also be used to accelerate the heart rate in BRADYC
ARDIA as a result of
coronary thrombosis.
Atropine Poisoning See ATROPINE; BELLADONNA POISONING.
Attention Deficit Disorder (Hyperactivity Syndrome) A lifelong disorder
characterised by overactive
behaviour, short attention span and poor concentration. It is thought to be caus
ed by a minor abnormality
that affects the part of the brain that allows us to concentrate and focus on ta
sks. Some scientists have
suggested that it may be caused by particular foods, particularly processed food
s containing artificial
additives, and recommend special diets. In some countries, attention deficit dis
order is diagnosed in up to
a tenth of all children; this may reflect differences in paediatric practice and
diagnosis rather than a
real variation in prevalence of the disorder. Behaviour therapy is the main trea
tment. Those children with
very severe symptoms of restlessness, short attention span and disturbed behavio
ur may respond to
additional treatment with methylphenidate (Ritalin ). This is an amphetamine-like
drug that is thought to
stimulate the part of the brain that is not working properly. Use of this drug h
as, however, been
controversial.
Audiogram A graph produced during hearing tests (with an audiometer) tha
t shows the hearing threshold
the minimal audible loudness level for a range of sound frequencies.
Audiometry The testing of hearing.
Auditory Nerve See VESTIBULOCOCHLEAR NERVE.
Aura The peculiar feeling which persons who are subject to epileptic sei
zures (see EPILEPSY) experience
just before the onset of an attack. It may be a sensation of a cold breeze, a pe
culiar smell, a vision of
some animal or person, or an undefinable sense of disgust. An aura gives warning
that a fit is coming and
may enable a place of safety or seclusion to be reached. It may also occur as a
precursor to a MIGRAINE
headache.
Aural Relating to the ear.
Auricle A term applied both to the pinna or flap of the ear, and also to
the ear-shaped tip of the
atrium of the heart.
Auriscope An instrument for examining the ear. The
Autoimmunity 65
source of illumination may be incorporated into the instrument, as in th
e electric auriscope, or it may
be an independent light which is reflected into the ear by means of a forehead m
irror. (See EAR, DISEASES
OF.)
Auscultation The method used by physicians to determine, by listening, t
he condition of certain
internal organs. The ancient physicians appear to have practised a kind of auscu
ltation, by which they were
able to detect the presence of air or fluids in the cavities of the chest and ab
domen. In 1819 the French
physician, Laennec, introduced the method of auscultation by means of the STETHO
SCOPE. Initially a wooden
cylinder, the stethoscope has evolved into a binaural instrument consisting of a
small expanded chest-piece
and two flexible tubes, the ends of which fit into the ears of the observer. Var
ious modifications of the
binaural stethoscope have been introduced. Conditions affecting the lungs can of
ten be recognised by means
of auscultation and the stethoscope. The same is true for the heart, in which di
sease can, by auscultation,
often be identified with striking accuracy. But auscultation is also helpful in
the investigation of
aneurysms (see ANEURYSM) and certain diseases of the OESOPHAGUS and STOMACH. The
stethoscope is also a
valuable aid in the detection of some forms of uterine tumours, especially in th
e diagnosis of pregnancy.
Autism A disorder, thought to be caused by a brain abnormality, that lea
ds to a lifelong inability to
relate in an ordinary way to people and situations. Autism is usually diagnosed
before the age of three. It
is rare, affecting around 20 people in every 10,000, and is three times more com
mon in boys than in girls.
The main features are a profound inability to form social relationships, delayed
speech development, and a
tendency to perform repeated compulsive actions or rituals. There is no cure at
present, but behaviour
therapy can help children to lead more normal lives.
AutoPrefix meaning self.
Autoantibody An antibody (see ANTIBODIES) produced by a persons immune sy
stem (see IMMUNITY) that acts
against the bodys own tissues, resulting in AUTOIMMUNITY.
Autoclave This is a very effective way of ensuring that material (e.g. s
urgical dressings) is
completely sterilised, and that even the most resistant bacteria with which it m
ay be contaminated are
destroyed. Its use is based upon the fact that water boils when its vapour press
ure is equal to the
pressure of the surrounding atmosphere. This means that if the pressure inside a
closed vessel is
increased, the temperature at which water inside the vessel boils will rise abov
e 100 degrees centigrade.
By adjusting the pressure, almost any temperature for the boiling of the water w
ill be obtained.
Autogenous Autogenous means self-generated and is the term applied to pr
oducts which arise within the
body. It is applied to bacterial vaccines manufactured from the organisms found
in discharges from the body
and used for the treatment of the person from whom the bacteria were derived.
Autoimmune Disorders A collection of conditions in which the bodys immune
system (see IMMUNITY)
attacks its own tissues, identifying them as foreign substances. Genetic factors
may play a part in this
abnormal function, but the causes are not clear. The disorder may affect one org
an (organspecific) or type
of cell, or several (non-organspecific). Among the autoimmune disorders are ADDI
SONS DISEASE; autoimmune
haemolytic anaemia and pernicious anaemia (see under ANAEMIA); autoimmune chroni
c active HEPATITIS;
DIABETES MELLITUS; MYASTHENIA GRAVIS; RHEUMATOID ARTHRITIS; and SYSTEMIC LUPUS E
RYTHEMATOSUS (SLE).
Treatment Any major deficiencies, such as thyroxin or insulin lack, shou
ld be corrected. The activity
of the immune system should then be reduced. CORTICOSTEROIDS and, in more severe
cases, strong
immunosuppressant drugs AZATHIOPRINE, CYCLOPHOSPHAMIDE or METHOTREXATE should be
administered.
Treatment is difficult because of the need to control the autoimmune condition w
ithout damaging the bodys
ability to combat other diseases.
Autoimmunity Autoimmunity is a reaction to an individuals own tissues (se
lf-antigens see ANTIGEN) to
which tolerance has been lost (see IMMUNITY). Autoantibodies are not necessarily
harmful and are commonly
encountered in healthy persons.
A
66 Autointoxication
Autoimmune disease ensues when the immune
A system attacks the target cells of the autoimmune reaction.
Autointoxication Literally means self-poisoning. Any condition of poisonin
g brought about by
substances formed in or by the body.
ation of the internal organs of a dead body. (See NECROPSY.)
Autosomal Dominant Gene See under GENETIC DISORDERS.
Auto-Suggestion
The disintegration and softening of dead cells brought about by enzymes
(see ENZYME) in the cells
themselves.
A self-induced receptive, hypnotic state which is believed to improve th
e bodys ability to help
itself. Doctors have long realised that if they suggested to a patient that a pa
rticular treatment would
work, it often did a type of placebo effect. Some techniques now make use of thi
s idea. For instance,
people can be taught muscular relaxation to control their anxiety states the BIO
FEEDBACK principle.
Automatism
Avascular
The performance of acts without conscious will, as, for example, after a
n attack of epilepsy or
concussion of the brain. In such conditions the person may perform acts of which
he or she is neither
conscious at the time nor has any memory afterwards. It is especially liable to
occur when persons
suffering from epilepsy, mental subnormality, or concussion consume alcoholic li
quors. It may also occur
following the taking of barbiturates or PSYCHEDELIC DRUGS. There are, however, o
ther cases in which there
are no such precipitatory factors. Thus it may occur following hypnosis, mental
stress or strain, or
conditions such as FUGUE or somnambulism (see SLEEP). The condition is of consid
erable importance from a
legal point of view, because acts done in this state, and for which the person c
ommitting them is not
responsible, may be of a criminal nature. According to English law, however, it
entails complete loss of
consciousness, and only then is it a defence to an action for negligence. A less
er impairment of
consciousness is no defence.
Without a blood supply. Avascular necrosis is the death of a tissue beca
use the blood supply has been
cut off.
Autologous Blood Transfusion See TRANSFUSION
Transfusion of blood.
Autolysis
Autonomic Nervous System Part of the nervous system which regulates the
bodily functions that are not
under conscious control: these include the heartbeat, intestinal movements, sali
vation, sweating, etc. The
autonomic nervous system consists of two main divisions the SYMPATHETIC NERVOUS
SYSTEM and the
PARASYMPATHETIC NERVOUS SYSTEM. The smooth muscles, heart and most glands are co
nnected to nerve fibres
from both systems and their proper functioning depends on the balance between th
ese two. (See also NERVES;
NERVOUS SYSTEM.)
Autopsy A POST-MORTEM EXAMINATION, or the examinAversion Therapy A form of psychological treatment in which such an unpl
easant response is induced to
his or her psychological aberration that the patient decides to give it up. Thus
the victim of alcoholism
is given a drug that makes the subsequent drinking of alcoholic liquors so unple
asant, by inducing nausea
and vomiting, that he or she decides to give up drinking. (See ALCOHOL; DISULFIR
AM.) Aversion therapy may
help in the treatment of alcoholism, drug addiction, sexual deviations such as t
ransvestism, and compulsive
gambling.
Avitaminosis The condition of a human being or an animal deprived of one
or more vitamins (see
VITAMIN).
Avulsion Forcible tearing away of one tissue from another. For example,
a tendon may be avulsed from
the bone to which it is attached, or a nerve may be injured and torn away avulse
d from the tissue in
which it runs.
Axilla Anatomical name for the armpit.
Axis The name applied to the second cervical vertebra. (See SPINAL COLUM
N.)
Axon Nerve fibre: an elongated projection of a nerve cell or NEURON(E) t
hat carries an electrical
impulse to the tissue at the end of the axon.
Azotaemia 67
A
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 insulating myelin which is interr
upted at intervals by nodes of
Lanvier, where other axons branch out. An axon may be more than a metre long. It
ends by branching into
several filaments called telodendria, and these are in contact with muscle or gl
and membranes and other
nerves (see NERVE).
Azathioprine A CYTOTOXIC and an immunosuppressive drug (see IMMUNOSUPPRE
SSION). In the first of these
capacities it is proving to be of value in the treatment of acute leukaemia. As
an immunosuppressive agent
it reduces the antibody response of the body (see ANTIBODIES), and is thereby he
lping to facilitate the
success
of transplant operations (see TRANSPLANTAby reducing the chances of the
transplanted organ (e.g. the
kidney) being rejected by the body. Azathioprine is also proving to be of value
in the treatment of
AUTOIMMUNE TION)
DISORDERS.
Azoospermia The condition characterised by lack of spermatozoa (see SPER
MATOZOON) in the SEMEN.
Azotaemia Azotaemia means the presence of UREA and other nitrogenous bod
ies in greater concentration
than normal in the blood. The condition is generally associated with advanced ty
pes of kidney disease (see
KIDNEYS, DISEASES OF).
B Babinski Reflex
When a sharp body is drawn along the sole of the foot, instead of the to
es bending down towards the
sole as usual, the great toe is turned upwards and the other toes tend to spread
apart. After the age of
about two years, the presence of this reflex indicates some severe disturbance i
n the upper part of the
central nervous system. The Babinski reflex may occur transiently during COMA or
after an epileptic fit and
need not indicate permanent damage.
Bacillus This is a big group (genus) of gram-positive (see GRAMS STAIN) r
od-like BACTERIA. Found
widely in the air and soil commonly as spores they feed on dead organic matter.
As well as infecting
and spoiling food, some are pathogenic to humans, causing, for example, ANTHRAX,
conjunctivitis (see EYE,
DISORDERS OF) and DYSENTERY. They are also the source of some antibiotics (See u
nder MICROBIOLOGY.)
Bacitracin A polypeptide antibiotic, with a spectrum similar to penicill
in. It is not absorbed if taken
orally but is valuable topically as an ointment in conjunction with neomycin or
polymyxin.
Backache Most people suffer from backache at times during their lives, m
uch of which has no
identifiable cause non-specific back pain. This diagnosis is one of the biggest
single causes of sickness
absence in the UKs working population. Certain occupations, such as those involvi
ng long periods of
sedentary work, lifting, bending and awkward physical work, are especially likel
y to cause backache. Back
pain is commonly the result of sporting activities. Non-specific back pain is pr
obably the result of
mechanical disorders in the muscles, ligaments and joints of the back: torn musc
les, sprained LIGAMENTS,
and FIBROSITIS. These disorders are not always easy to diagnose, but mild muscul
ar and ligamentous injuries
are usually relieved with symptomatic treatment warmth, gentle massage, analgesi
cs, etc. Sometimes back
pain is caused or worsened by muscle spasms, which may call for the use of antis
pasmodic drugs. STRESS and
DEPRESSION
(see MENTAL ILLNESS) can sometimes result in chronic backache and should
be considered if no clear
physical diagnosis can be made. If back pain is severe and/or recurrent, possibl
y radiating around to the
abdomen or down the back of a leg (sciatica see below), or is accompanied by wea
kness or loss of feeling
in the leg(s), it may be caused by a prolapsed intervertebral disc (slipped disc
) pressing on a nerve. The
patient needs prompt investigation, including MRI. Resting on a firm bed or boar
d can relieve the symptoms,
but the patient may need a surgical operation to remove the disc and relieve pre
ssure on the affected
nerve. The nucleus pulposus the soft centre of the intervertebral disc is at ris
k of prolapse under the
Bacteria
Mechanical and traumatic causes Congenital anomalies. Fractures of the s
pine. Muscular tenderness and
ligament strain. Osteoarthritis. Prolapsed intervertebral disc. Spondylosis.
Inflammatory causes Ankylosing spondylitis. Brucellosis. Osteomyelitis.
Paravertebral abscess.
Psoriatic arthropathy. Reiters syndrome. Spondyloarthropathy. Tuberculosis.
Neoplastic causes Metastatic disease. Primary benign tumours. Primary ma
lignant tumours.
Metabolic bone disease Osteomalacia. Osteoporosis. Pagets disease.
Referred pain Carcinoma of the pancreas. Ovarian inflammation and tumour
s. Pelvic disease. Posterior
duodenal ulcer. Prolapse of the womb.
Psychogenic causes Anxiety. Depression. People with backache can obtain
advice from www.backcare.org.uk
Baclofen A powerful muscle-relaxant used for patients with chronic sever
e spasticity increased muscle
rigidity resulting from disorders such as CEREBRAL PALSY, MULTIPLE SCLEROSIS (MS
) or traumatic partial
section of the SPINAL CORD. Important adverse effects include SEDATION, HYPOTONI
A and DELIRIUM.
Bacteraemia Bacteraemia is the condition in which
BACTERIA are present in the bloodstream.
Bacteria (Singular: bacterium.) Simple, single-celled, primitive organis
ms which are widely distributed
throughout the world in air, water, soil,
69
plants and animals including humans. Many are beneficial to the environm
ent and other living organisms,
but some cause harm to their hosts and can be lethal. Bacteria are classified ac
cording to their shape:
BACILLUS (rod-like), coccus (spherical see COCCI), SPIROCHAETE (corkscrew and sp
iralshaped), VIBRIO
(comma-shaped), and pleomorphic (variable shapes). Some are mobile, possessing s
lender hairs (flagellae) on
the surfaces. As well as having characteristic shapes, the arrangement of the or
ganisms is significant:
some occur in chains (streptococci) and some in pairs (see DIPLOCOCCUS), while a
few have a filamentous
grouping. The size of bacteria ranges from around 0.2 to 5 m and the smallest (MY
COPLASMA) are roughly the
same size as the largest viruses (poxviruses see VIRUS). They are the smallest o
rganisms capable of
existing outside their hosts. The longest, rod-shaped bacilli are slightly small
er than the human
erythrocyte blood cell (7 m). Bacterial cells are surrounded by an outer capsule
70 Bacteria
B
defence system is damaged (see IMMUNOLOGY) so that it becomes vulnerable
to any previously well-behaved
parasites. Various benign bacteria that permanently reside in the human body are
called normal flora and
are found at certain sites, especially the SKIN, OROPHARYNX, COLON and VAGINA. T
he bodys internal organs
are usually sterile, as are the blood and cerebrospinal fluid. Bacteria are resp
onsible for many human
diseases ranging from the relatively minor for example, a boil or infected finge
r to the potentially
lethal such as CHOLERA, PLAGUE or TUBERCULOSIS. Infectious bacteria enter the bo
dy through broken skin or
by its orifices: by nose and mouth into the lungs or intestinal tract; by the UR
ETHRA into the URINARY
TRACT
and KIDNEYS; by the vagina into the UTERUS and FALLOPIAN TUBES. Harmful
bacteria then cause disease by
producing poisonous endotoxins or exotoxins, and by provoking INFLAMMATION in th
e tissues for example,
abscess or cellulitis. Many, but not all, bacterial infections are communicable
namely, spread from host
to host. For example, tuberculosis is spread by airborne droplets, produced by c
oughing. In scientific
research and in hospital laboratories, bacteria are cultured in special nutrient
s. They are then killed,
stained with appropriate chemicals and suitably prepared for examination under a
MICROSCOPE. Among the
staining procedures is one first developed in the late 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 to be divided into those that
turned blue gram positive
and those that turned red gram negative. This straightforward test, still used t
oday, helps to identify
many bacteria and is a guide to which ANTIBIOTICS might be effective: for exampl
e, gram-positive bacteria
are usually more susceptible to penicillin G than gram-negative organisms. Infec
tions caused by bacteria
are commonly treated with antibiotics, which were widely introduced in the 1950s
. However, the conflict
between science and harmful bacteria remains unresolved, with the overuse and mi
suse of antibiotics in
medicine, veterinary medicine and the animal food industry contributing to the e
volution of bacteria that
are resistant to antibiotics. (See also MICROBIOLOGY.)
Bacterial Meningitis See MENINGITIS.
Bactericide Anything which kills BACTERIA; the term is, however, usually
applied to drugs and
antiseptics which do this. Hence bactericidal.
Bacteriology See MICROBIOLOGY.
Bacteriophage A
VIRUS which invades a bacterium (see BACTERIA). Containing either single
-stranded or double-stranded
DNA or RNA, a particular
phage generally may infect one or a limited number of bacterial strains
or species. After infection,
once phage nucleic acid has entered the host cell, a cycle may result whereby th
e bacteria are programmed
to produce viral components, which are assembled into virus particles and releas
ed on bacterial lysis
(disintegration). Other (temperate) phages induce a nonlytic, or lysogenic, stat
e, in which phage nucleic
acid integrates stably into and replicates with the bacterial chromosome. The re
lationship can revert to a
lytic cycle and production of new phages. In the process the phage may carry sma
ll amounts of donor
bacterial DNA to a new host: the production of diphtheria toxin by Corynebacteri
um diphtheriae and of
erythrogenic toxin by Streptococcus pyogenes are wellknown examples of this effe
ct.
Bacteriostatic A term applied to substances that stop bacterial growth a
nd cell division.
Bacterium See BACTERIA.
Bacteriuria The presence of unusual bacteria in the urine, usually a sig
n of infection in the kidneys,
bladder or urethra. Normal urine usually contains some harmless bacteria; howeve
r, if bacterial numbers in
a cleanly caught mid-stream specimen exceed 10,000 in each millilitre, that is a
bnormal. Investigation is
necessary to find a cause and start treatment. Patients found to have bacteriuri
a on SCREENING may never
have consulted a doctor but nearly all have a few symptoms, such as frequency or
urgency so-called
covert bacteriuria. Men have longer urethras and fewer urinary tract infections (U
TIs) than women. Risk
factors include diabetes mellitus, pregnancy, impaired voiding and genito-urinar
y malformations. Over 70
per cent of UTIs are due to E. coli, but of UTIs in hospital patients, only 40 p
er cent are caused by E.
coli.
Treatment Patients should be encouraged to drink plenty of water, with f
requent urination. Specific
antibiotic therapy with trimethoprim or amoxicillin may be needed.
Bacteroides A type of gram-negative (see GRAMS STAIN), anaerobic, rod-lik
e bacteria. They are
generally non-motile and usually found in the alimentary and urogenital tracts o
f mammals. Often present in
the mouth in association with periodontal disease (see TEETH, DISEASES OF).
Bacup Bacup stands for the British Association of Cancer United Patients
and their families and
friends. It was founded by Dr Vicky ClementJones after she was treated for ovari
an cancer, and it became
fully operational on 31 October 1985. The aim of the Association is to provide a
n information service to
cancer patients who want to know more about their illness or who need practical
advice on how to cope with
it. It does not seek to replace the traditional relationship between the doctor
and patient, nor does it
recommend specific treatment for particular patients; rather, its aim is to help
patients to understand
more about their illness so that they can communicate more effectively and freel
y with their medical
advisers and their families and friends. See www.cancerbacup.org.uk
Bagassosis An industrial lung disease occurring in those who work with b
agasse, which is the name
B
72 BAL
B
given to the broken sugar cane after sugar has been extracted from it. B
agasse, which contains 6 per
cent silica, is used in board-making. The inhalation of dust causes an acute lun
g affection, and
subsequently in some cases a chronic lung disease. (See ALVEOLITIS.)
BAL BAL is the abbreviation for British AntiLewisite. (See DIMERCAPROL.)
Balance The ability to balance is essential for a person to stand, walk
and run. Maintaining this
ability is a complex exercise of coordination dependent on the brain, sensory an
d motor nerves, and joints.
There is a regular supply of information to the brain about the positions of var
ious parts of the body and
it responds with relevant instructions to the motor parts of the body. Eyes, the
inner ear, skin and
muscles all provide information. The cerebellum (part of the brain) collates all
the information and
initiates action. Balance may be affected by disorders in the balancing mechanis
m of the inner ear
(semicircular canals) such as MENIERES DISEASE, and inflammation of the labyrinth
(labyrinthitis).
Infection of the middle ear, such as otitis media (see under EAR, DISEASES OF),
can also disturb the
ability to balance, sometimes accompanied by dizziness or VERTIGO. If the cerebe
llum is affected by disease
a tumour or a stroke, for example the result will be faulty muscular coordinatio
n leading to clumsiness
and the inability to walk properly.
Balanitis
floats away from the examining finger and then bounces back on to it.
Balsams Substances which contain resins and benzoic acid. Balsam of Peru
, balsam of tolu, and Friars
balsam (compound tincture of benzoin) are the chief. They are traditional remedi
es given internally for
colds, and aid expectoration, while locally they are used to cover abrasions and
stimulate ulcers.
BAN See BRITISH APPROVED NAMES.
Bandages Pieces of material used to support injured parts or to retain d
ressings in position. They come
in various forms including elastic materials and plaster of Paris. For more deta
iled information about
bandaging, the reader is referred to First Aid Manual, the authorised manual of
the St Johns Ambulance
Association, St Andrews Ambulance Association and British Red Cross Society.
Baranys Test A test for gauging the efficiency of the balancing mechanism
(the vestibular apparatus)
by applying hot or cold air or water to the external ear.
Barbers Itch See SYCOSIS.
Barbiturates
See ALOPECIA.
A group of drugs which depress the CENTRAL NERVOUS SYSTEM by inhibiting
the transmission of impulses
between certain neurons. Thus they cause drowsiness or unconsciousness (dependin
g on dose), reduce the
cerebral metabolic rate for oxygen, and depress respiration. Their use as sedati
ves and hypnotics has
largely been superseded by more modern drugs which are safer and more effective.
Some members of this group
of drugs for instance, phenobarbitone have selective anticonvulsant properties a
nd are used in the
treatment of GRAND MAL convulsions and status epilepticus (see EPILEPSY). The sh
ort-acting drugs
thiopentone and methohexitone are widely used to induce general ANAESTHESIA. (Se
e also DEPENDENCE.)
Ballottement
Barium Sulphate
The technique of examining a fluid-filled part of the body for the prese
nce of a floating object. For
example, a fetus can be pushed away by a finger inside the mothers vagina. The fe
tus
A radio-opaque white powder used in X-ray examinations of the stomach an
d gastrointestinal tract. The
barium sulphate may be swallowed to enable the oesophagus, stomach and
Inflammation of the GLANS PENIS. Acute balanitis is associated with alle
rgic DERMATITIS and HERPES
GENITALIS. Diabetics are at increased risk of non-specific secondary infections;
if recurrent balanitis
occurs, circumcision is sometimes advised.
Balantidiasis A form of dysentery caused by a protozoon known as Balanti
dium coli a common parasite
in pigs, which are usually the source of infection. It responds to metronidazole
.
Baldness
BCG Vaccine
small and large intestines to be assessed for disorders such as ulcerati
on, tumours, DIVERTICULAR
DISEASE and polyps. It may also be inserted into the RECTUM or descending COLON
to investigate for possible
disease. These procedures are usually done after endoscopy examinations have bee
n carried out.
Baroreceptor Specialised nerve ending which lines certain blood vessels
and acts as a stretch receptor
in the carotid sinus, aortic arch, atria, pulmonary veins and left ventricle. In
creased pressure in these
structures increases the rate of discharge of the baroreceptors. This informatio
n is relayed to the medulla
and is important in the control of blood pressure.
Barrier Creams Substances, usually silicone-based, applied to the skin b
efore work to prevent damage by
irritants. They are also used in medicine for the prevention of bedsores and nap
py rash, for example.
Barrier Nursing The nursing of a patient suffering from an infectious di
sease in such a way that the
risk of their passing on the disease to others is reduced. Thus, precautions are
taken to ensure that all
infective matter such as stools, urine, sputum, discharge from wounds, and anyth
ing that may be
contaminated by such infective matter (e.g. nurses uniforms, bedding and towels)
is so treated that it
will not convey the infection. (See NURSING.)
Bartholins Glands Two small glands opening either side of the external va
ginal orifice. Their
secretions help to lubricate the vulva, when a woman is sexually aroused. The gl
ands may become infected
and very painful; sometimes an abscess develops and local surgery is required. O
therwise antibiotics,
analgesics and warm baths are usually effective.
Basal Cell Carcinoma The most common form of skin cancer. Its main cause
is cumulative exposure to
ultraviolet light; most tumours develop on exposed sites, chiefly the face and n
eck. It grows very slowly,
often enlarging with a raised, pearly edge, and the centre may ulcerate (rodent
ulcer). It does not
metastasise (see METASTASIS) and can be cured by surgical excision or RADIOTHERA
PY. Small lesions can also
be successfuly treated by curettage and cauterisation (see ELECTRO73
CAUTERY), LASER
treatment or CRYOSURGERY. If the diagnosis is uncertain, a biopsy and hi
stological examination should
be done.
Basal Ganglion Grey matter near the base of the cerebral hemispheres, co
nsisting of the corpus striatum
(caudate nucleus and lenticular nucleus [globus pallidus and putamen]), claustru
m, and amygdaloid nucleus
(see BRAIN). The basal ganglia are involved in the subconscious regulation of vo
luntary movement, and
disorders in this region cause DYSKINESIA.
Basal Metabolism See METABOLISM.
Basilic Vein The prominent vein which runs from near the bend of the elb
ow upwards along the inner side
of the upper arm.
Basophilia The blueish appearance under the microscope of immature red b
lood corpuscles when stained by
certain dyes. This appearance, with the blue areas collected in points, is seen
in lead poisoning and the
condition is called punctate basophilia. The term basophilia may also mean an in
crease in the numbers of
basophil cells in the blood.
Bat Ears The term commonly applied to prominent ears. The condition may
be familial, but this is by no
means the rule. Strapping the ears firmly back has no effect and is merely an em
barrassment to the child.
Where the patient wishes it, the condition can be rectified by plastic surgery.
Bathers Itch Bathers itch, also called schistosome DERMATITIS, is the term
given to a blotchy rash on
the skin occurring in those bathing in water which is infested with the larvae o
f certain trematode worms
known as schistosomes (see SCHISTOSOMIASIS). The worm is parasitic in snails. Th
e skin rash is caused by
penetration of the skin by the free-swimming larval cercaria. Bathers itch is com
mon in many parts of the
world.
BCG Vaccine BCG (Bacillus Calmette-Gurin) vaccine, which was first introd
uced in France in 1908, is
the only vaccine that has produced significant immunity against the tubercle bac
illus (see TUBERCULOSIS)
and at the same time has proved safe enough for use in human subjects. BCG
B
74 BDA
B
vaccination is usually considered for the following groups of people. (1
) Schoolchildren: the routine
programme in schools usually covers children aged between ten and 14. (2) Studen
ts, including those in
teacher training colleges. (3) Immigrants from countries with a high prevalence
of tuberculosis (TB). (4)
Children and newborn infants born in the UK to parents from Group 3, or other ne
wborns at parents request.
(5) Health workers, such as nurses, and others likely to be exposed to infection
in their work. (6)
Veterinary workers who handle animals susceptible to TB. (7) Staff of prisons, r
esidential homes and
hostels for refugees and the homeless. (8) Household contacts of people known to
have active TB and newborn
infants in households where there is a history of the disease. (9) Those staying
for more than one month in
high-risk countries. A pre-vaccination tuberculin test is necessary in all age-g
roups except newborn
infants, and only those with negative tuberculin reactions are vaccinated. Compl
ications are few and far
between. A local reaction at the site of vaccination usually occurs between two
and six weeks after
vaccination, beginning as a small papule that slowly increases in size. It may p
roduce a small ulcer. This
heals after around two months, leaving a small scar. (See IMMUNITY; TUBERCULIN.)
BDA See BRITISH DENTAL ASSOCIATION.
Beclomethasone
l inhalant. It must be
regularly for its best
e much less likely to
suppress adrenal-gland
cannot fly. The average life is 36 months, but it can live for a year without foo
d. The bed bug remains
hidden during the day in cracks in walls and floors, and in beds. It does not tr
ansmit any known disease.
Eggs hatch out into larvae in 610 days, which become adult within about 12 weeks.
A temperature of 44 C
kills the adult in an hour. Various agents have been used to disinfect premises,
such as sulphur dioxide,
ethylene oxide mixed with carbon dioxide, hydrogen cyanide and heavy naphtha, bu
t insecticide is the most
effective disinfecting agent.
Bedpan A container made of metal, fibre or plastic into which a person c
onfined to bed can defaecate
and, in the case of a female, urinate. Men use a urinal a flask-shaped container
to urinate. Hospitals
have special cleaning and sterilising equipment for bedpans. They are much less
used than in the past
because patients are encouraged to be mobile as soon as possible, and also becau
se bedside commodes are
preferred where this is practical.
Bed Sores See ULCER.
Bed-Wetting See ENURESIS; NOCTURNAL ENURESIS.
Bee Stings See BITES AND STINGS.
Behaviour Therapy A form of psychiatric treatment based on learning theo
ry. Symptoms are considered to
be conditioned responses, and treatment is aimed at removing them, regardless of
the underlying diagnosis.
Desensitisation, operant conditioning, and aversion therapy are examples of beha
viour therapy. (See MENTAL
ILLNESS.)
Behets Syndrome This is a syndrome characterised by oral and genital ulcer
ation, UVEITIS and
ARTHROPATHY. THROMBOPHLEBITIS is a common complication, and involvement of the c
entral nervous system may
occur.
Benzodiazepines 75
Belching
Benign
See ERUCTATION.
Not harmful. Used especially to describe tumours that are not malignant.
Belladonna Poisoning Atropa belladonna (deadly nightshade) is a relative
ly rare plant and severe
poisoning is not common. The berries, which are black, ripen from August to Octo
ber and are the most
commonly ingested part of the plant. However, all parts of the plant are toxic.
The berries contain
ATROPINE and other unidentified ALKALOIDS, the leaves HYOSCINE and atropine, and
the roots hyoscine. All
these alkaloids have an ANTICHOLINERGIC effect which may cause a dry mouth, dila
ted pupils with blurred
vision, TACHYCARDIA, HALLUCINATIONS and PYREXIA. There may also be ATAXIA, agita
tion, disorientation and
confusion. In severe cases there may be CONVULSIONS, COMA, respiratory depressio
n and ARRHYTHMIA. Clinical
effects may be delayed in onset for up to 12 hours, and prolonged for several da
ys. Treatment is
supportive.
Bells Palsy Bells palsy, or idiopathic facial nerve palsy, refers to the i
solated paralysis of the
facial muscles on one or both sides. It is of unclear cause, though damage to th
e seventh cranial, or
FACIAL NERVE, possibly of viral origin, is thought likely. Occurring in both sex
es at any age, it presents
with a facial pain on the affected side, followed by an inability to close the e
ye or smile. The mouth
appears to be drawn over to the opposite side, and fluids may escape from the an
gle of the mouth. Lines of
expression are flattened and the patient is unable to wrinkle the brow. Rare cau
ses include mastoiditis,
LYME DISEASE, and hypertension.
Treatment Oral steroids, if started early, increase the rate of recovery
, which occurs in over 90 per
cent of patients, usually starting after two or three weeks and complete within
three months. Permanent
loss of function with facial contractures occurs in about 5 per cent of patients
. Recurrence of Bells
palsy is unusual.
B Endorphin A naturally occurring painkiller which is produced by the PI
TUITARY GLAND as part of a
prohormone (pre-pro-opianomelanocortin). It is an agonist at opioid receptors, a
nd its release is
stimulated by pain and stress. (See ENDORPHINS.)
Bends See COMPRESSED AIR ILLNESS.
Bennetts Fracture Bennetts fracture so-called after an Irish surgeon, Edwa
rd Hallaran Bennett
76 Benzothiadiazines
B
a hangover effect, and DEPENDENCE on these is now well recognised, so th
ey should not be prescribed for
more than a few weeks. Commonly used benzodiazepines include nitrazepam, flunitr
azepam (a controlled drug),
loprazolam, temazepam (a controlled drug) and chlormethiazole, normally confined
to the elderly. All
benzodiazepines should be used sparingly because of the risk of dependence.
Benzothiadiazines
Treatment consists of large doses of vitamin B1 orally or intramuscularl
y; a diet containing other
vitamins of the B group; and rest.
Infantile beriberi This is the result of maternal thiamine deficiency; a
lthough the mother is not
necessarily affected, the breast-fed baby may develop typical signs (see above).
Optic and third cranial,
and recurrent laryngeal nerves may be affected; encephalopathy can result in con
vulsions, coma and death.
See THIAZIDES.
Benzyl Benzoate An emulson that was widely used as a treatment for SCABI
ES but is less effective and
more irritant than newer scabicides. It is not advised for use in children.
Benzylpenicillin See PENICILLIN.
Bereavement The normal mental state associated with the death of a loved
one, and the slow coming to
terms with that death. The well-recognised stages of the bereavement reaction ar
e: denial, bargaining,
anger and acceptance. If bereavement symptoms are severe or prolonged, expert co
unselling may help.
Bereavement-like symptoms may occur after divorce, retirement or other life-chan
ging experiences.
Beriberi (Singhalese: beri = extreme weakness.) Formerly a major health
problem in many Asian
countries, beriberi is a nutritional deficiency disease resulting from prolonged
deficiency of the
water-soluble vitamin, THIAMINE (vitamin B1). It is often associated with defici
encies of other members of
the the vitamin B complex (see APPENDIX 5: VITAMINS). A major public-health prob
lem in countries where
highly polished rice constitutes the staple diet, beriberi also occurs sporadica
lly in alcoholics (see
WERNICKES ENCEPHALOPATHY) and in people suffering from chronic malabsorptive stat
es. Clinical symptoms
include weakness, paralysis involving especially the hands and feet (associated
with sensory loss,
particularly in the legs) and burning sensations in the feet (dry beriberi). Alter
natively, it is
accompanied by oedema, palpitations and a dilated heart (wet beriberi). Death us
ually results from cardiac
Bilateral
have had a myocardial infarction (heart attack see HEART, DISEASES OF),
or who suffer from
HYPERTENSION. Beta2 blockers reduce tremors in muscles elsewhere in the body whi
ch are a feature of anxiety
or the result of thyrotoxicosis (an overactive thyroid gland see under NonTHYROI
D GLAND, DISEASES OF).
cardioselective blockers also reduce the abnormal pressure caused by the increas
e in the fluid in the
eyeball that characterises GLAUCOMA. Many beta-blocking drugs are now available;
minor therapeutic
differences between them may influence the choice of a drug for a particular pat
ient. Among the common
drugs are: Primarily cardioselective Acebutolol Atenolol Betaxolol Celiprolol Me
toprolol
Non-cardioselective Labetalol Nadolol Oxprenolol Propanolol Timolol
77
estimation of the true value. For example, if a researcher is studying t
he effects of two different
drugs on the same disease and personally favours one, unless they have been blin
ded to which patient is
receiving which treatment, they may unwittingly cause bias in the results by reg
arding those treated with
their preferred drug as being healthier.
Bicarbonate of Soda Also known as baking soda. Bicarbonate of soda is an
alkali, sometimes used as a
home remedy for indigestion or for soothing insect bites.
Biceps A term used for a muscle that has two heads. The biceps femoris f
lexes the knee and extends the
hip, and the biceps brachii supinates the forearm and flexes the elbow and shoul
der.
Bicuspid
These powerful drugs have various sideeffects and should be prescribed a
nd monitored with care. In
particular, people who suffer from asthma, bronchitis or other respiratory probl
ems may develop breathing
difficulties. Longterm treatment with beta blockers should not be suddenly stopp
ed, as this may precipitate
a severe recurrence of the patients symptoms including, possibly, a sharp rise in
blood pressure.
Gradual withdrawal of medication should mitigate untoward effects.
Having two cusps. The premolars are bicuspid teeth, and the mitral valve
of the HEART is a bicuspid
valve.
Beta Blockers
Bifurcation
See BETA-ADRENOCEPTOR-BLOCKING DRUGS.
The point at which a structure (for example, a blood vessel) divides int
o two branches.
Betamethasone One of the CORTICOSTEROIDS which has an action comparable
to that of PREDNISOLONE, but in
much lower dosage. In the form of betamethasone valerate it is used as an applic
ation to the skin as an
ointment or cream.
Betatron See RADIOTHERAPY.
Bezoar A mass of ingested foreign material found in the stomach, usually
in children or people with
psychiatric illnesses. It may cause gastric obstruction and require surgical rem
oval. The commonest type
consists of hair and is known as a trichobezoar.
Bias A statistical term describing a systematic influence which leads to
consistent over- or underBifid Split into two parts.
Bifocal Lens A spectacle lens in which the upper part is shaped to assis
t distant vision and the lower
part is for close work such as reading.
Biguanides Biguanides are a group of oral drugs, of which METFORMIN is t
he only one available for
treatment, used to treat non-insulin-dependent diabetics when strict dieting and
treatment with
SULPHONYLUREAS have failed. Metformin acts mainly by reducing GLUCONEOGENESIS an
d by increasing the rate at
which the body uses up glucose. Hypoglycaemia is unusual, unless taken in overdo
se. Gastrointestinal
side-effects such as anorexia, nausea, vomiting and transient diarrhoea are comm
on initially and may
persist, particularly if large doses are taken. Metformin should not be given to
patients with renal
failure, in whom there is a danger of inducing lactic acidosis. (See also DIABET
ES MELLITUS.)
Bilateral Occurring on both sides of the body.
B
78 Bile
B
Bile
Binaural
A thick, bitter, greenish-brown fluid, secreted by the liver and stored
in the gall-bladder (see
LIVER). Consisting of water, mucus, bile pigments including BILIRUBIN, and vario
us salts, it is discharged
through the bile ducts into the intestine a few centimetres below the stomach. T
his discharge is increased
shortly after eating, and again a few hours later. It helps in the digestion and
absorption of food,
particularly fats, and is itself reabsorbed, passing back through the blood of t
he liver. In JAUNDICE,
obstruction of the bile ducts prevents discharge, leading to a build-up of bile
in the blood and deposition
in the tissues. The skin becomes greenish-yellow, while the stools become grey o
r white and the urine dark.
Vomiting of bile is a sign of intestinal obstruction, but may occur in any case
of persistent retching or
vomiting, and should be fully investigated.
Relating to both ears.
Bile Duct The channel running from the gall-bladder (see LIVER) to the D
UODENUM; carries BILE.
Bilharziasis Bilharziasis
is
another
name
for
SCHISTOSOMIASIS.
Biliary Colic Severe pain caused by the attempted (and sometimes success
ful) expulsion of a gall-stone
from the gall-bladder via the BILE DUCT. The pain, which is felt in the upper ri
ght corner of the abdomen,
may last for an hour or more. Strong ANALGESICS are required to subdue the pain
and the patient may need
hospital admission for examination and eventual surgery. Attacks may recur, and
the pain is sometimes
mistakenly diagnosed as signalling a heart attack.
Bilirubin The chief pigment in human BILE. It is derived from HAEMOGLOBI
N which is the red pigment of
the red blood corpuscles. The site of manufacture of bilirubin is the RETICULOEN
DOTHELIAL SYSTEM. When bile
is passed into the intestine from the gall-bladder (see LIVER), part of the bili
rubin is converted into
stercobilin and excreted in the FAECES. The remainder is reabsorbed into the blo
Birth Canal 79
for ways of annulling the lethal consequences of biological warfare.
Biomechanical Engineering The joint utilisation of engineering and biolo
gical knowledge to illuminate
normal and abnormal functions of the human body. Blood flow, the reaction of bon
es and joints to stress,
the design of kidney dialysis machines, and the development of artificial body p
arts are among the
practical results of this collaboration.
Biopsy Biopsy means the removal and examination of tissue from the livin
g body for diagnostic purposes.
For example, a piece of a tumour may be cut out and examined to determine whethe
r it is cancerous.
Bioremediation The use of the natural properties of living things to rem
ove hazards that threaten human
and animal health. When a pollutant first appears in a local environment, existi
ng microorganisms such as
bacteria attempt to make use of the potential source of energy and as a sideeffe
ct detoxify the polluting
substance. This is an evolutionary process that normally would take years. Scien
tists have engineered
appropriate genes from other organisms into BACTERIA, or sometimes plants, to ac
celerate this natural
evolutionary process. For effective digestion of waste, a micro-organism must quic
kly and completely
digest organic waste without producing unpleasant smells or noxious gases, be no
n-pathogenic and be able to
reproduce in hostile conditions. For example, American researchers have discover
ed an anaerobic bacterium
that neutralises dangerous chlorinated chemical compounds such as trichlorethane
, which can pollute soil,
into a harmless molecule called ethens. But the bacteria do not thrive in soil.
So the dechlorinating genes
in this bacterium are transferred to bacteria that are acclimatised to living in
toxic areas and can more
efficiently carry out the required detoxification. Other research has been aimed
at detoxifying the
byproducts of DDT, a troublesome and resistant pollutant. Bioremediation should
prove to be an
environmentally friendly and cost-effective alternative to waste incineration or
chemically based processes
for washing contaminated soils.
Bioterrorism Terror attacks on civilian communities using biological age
nts such as ANTHRAX and SMALLPOX. Particular problems in detecting and handling attacks are the time lags between exposure of a population to dange
rous agents and the onset of
victims symptoms, and the fact that early symptoms might initially be taken as th
e result of a naturally
occurring disease. Management of any biological attack must depend on systems al
ready in place for managing
new diseases, new epidemics or traditional diseases. The effectiveness of public
-health surveillance varies
widely from country to country, and even advanced economies may not have the sta
ff and facilities to
investigate anything other than a recognised epidemic. As attacks might well occ
ur without warning,
tackling them could be a daunting task. Intelligence warnings about proposed att
acks might, however, allow
for some preventive and curative measures to be set up. Medical experts in the U
S believe that deployment
of existing community disaster teams working to pre-prepared plans, and the deve
lopment of specially
trained strike teams, should cut the numbers of casualties and deaths from a bio
terrorist attack.
Nevertheless, bioterrorism is an alarming prospect.
Biotin One of the dozen or so vitamins included in the vitamin B complex
. It is found in liver, eggs
and meat, and also synthesised by bacteria in the gut. Absorption from the gut i
s prevented by avidin, a
constituent of egg-white. The daily requirement is small: a fraction of a millig
ram daily. Gross deficiency
results in disturbances of the skin, a smooth tongue and lassitude. (See APPENDI
X 5: VITAMINS.)
Bipolar Disorder A type of mental illness typified by mood swings betwee
n elation (mania) and
depression (see MENTAL ILLNESS).
Bird Fanciers Lung Also known as pigeon breeders lung, this is a form of e
xtrinsic allergic
ALVEOLITIS resulting from sensitisation to birds. In bird fanciers, skin tests s
ometimes show sensitisation
to birds droppings, eggs, protein and serum, even through there has been no evide
nce of any illness.
Birth Canal The passage that extends from the neck of the womb (UTERUS),
known as the CERVIX UTERI, to
the opening of the VAGINA. The baby passes along this passage during childbirth.
B
80 Birth Control
Birth Control See CONTRACEPTION.
B
Birth Defects See CONGENITAL.
Birth Marks Birth marks are of various kinds; the most common are port-w
ine marks (see NAEVUS). Pigment
spots are found, very often raised above the skin surface and more or less hairy
, being then called moles
(see MOLE).
Birth Pool A pool of warm water in which a woman can give birth to her b
aby. The infant is delivered
into the water. The method was introduced during the 1980s and is claimed to mak
e delivery less painful and
upsetting.
Birth Rate In 2003, 695,500 live births were registered in the United Ki
ngdom; 38 per cent occurred
outside marriage. Overall, total fertility is falling slowly. The number of birt
hs per 1,000 women aged
over 40 years has been rising, and in 1999 was 8.9 per cent. In Great Britain in
2003, 193,817 legal
abortions were performed under the Abortion Act 1967.
Bisacodyl Bisacodyl is a laxative which acts by stimulation of the nerve
endings in the colon by direct
contact with the mucous lining.
Bisexual Having the qualities of both sexes. The term is used to describ
e people who are sexually
attracted to both men and women.
Bismuth Various bismuth chelates and complexes, such as sucralfate, effe
ctive in healing gastric and
duodenal ulcers are available. They may act by a direct toxic effect on gastric
HELICOBACTER PYLORI, or by
stimulating mucosal prostaglandin (see PROSTAGLANDINS) or bicarbonate secretion.
Healing tends to be longer
than with H2-RECEPTOR ANTAGONISTS and relapse still occurs. New regimens are bei
ng developed involving
co-administration with antibiotics. ENCEPHALOPATHY, described with older highdos
e bismuth preparations, has
not been reported.
Bisphosphonates Bisphosphonates, of which disodium etidronate is one, ar
e a group of drugs used mainly
in the treatment of PAGETS DISEASE OF BONE and in
established vertebral osteoporosis (see BONE, DISORDERS OF). Their advan
tage over CALCITONIN (which has
to be given by subcutaneous or intramuscular injection) is that they can be take
n orally. They act by
reducing the increased rate of bone turnover associated with the disease. Disodi
um etidronate is used with
calcium carbonate in a 90-day cycle (duration of therapy up to three years) in t
he treatment of
osteoporosis.
Bites and Stings Animal bites are best treated as puncture wounds and si
mply washed and dressed. In
some cases ANTIBIOTICS may be given to minimise the risk of infection, together
with TETANUS toxoid if
appropriate. Should RABIES be a possibility, then further treatment must be cons
idered. Bites and stings of
venomous reptiles, amphibians, scorpions, snakes, spiders, insects and fish may
result in clinical effects
characteristic of that particular poisoning. In some cases specific ANTIVENOM ma
y be administered to reduce
morbidity and mortality. Many snakes are non-venomous (e.g. pythons, garter snak
es, king snakes, boa
constrictors) but may still inflict painful bites and cause local swelling. Most
venomous snakes belong to
the viper and cobra families and are common in Asia, Africa, Australia and South
America. Victims of bites
may experience various effects including swelling, PARALYSIS of the bitten area,
blood-clotting defects,
PALPITATION, respiratory difficulty, CONVULSIONS and other neurotoxic and cardia
c effects. Victims should
be treated as for SHOCK that is, kept at rest, kept warm, and given oxygen if re
quired but nothing by
mouth. The bite site should be immobilised but a TOURNIQUET must not be used. Al
l victims require prompt
transfer to a medical facility. When appropriate and available, antivenoms shoul
d be administered as soon
as possible. Similar management is appropriate for bites and stings by spiders,
scorpions, sea-snakes,
venomous fish and other marine animals and insects.
Bites and stings in the UK The adder (Vipera berus) is the only venomous
snake native to Britain; it is
a timid animal that bites only when provoked. Fatal cases are rare, with only 14
deaths recorded in the UK
since 1876, the last of these in 1975. Adder bites may result in marked swelling
, weakness, collapse,
shock, and in severe cases HYPOTENSION, non-specific changes in the electrocardi
ogram and peripheral
leucocytosis. Victims of adder bites
Blenorrhoea 81
should be transferred to hospital even if asymptomatic, with the affecte
d limb being immobilised and
the bite site left alone. Local incisions, suction, tourniquets, ice packs or pe
rmanganate must not be
used. Hospital management may include use of a specific antivenom, Zagreb . The we
ever fish is found in the
coastal waters of the British Isles, Europe, the eastern Atlantic, and the Medit
erranean Sea. It possesses
venomous spines in its dorsal fin. Stings and envenomation commonly occur when a
n individual treads on the
fish. The victim may experience a 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 as
hot as can be tolerated
for 30 minutes should ease the pain. Cold applications will worsen the discomfor
t. Simple ANALGESICS and
ANTIHISTAMINE DRUGS may be given. Bees, wasps and hornets are insects of the ord
er Hymenoptera and the
females possess stinging apparatus at the end of the abdomen. Stings may cause l
ocal pain and swelling but
rarely cause severe toxicity. Anaphylactic (see ANAPHYLAXIS) reactions can occur
in sensitive individuals;
these may be fatal. Deaths caused by upper-airway blockage as a result of stings
in the mouth or neck
regions are reported. In victims of stings, the stinger should be removed as qui
ckly as possible by
flicking, scraping or pulling. The site should be cleaned. Antihistamines and co
ld applications may bring
relief. For anaphylactic reactions ADRENALINE, by intramuscular injection, may b
e required.
Black Death An old name for PLAGUE.
Blackheads See ACNE.
Blackwater Fever This is caused by rapid breakdown of red blood cells (a
cute intravascular haemolysis),
with resulting kidney failure as the breakdown products block the vessels servin
g the kidney filtration
units (see KIDNEYS). It is associated with severe Plasmodium falciparum infectio
n. The complication is
frequently fatal, being associated with HAEMOGLOBINURIA, JAUNDICE, fever, vomiti
ng and severe ANAEMIA. In
an extreme case the patients urine appears black. Tender enlarged liver and splee
n are usually present.
The disease is triggered by quinine usage at subtherapeutic dosage in the presen
ce of P. falciparum
infection, especially in the nonimmune individual. Now that quinine is rarely
used for prevention of this infection (it is reserved for treatment), bl
ackwater fever has become very
unusual. Treatment is as for severe complicated P. falciparum infection with ren
al impairment; dialysis and
blood transfusion are usually indicated. When inadequately treated, the mortalit
y rate may be over 40 per
cent but, with satisfactory intensive therapy, this should be reduced substantia
lly.
Gall-bladder This is situated under the liver in the upper part of the a
bdomen, and its function is to
store the BILE, which it discharges into the intestine by the BILE DUCT. For fur
ther details, see LIVER.
Urinary bladder This is situated in the pelvis, in front of the last par
t of the bowel. In the full
state, the bladder rises up into the abdomen and holds about 570 ml (a pint) of
urine. Two fine tubes,
called the ureters, lead into the bladder, one from each kidney; and the urethra
, a tube as wide as a lead
pencil when distended, leads from it to the exterior a distance of 4 cm (1 inches
) in the female and 20
cm (8 inches) in the male. The exit from the bladder to the urethra is kept clos
ed by a muscular ring which
is relaxed every time urine is passed.
Bleeding See HAEMORRHAGE; VENESECTION.
Blenorrhoea An excessive discharge of mucus or slimy material from a sur
face, such as that of the eye,
nose, bowel, etc. The word catarrh is used with the same meaning, but also include
s the idea of
inflammation as the cause of such discharge.
B
82 Bleomycin
Bleomycin B
A CYTOTOXIC antibiotic, obtained from Streptomyces verticillus, used to
treat solid cancerous tumours
of the upper part of the gut and genital tract, and lymphomas. Like other cytoto
xic drugs it can have
serious side-effects, and bleomycin may cause pulmonary fibrosis and skin pigmen
tation.
Blepharitis Inflammation of the eyelids. (See ORDERS OF.)
EYE, DISBlepharospasm See EYE, DISORDERS OF.
Blind Loop Syndrome A disorder in which abnormal FAECES occur as a resul
t of a redundant loop in the
small INTESTINE. The loop obstructs the normal flow of the contents of the bowel
, causing stagnation. The
syndrome is characterised by light-yellow, smelly, fatty, bulky faeces. The pati
ent suffers from tiredness,
malaise and loss of weight. Previous abdominal surgery is sometimes the cause, b
ut the condition can be
inherited. Blockage of intestinal contents upsets the bowels normal bacterial bal
ance and hinders the
normal absorption of nutrients. Treatment is either with antibiotics or, if that
fails, surgery.
Blindness The statutory definition for the purposes of registration as a
blind person under the
National Assistance Act 1948 is that the person is so blind as to be unable to pe
rform any work for
which eyesight is essential. Generally this is vision worse than 6/60 in the bett
er eye, or with better
acuity than this but where the field of vision is markedly contracted in the grea
ter part of its extent.
Partial sight has no statutory definition, but there are official guidelines for
registering a person as
partially sighted: generally these are a corrected visual acuity of 3/ 60 or les
s in the better eye with
some contraction 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 wor
ld. The causes of blindness
vary with age and degree of development of the country. In western society the c
ommonest causes are
glaucoma, diabetic retinopathy, other retinal diseases and senile cataract. (See
also VISION.) Any blind
person, or his or her relatives, can
obtain help and advice from the Royal National Institute for the Blind (
www.rnib.org.uk).
Night blindness An inability to see in the dark. It can be associated wi
th retinitis pigmentosa or
vitamin A deficiency (see EYE, DISORDERS OF).
Blood Groups 83
marrow and lymphoid tissue. Plasma consists of water, ELECTROLYTES and p
lasma proteins; it comprises
4858 per cent of blood volume. Plasma proteins are produced mainly by the liver a
nd by certain types of
white cells. Blood volume and electrolyte composition are closely regulated by c
omplex mechanisms involving
the KIDNEYS, ADRENAL GLANDS and HYPOTHALAMUS.
Blood Bank A department in which blood products are prepared, stored, an
d tested prior to transfusion
into patients.
Blood Brain Barrier A functional, semi-permeable membrane separating the
brain and cerebrospinal fluid
from the blood. It allows small and lipid-soluble molecules to pass freely but i
s impermeable to large or
ionised molecules and cells.
Blood Clot A blood clot arises when blood comes into contact with a fore
ign surface for example,
damaged blood vessels or when tissue factors are released from damaged tissue. A
n initial plug of
PLATELETS is converted to a definitive clot by the deposition of FIBRIN, which i
s formed by the clotting
cascade and erythrocytes. (See COAGULATION.)
Blood Corpuscle See ERYTHROCYTES and LEUCOCYTES.
Blood Count The number of each of the cellular components per litre of b
lood. It may be calculated
using a microscope or by an automated process.
Blood, Diseases of See ANAEMIA; LEUKAEMIA; LYMPHOMA; MYELOMATOSIS; THROM
BOSIS.
Blood Donor An individual who donates his or her own blood for use in pa
tients of compatible blood
group who require transfusion.
Blood Gases Specifically, this describes the measurement of the tensions
of oxygen and carbon dioxide
in blood. However, it is commonly used to describe the analysis of a sample of h
eparinised arterial blood
for measurement of oxygen, carbon dioxide, oxygen saturation, pH, bicarbonate, a
nd base excess (the amount
of acid
required to return a unit volume of the blood to normal pH). These value
s are vital in monitoring the
severity of illness in patients receiving intensive care or who have severe resp
iratory illness, as they
provide a guide to the effectiveness of oxygen transport between the outside air
and the body tissues. Thus
they are both a guide to whether the patient is being optimally ventilated, and
also a general guide to the
severity of their illness.
Blood Groups People are divided into four main groups in respect of a ce
84 Blood-Letting
B
are no naturally occurring Rh antibodies. However, such antibodies may d
evelop in a Rhnegative person
if the Rh antigen is introduced into his or her circulation. This can occur (a)
if a Rh-negative person is
given a transfusion of Rh-positive blood, and (b) if a Rh-negative mother marrie
d to a Rh-positive husband
becomes pregnant and the fetus is Rh-positive. If the latter happens, the mother
develops Rh antibodies
which can pass into the fetal circulation, where they react with the babys Rh ant
igen and cause HAEMOLYTIC
DISEASE of the fetus and newborn. This means that, untreated, the child may be s
tillborn or become
jaundiced shortly after birth. As about one in six expectant mothers is Rhnegati
ve, a blood-group
examination is now considered an essential part of the antenatal examination of
a pregnant woman. All such
Rh-negative expectant mothers are now given a Rhesus card showing that they belong
to the rhesus-negative
blood group. This card should always be carried with them. Rh-positive blood sho
uld never be transfused to
a Rh-negative girl or woman.
Blood-Letting See VENESECTION.
Blood-Poisoning See SEPTICAEMIA.
Blood Pressure Blood pressure is that pressure which must be applied to
an artery in order to stop the
pulse beyond the point of pressure. It may be roughly estimated by feeling the p
ulse at the wrist, or
accurately measured using a SPHYGMOMANOMETER. It is dependent on the pumping for
ce of the heart, together
with the volume of blood, and on the elasticity of the blood vessels. The blood
pressure is biphasic, being
greatest (systolic pressure) at each heartbeat and falling (diastolic pressure)
between beats. The average
systolic pressure is around 100 mm Hg in children and 120 mm Hg in young adults,
generally rising with age
as the arteries get thicker and harder. Diastolic pressure in a healthy young ad
ult is about 80 mm Hg, and
a rise in diastolic pressure is often a surer indicator of HYPERTENSION than is
a rise in systolic
pressure; the latter is more sensitive to changes of body position and emotional
mood. Hypertension has
various causes, the most important of which are kidney disease (see KIDNEYS, DIS
EASES OF), genetic
predisposition and, to some extent, mental stress. Systolic pressure may well be
over 200 mm Hg. Abnormal
hypertension is often
accompanied by arterial disease (see ARTERIES, with an increased risk of
STROKE, heart attack and heart
failure (see HEART, DISEASES OF). Various ANTIHYPERTENSIVE DRUGS are available;
these should be carefully
evaluated, considering the patients full clinical history, before use. HYPOTENSIO
N may result from
Bone
called a carbuncle. Release of the pus and an oral antibiotic lead to ra
pid healing. Recurrent boils
are usually due to a reservoir of staphylococcal bacteria (see STAPHYLOCOCCUS) i
n a nostril or elsewhere,
so an intranasal antibiotic cream may be prescribed. Underlying DIABETES MELLITU
S should always be
excluded.
Bolam Test A medico-legal defence for a clinician accused of failing to
provide an acceptable standard
of care for one of his or her qualification and experience. The defence is that
a responsible body of
medical practitioners would have taken the same action, even though others would
have acted differently.
The precise size of a responsible body has not been defined. The test has been mod
ified following a case
referred to as Bolitho, in which it was held that the Bolam defence failed if it
could be shown that the
actions relied upon, although shown to be carried out by some responsible doctor
s, were nonetheless
illogical.
Bolus A lump of food prepared for swallowing by chewing and mixing with
saliva. The term is also used
to describe the rapid intravenous injection of fluid or a drug, as opposed to a
slower infusion.
Bonding The formation of a close, selective attachment between two indiv
iduals, as in the relationship
between a mother and her baby.
Bone The framework upon which the rest of the body is built up. The bone
s are generally called the
skeleton, though this term also includes the cartilages which join the ribs to t
he breastbone, protect the
larynx, etc.
Structure of bone Bone is composed partly of fibrous tissue, partly of b
one matrix comprising phosphate
and carbonate of lime, intimately mixed together. The bones of a child are about
two-thirds fibrous tissue,
whilst those of the aged contain one-third; the toughness of the former and the
brittleness of the latter
are therefore evident. The shafts of the limb bones are composed of dense bone,
the bone being a hard tube
surrounded by a membrane (the periosteum) and enclosing a fatty substance (the B
ONE MARROW); and of
cancellous bone, which forms the short bones and the ends of long bones, in whic
h a fine lace-work of bone
fills up the
85
whole interior, enclosing marrow in its meshes. The marrow of the smalle
r bones is of great importance.
It is red in colour, and in it red blood corpuscles are formed. Even the densest
bone is tunnelled by fine
canals (Haversian canals) in which run small blood vessels, nerves and lymphatic
86 Bone, Disorders of
B
with their cartilages, and the breastbone; and an appendicular portion c
omprising the four limbs. The
hyoid bone in the neck, together with the cartilages protecting the larynx and w
indpipe, may be described
as the visceral skeleton. The skull consists of the cranium, which has eight bon
es, viz. occipital, two
parietal, two temporal, one frontal, ethmoid, and sphenoid; and of the face, whi
ch has 14 bones, viz. two
maxillae or upper jaw-bones, one mandible or lower jaw-bone, two malar or cheek
bones, two nasal, two
lacrimal, two turbinal, two palate bones, and one vomer bone. (For further detai
ls, see SKULL.) The
vertebral column consists of seven vertebrae in the cervical or neck region, 12
dorsal vertebrae, five
vertebrae in the lumbar or loin region, the sacrum or sacral bone (a mass formed
of five vertebrae fused
together and forming the back part of the pelvis, which is closed at the sides b
y the haunch-bones), and
finally the coccyx (four small vertebrae representing the tail of lower animals)
. The vertebral column has
four curves: the first forwards in the neck, the second backwards in the dorsal
region, the third forwards
in the loins, and the lowest, involving the sacrum and coccyx, backwards. These
are associated with the
erect attitude, develop after a child learns to walk, and have the effect of dim
inishing jars and shocks
before these reach internal organs. This is aided still further by discs of cart
ilage placed between each
pair of vertebrae. Each vertebra has a solid part, the body in front, and behind
this a ring of bone, the
series of rings one above another forming a bony canal up which runs the spinal
cord to pass through an
opening in the skull at the upper end of the canal and there join the brain. (Fo
r further details, see
SPINAL COLUMN.) The ribs 12 in number, on each side are attached behind to the 1
2 dorsal vertebrae,
while in front they end a few inches away from the breastbone, but are continued
forwards by cartilages. Of
these the upper seven reach the breastbone, these ribs being called true ribs; t
he next three are joined
each to the cartilage above it, while the last two have their ends free and are
called floating ribs. The
breastbone, or sternum, is shaped something like a short sword, about 15 cm (6 i
nches) long, and rather
over 25 cm (1 inch) wide. AXIAL SKELETON
by joints. In the shoulder lie the clavicle or collar-bone (which is imm
ediately beneath the skin, and
forms a prominent object on the front of the neck), and the scapula or shoulderblade behind the chest. In
the upper arm is a single bone, the humerus. In the forearm are two bones, the r
adius and ulna; the radius,
in the movements of alternately turning the hand palm up and back up (called sup
ination and pronation
respectively), rotating around the ulna, which remains fixed. In the carpus or w
rist are eight small bones:
Bone, Disorders of
Examples of fractures: the fibula (thin bone) has a simple fracture of i
ts shaft and a comminuted
fracture at its lower end; the tibia has a compound fracture of its shaft.
Fractures where the skin remains intact or merely grazed. COMPOUND FRACT
URES have at least one wound
which is in communication with the fracture, meaning that bacteria can enter the
fracture site and cause
infection. A compound fracture is also more serious than a simple fracture becau
se there is greater
potential for blood loss. Compound fractures usually need hospital admission, an
tibiotics and careful
reduction of the fracture. Debridement (cleaning and excising 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 run
s 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
wrist, in the humerus or at the collar-bone depending on the force of impact and
age of the person. FATIGUE
FRACTURES These occur after the bone has been under recurrent stress. A typical
example is the march
fracture of the second toe, from which army recruits suffer after long marches.
PATHOLOGICAL FRACTURES
These occur in bone which is already diseased for example, SIMPLE FRACTURES
87
by osteoporosis (see below) in post-menopausal women. Such fractures are
typically crush fractures of
the vertebrae, fractures of the neck of the femur, and COLLES FRACTURE (of the wr
ist). Pathological
fractures also occur in bone which has secondary-tumour deposits. GREENSTICK FRA
CTURES 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 n
eed any deformity corrected
and plaster of Paris to maintain the correction. COMPLICATED FRACTURES These inv
olve damage 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 mor
e than two fragments. It
usually means that the injury was more violent and that there is more risk of da
mage to vessels and nerves.
These fractures are unstable and take longer to unite. Rehabilitation tends to b
e protracted. DEPRESSED
FRACTURES Most commonly found in skull fractures. A fragment of bone is forced i
nwards so that it lies
lower than the level of the bone surrounding it. It may damage the brain beneath
it.
Depressed fracture of the skull (sagittal view).
These occur when the bone is broken but the force has not been severe en
ough to cause visible
displacement. These fractures may be easily missed.
HAIR-LINE FRACTURES
Symptoms and signs The fracture site is usually painful, swollen and def
ormed. There is asymmetry of
contour between limbs. The limb is held uselessly. If the fracture is in the upp
er
B
88 Bone, Disorders of
B
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 limb may appear short because of muscle spasm. Ex
amination may reveal
crepitus a bony grating at the fracture site. The diagnosis is confirmed by radi
ography.
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 cou
ple 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. Treatm
ent is initially to relieve
pain and may involve temporary splinting of the fracture site. Reducing the frac
ture means restoring the
bones to their normal position; this is particularly important at the site of jo
ints where any small
displacement may limit movement considerably.
Injury to the spine: compression fracture of 1st lumbar vertebra with no
damage to spinal cord.
Injury to the spine: fracture/dislocation of 12th thoracic vertebra with
damage to spinal cord.
Impacted fracture of neck of left femur.
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 restore
s the fragments of the
fracture into their normal position: these are kept in position with plaster of
Paris. If closed traction
does not work, then open reduction of the fracture may
Bone, Disorders of
be needed. This may involve fixing the fracture with internal-fixation m
ethods, using metal plates,
wires or screws to hold the fracture site in a rigid position with the two ends
closely opposed. This
allows early mobilisation after fractures and speeds return to normal use. Exter
nal fixators are usually
metal devices applied to the outside of the limb to support the fracture site. T
hey are useful in compound
fractures where internal fixators are at risk of becoming infected. Consolidatio
n of a fracture means that
repair is complete. The time taken for this depends on the age of the patient, t
he bone and the type of
fracture. A wrist fracture may take six weeks, a femoral fracture three to six m
onths in an adult.
Complications of fractures are fairly common. In non-union, the fracture does no
t unite usually because
there has been too much mobility around the fracture site. Treatment may involve
internal fixation (see
above). Malunion means that the bone has healed with a persistent deformity and
the adjacent joint may then
develop early osteoarthritis. Myositis ossificans may occur at the elbow after a
fracture. A big mass of
calcified material develops around the fracture site which restricts elbow movem
ents. Late surgical removal
(after 612 months) is recommended. Fractured neck of FEMUR typically affects elde
rly women after a trivial
injury. The bone is usually osteoporotic. The leg appears short and is rotated o
utwards. Usually the
patient is unable to put any weight on the affected leg and is in extreme pain.
The fractures are
classified according to where they occur: subcapital where the neck joins the he
ad of the femur.
intertrochanteric through the trochanter. subtrochanteric transversely through t
he upper end of the femur
(rare). Most of these fractures of the neck of femur need fixing by metal plates
or hip replacements, as
immobility in this age group has a mortality of nearly 100 per cent. Fractures o
f the femur shaft are
usually the result of severe trauma such as a road accident. Treatment may be co
nservative or operative. In
fractures of the SPINAL COLUMN, mere damage to the bone as in the case of the so
called compression
fracture, in which there is no damage to the spinal cord is not necessarily seri
ous. If, however, the
spinal cord is damaged, as in the so-called fracture dislocation, the accident m
ay be a very serious one,
the usual result being paralysis of the parts of the body below the level of the
injury. Therefore the
higher up
89
the spine is fractured, the more serious the consequences. The injured p
erson should not be moved until
skilled assistance is at hand; or, if he or she must be removed, this should be
done on a rigid shutter or
door, not on a canvas stretcher or rug, and there should be no lifting which nec
essitates bending of the
back. In such an injury an operation designed to remove a displaced piece of bon
e and free the spinal cord
from pressure is often necessary and successful in relieving the paralysis. DISL
OCATIONS or SUBLUXATION of
the spine are not uncommon in certain sports, particularly rugby. Anyone who has
had such an injury in the
cervical spine (i.e. in the neck) should be strongly advised not to return to an
y form of body-contact or
vehicular sport. Simple fissured fractures and depressed fractures of the skull
often follow blows or falls
on the head, and may not be serious, though there is always a risk of damage whi
ch is potentially serious
to the brain at the same time. Compound fractures may result in infection within
the skull, and if the
skull is extensively broken and depressed, surgery is usually required to check
any intercranial bleeding
or to relieve pressure on the brain. The lower jaw is often fractured by a blow
on the face. There is
generally bleeding from the mouth, the gum being torn. Also there are pain and g
rating sensations on
chewing, and unevenness in the line of the teeth. The treatment is simple, the l
ine of teeth in the upper
jaw forming a splint against which the lower jaw is bound, with the mouth closed
.
Congenital diseases These are rare but may produce certain types of dwar
fism or a susceptibility to
fractures (osteogenesis imperfecta).
Infection of bone (osteomyelitis) may occur after an open fracture, or i
n newborn babies with
SEPTICAEMIA. Once established it is very difficult to eradicate. The bacteria ap
pear capable of lying
dormant in the bone and are not easily destroyed with antibiotics so that prolon
ged treatment is required,
as might be surgical drainage, exploration or removal of dead bone. The infectio
n may become chronic or
recur.
Osteomalacia (rickets) is the loss of mineralisation of the bone rather
than simple loss of bone mass.
It is caused by vitamin D deficiency and is probably the most important bone dis
ease in the developing
world. In sunlight the skin can synthesise vitamin D (see APPENDIX 5:
B
90 Bone, Disorders of
B
VITAMINS), but normally rickets is caused by a poor diet, or by a failur
e to absorb food normally
(malabsorbtion). In rare cases vitamin D cannot be converted to its active state
due to the congenital lack
of the specific enzymes and the rickets will fail to respond to treatment with v
itamin D. Malfunction of
the parathyroid gland or of the kidneys can disturb the dynamic equilibrium of c
alcium and phosphate in the
body and severely deplete the bone of its stores of both calcium and phosphate.
Osteoporosis A metabolic bone disease resulting from low bone mass (oste
openia) due to excessive bone
resorption. Sufferers are prone to bone fractures from relatively minor trauma.
With bone densitometry it
is now possible to determine individuals risk of osteoporosis and monitor their r
esponse to treatment. By
the age of 90 one in two women and one in six men are likely to sustain an osteo
porosisrelated fracture.
The incidence of fractures is increasing more than would be expected from the ag
eing of the population,
which may reflect changing patterns of exercise or diet. Osteoporosis may be cla
ssified as primary or
secondary. Primary consists of type 1 osteoporosis, due to accelerated trabecula
r bone loss, probably as a
result of OESTROGENS deficiency. This typically leads to crush fractures of vert
ebral bodies and fractures
of the distal forearm in women in their 60s and 70s. Type 2 osteoporosis, by con
trast, results from the
slower age-related cortical and travecular bone loss that occurs in both sexes.
It typically leads to
fractures of the proximal femur in elderly people. Secondary osteoporosis accoun
ts for about 20 per cent of
cases in women and 40 per cent of cases in men. Subgroups include endocrine (thy
rotoxicosis see under
THYROID GLAND, DISEASES OF, primary HYPERPARATHYROIDISM, CUSHINGS SYNDROME and HY
POGONADISM);
gastrointestinal (malabsorption syndrome, e.g. COELIAC DISEASE, or liver disease
, e.g. primary biliary
CIRRHOSIS); rheumatological (RHEUMATOID ARTHRITIS or ANKYLOSING SPONDYLITIS); ma
lignancy (multiple MYELOMA
or metastatic CARCINOMA); and drugs (CORTICOSTEROIDS, HEPARIN). Additional risk
factors for osteoporosis
include smoking, high alcohol intake, physical inactivity, thin body-type and he
redity. Individuals at risk
of osteopenia, or with an osteoporosis-related fracture, need investigation with
spinal radiography and
bone densitometry. A small fall in bone density results in a large increase in t
he risk of fracture, which
has
important implications for preventing and treating osteoporosis.
Treatment Antiresorptive drugs: hormone replacement therapy also valuabl
e in treating menopausal
symptoms; treatment for at least five years is necessary, and prolonged use may
increase risk of breast
Botulism
under normal load (a pathological fracture). The bone eroded away by the
tumour may also cause problems
by causing high levels of calcium in the plasma. is a malignant growth affecting
long bones, particularly
the tibia (calfbone). The presenting symptoms are a throbbing pain in the limb a
nd a high temperature.
Treatment is combined surgery, radiotherapy and chemotherapy.
EWINGS TUMOUR
MYELOMA is a generalised malignant disease of blood cells which produces
tumours in bones which have
red bone marrow, such as the skull and trunk bones. These tumours can cause path
ological fractures.
is a harmless small growth which can occur in any bone. Its pain is typi
cally removed by aspirin.
OSTEOID OSTEOMA
is a malignant tumour of bone with a peak incidence between the ages of
ten and 20. It typically
involves the knees, causing a warm tender swelling. Removal of the growth with b
one conservation techniques
can often replace amputation as the definitive treatment. Chemotherapy can impro
ve long-term survival.
OSTEOSARCOMA
91
Bone Transplant The insertion of a piece of bone from another site or fr
om another person to fill a
defect, provide supporting tissue, or encourage the growth of new bone.
Borborygmus Flatulence in the bowels (tummy rumbling).
Bornholm Disease Bornholm disease, also known as devils grip, and epidemi
c myalgia, is an acute
infective disease due to COXSACKIE VIRUSES. It is characterised by the abrupt on
set of pain around the
lower margin of the ribs, headache, and fever; it occurs in epidemics, usually d
uring warm weather, and is
more common in young people than in old. The illness usually lasts seven to ten
days. It is practically
never fatal. The disease is named after the island of Bornholm in the Baltic, wh
ere several epidemics have
been described.
Botulinum Toxin The
toxin
of
the
anaerobic
bacterium
CLOSTRIDIUM botulinum is now routinely used to treat focal DYSTONIA in a
dults. This includes
blepharospasm (see EYE, DISORDERS OF), SPASMODIC TORTICOLLIS, muscular spasms of
the
PLATELETS.
face, squint and some types of tremor. Injected close to where the nerve
enters the affected muscles,
the toxin blocks nerve transmissions for up to four months, so relieving symptom
s. The toxin is also used
in cerebral palsy. Although very effective, there are many possible unwanted eff
ects, especially if too
high a dose is used or the injection is misplaced.
Bone Marrow Transplant
Botulism
The procedure by which malignant or defective bone marrow in a patient i
s replaced with normal bone
marrow. Sometimes the patients own marrow is used (when the disease is in remissi
on); after storage using
tissue-freezing technique (cryopreservation) it is reinfused into the patient on
ce the diseased marrow has
been treated (autologous transplant). More commonly, a transplant uses marrow fr
om a donor whose tissue has
been matched for compatibility. The recipients marrow is destroyed with CYTOTOXIC
drugs before
transfusion. The recipient is initially nursed in an isolated environment to red
uce the risk of infection.
Disorders that can be helped or even cured include certain types of LEUKAEMIA an
d many inherited disorders
of the immune system (see IMMUNITY).
A rare type of food poisoning with a mortality greater than 50 per cent,
caused by the presence of the
exotoxin of the anaerobic bacterium Clostridium botulinum, usually in contaminat
ed tinned or bottled food.
Symptoms develop a few hours after ingestion. The toxin has two components, one
having haemagglutinin
activity and the other neurotoxic activity which produces most of the symptoms.
It has a lethal dose of as
little as 1 mg/kg and is highly selective for cholinergic nerves. Thus the sympt
oms are those of autonomic
parasympathetic blockade (dry mouth, constipation, urinary retention, mydriasis,
blurred vision) and
progress to blockade of somatic cholinergic transmission (muscle weakness). Deat
h results from respiratory
muscle paralysis. Treatment consists of supportive measures and
Bone Graft See BONE TRANSPLANT.
Bone Marrow Bone marrow is the soft substance occupying the interior of
bones. It is the site of
formation of ERYTHROCYTES, granular LEUCOCYTES and
92 Bougies
4 aminopyridine and 3, 4 di-aminopyridine, which may antagonise the effe
ct of the toxin.
B
Bougies Solid instruments
body in order either to apply
medicaments which they contain or
to dilate a narrow part or
stricture of the passage. Thus we
al bougies and rectal
bougies, made usually of flexible
l.
Consequently, a compensation package for patients and relatives was made availab
le. Meanwhile, a ban on the
export of UK beef and restrictions on the type of meat and products made from be
ef that can be sold to the
public were put in place. Although initially thought to be a problem primarily c
onfined to the UK, several
other countries notably France, Germany, Spain, Switzerland and the United State
s have also discovered
BSE in their cattle.
Bowels See INTESTINE.
Bowens Disease An uncommon chronic localised skin disease, presenting as
a solitary chronic fixed
irregular plaque mimicking eczema or psoriasis. It is a fairly benign form of CA
RCINOMA in situ in the
EPIDERMIS but can occasionally become invasive. It is curable by CRYOTHERAPY or
surgical excision.
Bow Leg Also known as genu varum: a deformity of the legs which comprise
s outward curvature between
knee and ankle. It may be normal in infancy, and occurs in osteoarthritis, RICKE
TS and other metabolic bone
diseases. In early childhood it may correct with growth, but in other cases surg
ical correction by
osteotomy or ephiphyseal stapling is possible.
Boxing Injuries Boxing injuries rank eighth in frequency among sports in
juries. According to the Report
on the Medical Aspects of Boxing issued by the Committee on Boxing of the Royal
College of Physicians of
London in 1969, of 224 exprofessional boxers examined, 37 showed evidence of bra
in damage and this was
disabling in 13. The first type of damage occurs as an acute episode in which on
e or more severe blows
leads to loss of consciousness and occasionally to death. Death in the acute pha
se is usually due to
intracranial haemorrhage and this carries a mortality of 45 per cent even with t
he sophisticated surgical
techniques currently available. The second type of damage develops over a
Brain 93
much longer period and is cumulative, leading to the atrophy of the cere
bral cortex and brain stem. The
repair processes of the brain are very limited and even after mild concussion it
may suffer a small amount
of permanent structural damage. Brain-scanning techniques now enable brain damag
e to be detected during
life, and brain damage of the type previously associated with the punch-drunk sy
ndrome is now being
detected before obvious clinical signs have developed. Evidence of cerebral atro
phy has been found in
relatively young boxers including amateurs and those whose careers have been con
sidered successful. The
tragedy is that brain damage can only be detected after it has occurred. Many do
ctors are opposed to
boxing, even with the present, more stringent medical precautions taken by those
responsible for running
the sport. Since the Royal Colleges survey in 1969, the British Medical Associati
on and other UK medical
organisations have declared their opposition to boxing on medical grounds, as ha
ve medical organisations in
several other countries. In 1998, the Dutch Health Council recommended that prof
essional boxing should be
banned unless the rules are tightened. It claimed that chronic brain damage is s
een in 4080 per cent of
boxers and that one in eight amateur bouts end with a concussed participant. The
re is currently no legal
basis on which to ban boxing in the UK, although it has been suggested that an i
njured boxer might one day
sue a promoter. One correspondent to the British Medical Journal in 1998 suggest
ed that since medical cover
is a legal requirement at boxing promotions, the profession should consider if i
ts members should withdraw
participation.
Brachial Brachial means belonging to the upper arm. There are, for example
, a brachial artery, and a
brachial plexus of nerves through which run all the nerves to the arm. The brach
ial plexus lies along the
outer side of the armpit, and is liable to be damaged in dislocation at the shou
lder.
Brachycephalic Brachycephalic means short-headed and is a term applied t
o skulls the breadth of which
is at least four-fifths of the length.
Brachydactyly The conditions in which the fingers or toes are abnormally
short.
Bradycardia Slowness of the beating of the heart with corresponding slow
ness of the pulse (below 60 per
minute). (See HEART, DISEASES OF.)
Bradykinesia Bradykinesia refers to the slow, writhing movements of the
body and limbs that may occur
in various brain disorders (see ATHETOSIS).
Bradykinin Bradykinin is a substance derived from plasma proteins; it pl
ays an important role in many
of the reactions of the body, including INFLAMMATION. Its prime action is in pro
ducing dilatation of
arteries and veins. It has also been described as the most powerful pain-producin
g agent known.
Braille A system of printing or writing devised for blind people. Develo
ped by the Frenchman Louis
Braille, the system is based on six raised dots which can be organised in differ
ent combinations within two
grades. Each system in Grade I represents an individual letter or punctuation ma
rk. Grade IIs symbols
represent common combinations of letters or individual words. Braille is accepte
d for all written
languages, mathematics, science and music, with Grade II the more popular type.
Brain The brain and spinal cord together form the central nervous sytem
(CNS). Twelve cranial nerves
leave each side of the brain (see NERVES, below) and 31 spinal nerves from each
side of the cord: together
these nerves form the peripheral nervous system. Complex chains of nerves lying
within the chest and
abdomen, and acting largely independently of the peripheral system, though linke
d with it, comprise the
AUTONOMIC NERVOUS SYSTEM and govern the activities of the VISCERA. The control c
entre of the whole nervous
system is the brain, which is located in the skull or cranium. As well as contro
lling the nervous system it
is the organ of thought, speech and emotion. The central nervous system controls
the bodys essential
functions such as breathing, body temperature (see HOMEOSTASIS) and the heartbea
t. The bodys various
sensations, including sight, hearing, touch, pain, positioning and taste, are co
mmunicated to the CNS by
nerves distributed throughout the relevant tissues. The information is then sort
ed and interpreted by
specialised areas in the brain. In
B
94 Brain
B
response these initiate and coordinate the motor output, triggering such
voluntary activities as
movement, speech, eating and swallowing. Other activities for example, breathing
, digestion, heart
contractions, maintenance of BLOOD PRESSURE, and filtration of waste products fr
om blood passing through
the kidneys are subject to involuntary control via the autonomic system. There i
s, however, some overlap
between voluntary and involuntary controls.
Divisions This forms nearly 70 per cent of the brain and consists of two
cerebral hemispheres which
occupy the entire vault of the cranium and are incompletely separated from one a
nother by a deep mid-line
cleft, the longitudinal cerebral fissure. At the bottom of this cleft the two he
mispheres are united by a
thick band of some 200 million crossing nerve fibres the corpus callosum. Other
clefts or fissures
(sulci) make deep impressions, dividing the cerebrum into lobes. The lobes of th
e cerebrum are the frontal
lobe in the forehead region, the parietal lobe on the side and upper part of the
brain, the occipital lobe
to the back, and the temporal lobe lying just above the region of the ear. The o
uter 3 mm of the cerebrum
is called the cortex, which consists of grey matter with the nerve cells arrange
d in six layers. This
region is concerned with conscious thought, sensation and movement, operating in
a similar manner to the
more primitive areas of the brain except that incoming information is subject to
much greater analysis.
Numbers of shallower infoldings of the surface, called furrows or sulci, separat
e raised areas called
convolutions or gyri. In the deeper part, the white matter consists of nerve fib
res connecting different
parts of the surface and passing down to the lower parts of the brain. Among the
white matter lie several
rounded masses of grey matter, the lentiform and caudate nuclei. In the centre o
f each cerebral hemisphere
is an irregular cavity, the lateral ventricle, each of which communicates with t
hat on the other side and
behind with the third ventricle through a small opening, the inter-ventricular f
oramen, or foramen of
Monro.
CEREBRUM
Two large masses of grey matter embedded in the base of the cerebral hem
ispheres in humans, but forming
the chief part of the brain in many animals. Between these masses lies the third
ventricle, from which the
infundibulum, a funnel-shaped process, projects downwards into the pituitary bod
y, and
BASAL NUCLEI
above lies the PINEAL GLAND. This region includes the important HYPOTHAL
Brain, Diseases of
spinal cord where they end near, and exert a control upon, cells from wh
ich in turn spring the nerves
to the body. Both grey and white matter are bound together by a network of cells
called GLIA which make up
60 per cent of the brains weight. These have traditionally been seen as simple st
ructures whose main
function was to glue the constituents of the brain together. Recent research, ho
wever, suggests that glia
are vital for growing synapses between the neurons as they trigger these cells t
o communicate with each
other. So they probably participate in the task of laying down memories, for whi
ch synapses are an
essential key. The research points to the likelihood that glial cells are as com
plex as neurons,
functioning biochemically in a similar way. Glial cells also absorb potassium pu
mped out by active neurons
and prevent levels of GLUTAMATE the most common chemical messenger in the brain
from becoming too high.
The general arrangement of fibres can be best understood by describing the cours
e of a motor nerve-fibre.
Arising in a cell on the surface in front of the central sulcus, such a fibre pa
sses inwards towards the
centre of the cerebral hemisphere, the collected mass of fibres as they lie betw
een the lentiform nucleus
and optic thalamus being known as the internal capsule. Hence the fibre passes d
own through the crus
cerebri, giving off various small connecting fibres as it passes downwards. Afte
r passing through the pons
it reaches the medulla, and at this point crosses to the opposite side (decussat
ion of the pyramids).
Entering the spinal cord, it passes downwards to end finally in a series of bran
ches (arborisation) which
meet and touch (synapse) similar branches from one or more of the cells in the g
rey matter of the cord (see
SPINAL CORD). Four vessels carry blood to the brain: two internal carotid arteri
es in front, and two
vertebral arteries behind. These communicate to form a circle (circle of Willis)
inside the skull, so that
if one is blocked, the others, by dilating, take its place. The chief branch of
the internal carotid artery
on each side is the middle cerebral, and this gives off a small but very importa
nt branch which pierces the
base of the brain and supplies the region of the internal capsule with blood. Th
e chief importance of this
vessel lies in the fact that the blood in it is under especially high pressure,
owing to its close
connection with the carotid artery, so that haemorrhage from it is liable to occ
ur and thus give rise to
stroke. Two veins, the internal cereBLOOD VESSELS
95
bral veins, bring the blood away from the interior of the brain, but mos
t of the small veins come to
the surface and open into large venous sinuses, which run in grooves in the skul
l, and finally pass their
blood into the internal jugular vein that accompanies the carotid artery on each
side of the neck. The
brain is separated from the skull by three membranes: the dura mater, a thick fi
brous membrane; the
arachnoid mater, a more delicate structure; and the pia mater, adhering to the s
urface of the brain and
containing the blood vessels which nourish it. Between each pair is a space cont
aining fluid on which the
brain floats as on a water-bed. The fluid beneath the arachnoid membrane mixes w
ith that inside the
ventricles through a small opening in the fourth ventricle, called the median ap
erture, or foramen of
Magendie. These fluid arrangements have a great influence in preserving the brai
n from injury. MEMBRANES
NERVES
I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII.
Twelve nerves come off the brain: Olfactory, to the nose (smell). Optic,
to the eye (sight). Oculomotor
Trochlear, to eye-muscles. Abducent Trigeminal, to skin of face. Facial, to musc
les of face.
Vestibulocochlear, to ear (hearing and balancing). Glossopharyngeal, to tongue (
taste). Vagus, to heart,
larynx, lungs, and stomach. Spinal accessory, to muscles in neck. Hypoglossal, t
o muscles of tongue.
Brain, Diseases of These consist either of expanding masses (lumps or tu
mours), or of areas of
shrinkage (atrophy) due to degeneration, or to loss of blood supply, usually fro
m blockage of an artery.
Tumours All masses cause varying combinations of headache and vomiting s
ymptoms of raised pressure
within the inexpansible bony box formed by the skull; general or localised epile
ptic fits; weakness of
limbs or disordered speech; and varied mental changes. Tumours may be primary, a
rising in the brain, or
secondary deposits from tumours arising in the lung, breast or other organs. Som
e brain tumours are benign
and curable by surgery: examples include meningiomas and pituitary tumours. The
symptoms depend on the size
and situation
B
96 Brain, Diseases of
B
of the mass. Abscesses or blood clots (see HAEMATOMA) on the surface or
within the brain may resemble
tumours; some are removable. Gliomas ( see GLIOMA) are primary malignant tumours
arising in the glial
tissue (see GLIA) which despite surgery, chemotherapy and radiotherapy usually h
ave a bad prognosis, though
some astrocytomas and oligodendronogliomas are of low-grade malignancy. A promis
ing line of research in the
US (in the animal-testing stage in 2000) suggests that the ability of stem cells
from normal brain tissue
to home in on gliomal cells can be turned to advantage. The stem cells were chemic
ally manipulated to
carry a poisonous compound (5-fluorouracil) to the gliomal cells and kill them,
without damaging normal
cells. Around 80 per cent of the cancerous cells in the experiments were destroy
ed in this way. Clinical
examination and brain scanning (CT, or COMPUTED TOMOGRAPHY; magnetic resonance i
maging (MRI) and functional
MRI) are safe, accurate methods of demonstrating the tumour, its size, position
and treatability.
Parkinsons disease, hereditary Huntingtons chorea, or, in children with bi
rth defects of the brain,
athetosis and dystonias. Modern drugs, such as DOPAMINE drugs in PARKINSONISM, a
nd other treatments can
improve the symptoms and reduce the disabilities of some of these diseases.
Drugs and injury Alcohol in excess, the abuse of many sedative drugs and
artificial brain stimulants
such as cocaine, LSD and heroin (see DEPENDENCE) can damage the brain; the effec
ts can be reversible in
early cases. Severe head injury can cause localised or diffuse brain damage (see
HEAD INJURY).
Cerebral palsy Damage to the brain in children can occur in the uterus d
uring pregnancy, or can result
from rare hereditary and genetic diseases, or can occur during labour and delive
ry. Severe neurological
illness in the early months of life can also cause this condition in which stiff
spastic limbs, movement
disorders and speech defects are common. Some of these children are learning-dis
abled.
Strokes When a blood vessel, usually an artery, is blocked by a clot, th
rombus or embolism, the local
area of the brain fed by that artery is damaged (see STROKE). The resulting infa
rct (softening) causes a
stroke. The cells die and a patch of brain tissue shrinks. The obstruction in th
e blood vessel may be in a
small artery in the brain, or in a larger artery in the neck. Aspirin and other
anti-clotting drugs reduce
recurrent attacks, and a small number of people benefit if a narrowed neck arter
y is cleaned out by an
operation endarterectomy. Similar symptoms develop abruptly if a blood vessel bu
rsts, causing a cerebral
haemorrhage. The symptoms of a stroke are sudden weakness or paralysis of the ar
Brain-Stem Death
gitis, but early diagnosis is essential. Severe headaches, fever, vomiti
ng and increasing sleepiness
are the principal symptoms which demand urgent advice from the doctor, and usual
ly admission to hospital.
Group B meningococcus is the commonest of the bacterial infections, but Group C
causes more deaths. A
vaccine against the latter has been developed and has reduced the incidence of c
ases by 75 per cent. If
infection spreads from an unusually serious sinusitis or from a chronically infe
cted middle ear, or from a
penetrating injury of the skull, an abscess may slowly develop. Brain abscesses
cause insidious drowsiness,
headaches, and at a late stage, weakness of the limbs or loss of speech; a high
temperature is seldom
present. Early diagnosis, confirmed by brain scanning, is followed by antibiotic
s and surgery in hospital,
but the outcome is good in only half of affected patients.
Cerebral oedema Swelling of the brain can occur after injury, due to eng
orgement of blood vessels or an
increase in the volume of the extravascular brain tissue due to abnormal uptake
of water by the damaged
grey (neurons) matter and white (nerve fibres) matter. This latter phenomenon is
called cerebral oedema and
can seriously affect the functioning of the brain. It is a particularly dangerou
s complication following
injury because sometimes an unconscious person whose brain is damaged may seem t
o be recovering after a few
hours, only to have a major relapse. This may be the result of a slow haemorrhag
e from damaged blood
vessels raising intracranial pressure, or because of oedema of the brain tissue
in the area surrounding the
injury. Such a development is potentially lethal and requires urgent specialist
treatment to alleviate the
rising intracranial pressure: osmotic agents (see OSMOSIS) such as mannitol or f
rusemide are given
intravenously to remove the excess water from the brain and to lower intracrania
l pressure, buying time for
definitive investigation of the cranial damage.
Brain Injuries Most blows to the head cause no loss of consciousness and
no brain injury. If someone is
knocked out for a minute or two, there has been a brief disturbance of the brain
cells (concussion);
usually there are no after-effects. Most patients so affected leave hospital wit
hin 13 days, have no
organic signs, and recover and return quickly to work without further complaints
.
97
Severe head injuries cause unconsciousness for hours or many days, follo
wed by loss of memory before
and after that period of unconsciousness. The skull may be fractured; there may
be fits in the first week;
and there may develop a blood clot in the brain (intracerebral haematoma) or wit
hin the membranes covering
the brain (extradural and subdural haematomata). These clots compress the brain,
98 Bran
B
tests must be repeated after a suitable interval before
lared. Imaging techniques are
not required for death to be diagnosed. The test for brain-stem
dilated pupils of the eyes
Absent CORNEAL REFLEX Absent VESTIBULO-OCULAR REFLEX No cranial
o somatic (physical)
stimulation Absent gag and cough reflexes No respiratory effort
PNOEA despite adequate
concentrations of CARBON DIOXIDE in the arterial blood.
Bran The meal derived from the outer covering of a cereal grain. It cont
ains little or no carbohydrate,
and is mainly used to provide ROUGHAGE in the control of bowel function and the
prevention of constipation.
Branchial Cyst A cyst arising in the neck from remnants of the embryolog
ical branchial clefts. They are
usually fluid-filled and will therefore transilluminate.
Breasts Breasts, or mammary glands, occur only in mammals and provide mi
lk for feeding the young. These
paired organs are usually fully developed only in adult females, but are present
in rudimentary form in
juveniles and males. In women, the two breasts over-lie the second to sixth ribs
on the front of the chest.
On the surface of each breast is a central pink disc called the areola, which su
rrounds the nipple. Inside,
the breast consists of fat, supporting tissue and glandular tissue, which is the
part that produces
milk following childbirth. Each breast consists of 1220 compartments arra
nged radially around the
nipple: each compartment opens on to the tip of the nipple via its own duct thro
ugh which the milk flows.
The breast enlargement that occurs in pregnancy is due to development of the gla
ndular part in preparation
for lactation. In women beyond childbearing age, the glandular part of the breas
ts reduces (called
involution) and the breasts become less firm and contain relatively more fat.
Breasts, Diseases of The female breasts may be expected to undergo hormo
ne-controlled enlargement at
puberty, and later in pregnancy, and the glandular part of the breast undergoes
evolution (shrinkage) after
the menopause. The breast can also be affected by many different diseases, with
common symptoms being pain,
nipple discharge or retraction, and the formation of a lump within the breast.
Benign disease is much more common than cancer, particularly in young wo
men, and includes acute
inflammation of the breast (mastitis); abscess formation; and benign breast lump
s, which may be
fibroadenosis diffuse lumpiness also called chronic mastitis or fibrocystic dise
ase in which one or
more fluidfilled sacs (cysts) develop. Women who are breast feeding are particul
arly prone to mastitis, as
infection may enter the breast via the nipple. The process may be arrested befor
e a breast abscess forms by
prompt treatment with antibiotics. Non-bacterial inflammation may result from ma
mmary duct 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 should be with antibiotic
s, but if an abscess does form
it should be surgically drained. Duct ectasia, with or without local mastitis, i
s the usual benign cause of
various nipple complaints, with common symptoms being nipple retraction, dischar
ge and skin change. Breast
lumps form the chief potential danger and may be either solid or cystic. Simple
examination may fail to
distinguish the two types, but aspiration of a benign cyst usually results in it
s disappearance. If the
fluid is bloodstained, or if a lump still remains, malignancy is possible, and a
ll solid lumps need
histological (tissue examination) or cytological (cell examination) assessment.
As well as having their
medical and family history taken, any women with a breast lump should undergo tr
iple assessment: a
combination of clinical examination, imaging mammography for the over-35s and ul
trasonagraphy for the
under-35s and fine-needle aspiration. The medical history should include details
of any previous lumps,
family history (up to 10 per cent of breast cancer in western countries is due t
o genetic disposition),
pain, nipple discharge, change in size related to menstrual cycle and parous sta
te, and any drugs being
taken by the patient. Breasts should be inspected with the arms up and down, not
ing position, size,
consistency, mobility, fixity, and local lymphadenopathy (glandular swelling). N
ipples should be examined
for the presence of inversion or discharge. Skin involvement (peau dorange) shoul
d be noted, and, in
particular, how long changes have been present. Fineneedle aspiration and cytolo
gical examination of the
fluid are essential with ULTRASOUND, MAMMOGRAPHY and possible BIOPSY being consi
dered, depending on the
patients age and the extent of clinical suspicion that cancer may be present. The
commonest solid benign
lump is a fibroadenoma, particularly in women of childbearing age, and is a pain
less, mobile lump. If
small, it is usually safe to leave it alone, provided that the patient is warned
to seek medical advice if
its size or character changes or if the lump becomes painful. Fibroadenosis (dif
fuse lumpiness often in the
upper, outer quadrant) is a common (benign) lump. Others include periductal mast
itis, fat NECROSIS,
GALACTOCELE, ABSCESS, and non-breast-tissue lumps for example, a LIPOMA (fatty t
issue) or SEBACEOUS CYST.
A woman with breast discharge should have a mammograph, ductograph, or total duc
t excision until the cause
of any underlying duct ectasia is known. Appropriate treatment should then be gi
ven.
Malignant disease most commonly but not exclusively occurs in post-menop
ausal women, classically
presenting as a slowly growing, painless, firm lump. A bloodstained nipple disch
arge or eczematous skin
change may also be suggestive of cancer. The most commonly used classification o
f invasive cancers has
split them into two types, ductal and lobular, but this is no longer suitable. T
100 Breastbone
B
it may occasionally cause endometrial carcinoma. Analysis in the mid-199
0s of large-scale international
studies of breast-cancer treatments showed wide variations in their effectivenes
s. As a result the NHS has
encouraged hospitals to set up breast-treatment teams containing all the relevan
t health professional
experts and to use those treatments shown to be most effective. As well as the p
hysical treatments
provided, women with suspected or proven breast cancer should be offered psychol
ogical support because up
to 30 per cent of affected women develop an anxiety state or depressive illness
within a year of diagnosis.
Problems over body image and sexual difficulties occur in and around one-quarter
of patients. Breast
conservation and reconstructive surgery can improve the physical effects of mast
ectomy, and women should be
advised on the prostheses and specially designed brassieres that are available.
Specialist nurses and
self-help groups are invaluable in supporting affected women and their partners
with the problems caused by
breast cancer and its treatment. Breast Cancer Care, British Association of Canc
er United Patients (BACUP),
Cancerlink, and Cancer Relief Macmillan Fund are among voluntary organisations p
roviding support.
Breast Screening A set of investigations aimed at the early detection of
breast cancer. It includes
self-screening by monthly examination of the breasts, and formal programmes of s
creening by palpation and
mammography in special clinics. In the UK the NHS offers regular mammography exa
minations to all women
between 50 and 64 years of age; in 19956, 1.1 million women were screened 76 per
cent of those invited.
More than 5,500 cancers were detected 5.3 per 1,000 women screened.
Breath-Holding
See STERNUM.
Breath-holding attacks are not uncommon in infants and toddlers. They ar
e characterised by the child
suddenly stopping breathing in the midst of a bout of crying evoked by pain, som
e emotional upset, or loss
of temper. The breath may be held so long that the child goes blue in the face.
The attack is never fatal
and the condition disappears spontaneously after the age of 35 years, but once a
child has acquired the
habit it may recur quite often. It is important for a paediatrician to determine
that such events are not
epileptic (see EPILEPSY). Generally they require no treatment other than reassur
ance, as recovery is
spontaneous and rapid although a small number of severely affected children have
been helped by a
PACEMAKER. Parents should avoid dramatising the attacks.
Breast Feeding
Breathing
Breastbone
This is the natural way to feed a baby from birth to WEANING. Human milk
is an ideal food, containing a
proper balance of nutrients as well as an essential supply of antibodies to prot
ect the infant against
infections. Breast feeding also strengthens the physical bond between mother and
child. For the first few
weeks, feeding should be on demand. Difficulties over breast feeding, discourage
ment from health-care
providers and the pressures of modern life, especially for working mothers, can
make it hard to continue
breast feeding for more than a few weeks, or even to breast feed at all. Sometim
es infections occur,
producing soreness and even an abscess. Mothers should seek advice from their he
alth visitor about breast
feeding, especially if problems arise.
Breast Reconstruction See MAMMOPLASTY.
Breast Reduction See MAMMOPLASTY.
See RESPIRATION.
Breathlessness Breathlessness, or dyspnoea, may be due to any condition
which renders the blood
deficient in oxygen, and which therefore produces excessive involuntary efforts
to gain more air. Exercise
is a natural cause, and acute anxiety may provoke breathlessness in otherwise he
althy people. Deprivation
of oxygen for example, in a building fire will also cause the victim to raise hi
s or her breathing
rate. Disorders of the lung may diminish the area available for breathing for ex
ample, ASTHMA, PNEUMONIA,
TUBERCULOSIS, EMPHYSEMA, BRONCHITIS, collections of fluid in the pleural cavitie
s, and pressure caused by a
TUMOUR or ANEURYSM. Pleurisy causes short, rapid breathing to avoid the pain of
deep inspiration. Narrowing
of the air passages may produce sudden and alarming attacks of difficult breathi
ng, especially among
children for CROUP, asthma and example, in DIPHTHERIA.
Bronchiectasis 101
Most cardiac disorders (see HEART, DISEASES OF ) cause breathlessness, e
specially when the person
undergoes any special exertion.
is a frequent cause. Anaemia Obesity is often associated with shortness
of
breath. Mountain climbing may cause breathlessness because, as altitude
increases, the amount of oxygen
in the air falls (see ALTITUDE SICKNESS). (See also LUNGS and RESPIRATION.)
Breath Sounds The transmitted sounds of breathing, heard when a stethosc
ope is applied to the chest.
Normal breath sounds are described as vesicular. Abnormal sounds may be heard wh
en there is increased fluid
in the lungs or fibrosis (crepitation or crackles), when there is bronchospasm (
rhonchi or wheezes), or
when the lung is airless (consolidated bronchial breathing). Breath sounds are a
bsent in people with
pleural effusion, pneumothorax, or after pneumonectomy.
Breech Delivery See BREECH PRESENTATION.
Breech Presentation By the 32nd week of pregnancy most babies are in a h
ead-down position in the womb.
Up to 4 per cent of them, however, have their buttocks (breech) presenting at th
e neck of the womb. If the
baby is still a breech presentation at the 34th to 35th week the obstetrician ma
y, by external
manipulation, try to turn it to the head-down position. If this is not successfu
l, the fetus is left in the
breech position. Breech deliveries are more difficult for mother and baby becaus
e the buttocks are less
efficient than the head at dilating the cervix and vagina. An EPISIOTOMY is usua
lly necessary to assist
delivery, and obstetric FORCEPS may also have to be applied to the babys head. If
the infant and/or the
mother become unduly distressed, the obstetrician may decide to deliver the baby
by CAESAREAN SECTION; some
obstetricians prefer to deliver most breech-presentation babies using this metho
d. (See PREGNANCY AND
LABOUR.)
Brights Disease See KIDNEYS, DISEASES OF Glomerulonephritis.
British Approved Names (BAN) The officially approved name for a medicina
l substance used in the UK. A
1992 European Union directive required the use of a Recommended International No
n-proprietary Name (rINN)
for these substances. Usually the BAN
and rINN were identical; where there was a difference, the rINN nomencla
ture is now used. An exception
is adrenaline, which remains the official name in Europe with the rINN epinephri
ne being a synonym.
British Dental Association See APPENDIX 8: PROFESSIONAL ORGANISATIONS.
102 Bronchioles
B
infected. The initial infection may be due to bacterial or viral pneumon
ia or to the infection of the
lungs complicating measles or whoopingcough. Once a common disease, immunisation
of infants against
infectious diseases and the use of antibiotics have greatly reduced the incidenc
e of bronchiectasis. (See
CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD).)
Treatment consists of postural drainage of excessive lung secretions, an
d antibiotics.
Bronchioles The term applied to the finest divisions of the bronchial tu
bes of the LUNGS.
Bronchiolitis The name sometimes applied to bronchitis affecting the fin
est bronchial tubes, also known
as capillary bronchitis. Major epidemics occur every winter in Northern Europe i
n babies under 18 months
due to respiratory syncytial virus (RSV). Many are admitted to hospital; some ne
ed artificial ventilation
for a time and a very small number die.
Bronchiolitis Obliterans A rare disorder involving gradually increasing
FIBROSIS and destruction of
lung tissue following an attack of BRONCHIOLITIS.
Bronchitis Inflammation of the bronchial tubes (see AIR PASSAGES; BRONCH
US; LUNGS). This may occur as
an acute transient illness or as a chronic condition.
Acute bronchitis is due to an acute infection viral or bacterial of the
bronchi. This is
distinguished from PNEUMONIA by the anatomical site involved: bronchitis affects
the bronchi whilst
pneumonia affects the lung tissue. The infection causes a productive cough, and
fever. Secretions within
airways sometimes lead to wheezing. Sometimes the specific causative organism ma
y be identified from the
sputum. The illness is normally self-limiting but, if treatments are required, b
acterial infections respond
to a course of antibiotics.
Chronic bronchitis is a clinical diagnosis applied to patients with chro
nic cough and sputum
production. For epidemiological studies it is defined as cough productive of sput
um on most days during at
least three consecutive months for not less than two consecutive years. Chronic b
ronchitis is classified
as a CHRONIC PULMONARY OBSTRUCTIVE DISEASE (COPD);
chronic ASTHMA and EMPHYSEMA are the others. In the past, industrial wor
kers regularly exposed to
heavily polluted air commonly developed bronchitis. The main aetiological factor
is smoking; this leads to
an increase in size and number of bronchial mucous glands. These are responsible
for the excessive mucus
production within the bronchial tree, causing a persistent productive cough. The
increased number of mucous
glands along with the influx of inflammatory cells may lead to airwaynarrowing:
when airway-narrowing
occurs, it slows the passage of air, producing breathlessness. Other less import
ant causative factors
include exposure to pollutants and dusts. Infections do not cause the disease bu
t frequently produce
exacerbations with worsening of symptoms.
Treatments involve the use of antibiotics to treat the infections that p
roduce exacerbations of
symptoms. Bronchodilators (drugs that open up the airways) help to reverse the a
irwaynarrowing that causes
the breathlessness. PHYSIOTHERAPY is of value in keeping the airways clear of MU
CUS. Cessation of smoking
reduces the speed of progression.
Bronchodilator This type of drug reduces the tone of smooth muscle in th
e lungs BRONCHIOLES and
therefore increases their diameter. Such drugs are used in the treatment of dise
ases that cause
bronchoconstriction, such as ASTHMA and BRONCHITIS. As bronchiolar tone is a bal
ance between sympathetic
and parasympathetic activity, most bronchodilators are either B2 receptor agonis
ts or cholinergic receptor
antagonists although theophyllines are also useful.
Bronchography A radiographic procedure using a radio-opaque substance in
jected into the bronchial tree
to show its outline. This is a simple procedure carried out under general anaest
hesia and allows the
accurate location of, for example, a lung ABSCESS, BRONCHIECTASIS, or a TUMOUR i
n the lung.
Bronchopleural Fistula An abnormal communication between the tracheo-bro
nchial tree and the pleural
cavity (see LUNGS). Most commonly occurring from breakdown of the bronchial stum
p following pneumonectomy,
it may also be caused by trauma, neoplasia or inflammation.
Bruxism
Broncho-Pneumonia See PNEUMONIA.
Bronchoscope An instrument constructed on the principle of the telescope
, which on introduction into
the mouth is passed down through the LARYNX and TRACHEA and enables the observer
to see the interior of the
larger bronchial tubes. The bronchoscope has largely been superseded by fibreopt
ic bronchoscopy. (See
ENDOSCOPE.)
Bronchoscopy The use of a bronchoscope to visualise the interior of the
bronchial tubes.
Bronchospasm Muscular contraction of the bronchi (air passages) in the L
UNGS, causing narrowing. The
cause is usually a stimulus, as in BRONCHITIS and ASTHMA. The result is that the
patient can inhale air
into the lungs but breathing out becomes difficult and requires muscular effort
of the chest. Exhalation is
accompanied by audible noises in the airways which can be detected with a STETHO
SCOPE. Reversible
obstructive airways disease can be relieved with a BRONCHODILATOR drug; if the b
ronchospasm cannot be
relieved by drugs it is called irreversible. (See CHRONIC OBSTRUCTIVE PULMONARY
DISEASE
(COPD).)
Bronchus Bronchus, or bronchial tube, is the name applied to tubes into
which the TRACHEA divides, one
going to either lung. The name is also applied to the divisions of these tubes d
istributed throughout the
lungs, the smallest being called bronchioles.
Brucellosis Also known as undulant fever, or Malta fever.
Causes In Malta and the Mediterranean littoral, the causative organism i
s the bacterium Brucella
melitensis which is conveyed in goats milk. In Great Britain, the US and South Af
rica, the causative
organism is the Brucella abortus, which is conveyed in cows milk: this is the org
anism which is
responsible for contagious abortion in cattle. In Great Britain brucellosis is l
argely an occupational
disease and is now prescribed as an industrial disease (see OCCUPATIONAL DISEASE
S), and insured persons who
contract the disease at work can claim industrial injuries benefit. The incidenc
e of brucellosis in the UK
has fallen from more than 300 cases a year in 1970 to single figures.
103
Symptoms The characteristic features of the disease are undulating fever
, drenching sweats, pains in
the joints and back, and headache. The liver and spleen may be enlarged. The dia
gnosis is confirmed by the
finding of Br. abortus, or antibodies to it, in the blood. Recovery and convales
cence tend to be slow.
104 Bubo
cause should be treated but, if unsuccessful, a plastic splint can be fi
tted over the teeth.
B
Bubo (Plural: buboes.) A swelling of a lymphatic gland in the groin in v
enereal disease (see SEXUALLY
TRANSMITTED DISEASES (STDS)) or in
Bulla An air- or fluid-filled bubble occurring in the skin or lungs. The
latter may be congenital or
the result (in adults) of EMPHYSEMA. Skin bullae are really blisters.
Bumetanide
Relating to the mouth or inside of the cheek.
Bumetanide is a strong loop diuretic which is active when taken by mouth
. It acts quickly within a
half-hour and its action is over in a few hours. (See THIAZIDES; DIURETICS.)
Budgerigar-Fanciers Lung
Bundle Branch Block
Budgerigar-fanciers lung is a form of extrinsic allergic ALVEOLITIS, resu
lting from sensitisation to
budgerigars, or parakeets as they are known in North America. Skin tests have re
vealed sensitisation to the
birds droppings and/or serum. As it is estimated that budgerigars are kept in 5 6
million homes in
Britain, current figures suggest that anything up to 900 per 100,000 of the popu
lation are exposed to the
risk of developing this condition.
An abnormality of the conduction of electrical impulses through the vent
ricles of the HEART, resulting
in delayed depolarisation of the ventricular muscle. The electrocardiograph (see
ELECTROCARDIOGRAM (ECG))
shows characteristic widening of the QRS complexes. Abnormalities of the right a
nd left bundle branches
cause delayed contraction of the right and left ventricles respectively.
PLAGUE.
Buccal
Buergers Disease See THROMBOANGIITIS OBLITERANS.
Bulbar Paralysis See PARALYSIS; MOTOR NEURONE DISEASE (MND).
Bulimia Bulimia means insatiable appetite of psychological origin. This
eating-disorder symptom may be
of psychological origin or the result of neurological disease for example, a les
ion of the HYPOTHALAMUS.
Bulimia nervosa is linked to anorexia nervosa and is sometimes called the binge
and purge syndrome. Bulimia
nervosa is characterised by overpowering urges to eat large amounts of food, fol
properly. This will show itself by the development of JAUNDICE and the appearanc
e of albumin in the urine
(see PROTEINURIA). In addition, the circulation begins to fail with a resultant
lack of oxygen (see ANOXIA)
in the tissues, and the victim becomes cyanosed (see CYANOSIS), restless and col
lapsed: in some cases,
death ensues. In addition, there is a strong risk of infection occurring. This i
s the case with severe
burns in particular, which leave a large raw surface exposed and very vulnerable
to any micro-organisms.
The combination of shock and infection can all too often be lifethreatening unle
ss expert treatment is
immediately available. The immediate outcome of a burn is largely determined by
its extent. This is of more
significance than the depth of the burn. To assess the extent of a burn in relat
ion to the surface of the
body, what is known as the Rule of Nine has been evolved. The head and each arm
cover 9 per cent of the
body surface, whilst the front of the body, the back of the body, and each leg e
ach cover 18 per cent, with
the perineum (or crutch) accounting for the remaining 1 per cent. The greater th
e extent of the burn, the
more seriously ill will the victim become from loss of fluid from his or her cir
culation, and therefore the
more prompt should be his or her removal to hospital for expert treatment. The d
epth of the burn, unless
this is very great, is mainly of import when the question arises as to how much
surgical treatment,
including skin 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, when there is sufficien
t skin tissue left to ensure
the burn. In the case of quite minor burns or scalds, all that may be ne
cessary if they are seen
A mental state of physical and emotional exhaustion; an anxiety disorder
that is a stress reaction to a
persons reduced capability to cope with the demands of his or her occupations. Sy
mptoms of burnout include
tiredness, poor sleeping pattern, irritability and reduced performance at work;
increased susceptibility to
physical illness and abuse of alcohol and addictive drugs can also occur. Treatm
ent can be difficult and
may require a change to a less stressful lifestyle, counselling and, in severe c
ases, psychotherapy and
carefully supervised use of ANXIOLYTICS or ANTIDEPRESSANT DRUGS.
Burns and Scalds
B
Byte
necessary. For example, the condition of housemaids knee is a chronic inf
lammation of the patellar
bursa in front of the knee, due to too much kneeling. Chronic bursitis affecting
ligaments round the wrist
and ankle is generally called a GANGLION.
Buspirone A non-benzodiazepine drug used to treat anxiety. It is believe
d to act at specific serotonin
receptors of NEURON(E) cells. The patient may take as long as two weeks to respo
nd to treatment.
Busulfan A drug used almost exclusively to treat chronic myeloid LEUKAEM
IA; it is given by mouth.
Excessive suppression of myelocytes may lead to irreversible damage to BONE MARR
OW and therefore to the
manufacture of blood cells, so frequent blood counts are necessary to check on t
he numbers of red and white
cells.
Butyrophenones Butyrophenones are a group of drugs, including haloperido
l, used to treat psychotic
illness (see MENTAL ILLNESS).
Bypass Operation A technique by which narrowing or blockage of
107
an artery (see ARTERIES), vein (see VEINS) or a section of the gastroint
estinal tract is bypassed using
surgery. Arterial blockages usually caused by ATHEROSCLEROSIS in the carotid, co
ronary or iliofemoral
arteries are bypassed utilising sections of artery or vein taken from elsewhere
in the patient. Tumour
growths in the intestines are sometimes too large to remove and can be bypassed
by linking up those parts
of the intestines on each side of the growth.
Byssinosis Chronic inflammatory thickening of the lung tissue, due to th
e inhalation of dust in textile
factories. It is found chiefly among cotton and flax workers and, to a lesser ex
tent, among workers in soft
hemp. It is rare or absent in workers in jute and the hard fibres of hemp and si
sal. With much-improved
working conditions in the UK, where byssinosis is one of the PRESCRIBED DISEASES
, the disease is rare, but
it is still common in some Asian countries where textiles are manufactured.
Byte Computer terminology describing a group of neighbouring bits, usual
ly four, six or eight, working
as a unit for the storage and manipulation of data in a computer.
B
C Cachet
An oval capsule that encloses a dose of unpleasant medicine.
Cachexia Severe weight loss and listlessness produced by serious disease
such as cancer or
tuberculosis, or by prolonged starvation.
Cadaver A dead body.
Cadmium A metallic element which, when molten, gives off fumes that can
cause serious irritation of the
lungs if inhaled.
Cadmium Poisoning Cadmium poisoning is a recognised hazard in certain in
dustrial processes, such as the
manufacture of alloys, cadmium plating and glass blowing. Sewage sludge, which i
s used as fertiliser, may
be contaminated by cadmium from industrial sources; such cadmium could be taken
up into vegetable crops and
cadmium levels in sewage are carefully monitored. A tin-like metal, cadmium accu
mulates in the body.
Long-term exposure can lead to EMPHYSEMA, renal failure (see KIDNEYS, DISEASES O
F) and urinary-tract
CALCULI. Acute exposure causes GASTROENTERITIS and PNEUMONITIS. Cadmium contamin
ation of food is the most
likely source of poisoning. The EU Directive on the Quality of Water for Human C
onsumption lays down 5
milligrams per litre as the upper safe level.
Caecum The dilated first part of the large intestine lying in the right
lower corner of the abdomen.The
small intestine and the appendix open into it, and it is continued upwards throu
gh the right flank as the
ascending colon.
Caesarean Section The operation used to deliver a baby through its mothe
rs abdominal wall. It is
performed when the risks to mother or child of vaginal delivery are thought to o
utweigh the problems
associated with operative delivery. One of the most common reasons for Caesarean
section is disproportion between the size of the fetal head and the maternal pelvis. Th
e need for a Caesarean should
be assessed anew in each pregnancy; a woman who has had a Caesarean section in t
he past will not
automatically need to have one for subsequent deliveries. Caesarean-section rate
s vary dramatically from
hospital to hospital, and especially between countries, emphasising that the cri
teria for operative
delivery are not universally agreed. The current rate in the UK is about 23 per
cent, and in the USA, about
28 per cent. The rate has shown a steady rise in all countries over the last dec
ade. Fear of litigation by
patients is one reason for this rise, as is the uncertainty that can arise from
abnormalities seen on fetal
monitoring during labour. Recent research suggesting that vaginal delivery is be
coming more hazardous as
the age of motherhood rises may increase the pressure from women to have a Caesa
Calcium Gluconate
soothe and protect the skin in many conditions such as eczema and urtica
ria.
109
The heel-bone or os calcis, and the largest bone in the foot.
CALCULI (stones) in the KIDNEYS or gallbladder (see LIVER). The recommen
ded daily intakes of calcium
are: 500 mg for children, 700 mg for adolescents, 500900 mg for adults and 1,200
mg for pregnant or
nursing mothers.
Calcicosis
Calcium-Channel Blockers
Calcaneus
Calcicosis is a traditional term applied to disease of the lung caused b
y the inhalation of marble dust
by marble-cutters.
Calciferol This is an outdated term for ergocaliciferol or vitamin D2 (s
ee APPENDIX 5: VITAMINS).
Calcification The deposition of CALCIUM salts in body tissues, normally
BONE and TEETH, though abnormal
deposits can occur in damaged muscles or the walls of arteries.
Calcinosis Abnormal deposition of tissue.
CALCIUM
in the body
Calcitonin A hormone, produced by the THYROID GLAND, which is involved i
n the metabolism of bone.
Acting to lower concentrations of CALCIUM and PHOSPHATES in the blood, calcitoni
n is given by injection in
the treatment of some patients with HYPERCALCAEMIA (especially when associated w
ith malignant disease). In
severe cases of PAGETS DISEASE OF BONE it is used mainly for pain relief, but als
o relieves some of the
neurological complications such as deafness.
Calcium The metallic element present in chalk and other forms of lime. T
he chief preparations used in
medicine are calcium carbonate (chalk), calcium chloride, calcium gluconate, cal
cium hydroxide (slaked
lime), liquor of calcium hydroxide (lime-water), calcium lactate, and calcium ph
osphate. Calcium gluconate
is freely soluble in water and is used in conditions in which calcium should be
given by injection. Calcium
is a most important element in diet; the chief sources of it are milk and cheese
. Calcium is especially
needed by the growing child and the pregnant and nursing mother. The uptake of c
alcium by the baby is
110 Calculi
Calculi The general name given to concretions in, for example, the URINA
RY BLADDER, KIDNEYS or
gall-bladder (see LIVER).
C Caldicott Guardian A senior health professional in all NHS trusts, who
se responsibility it is to
preserve the confidentiality of patient information.
Calibre A talking-book service which is available to all blind and handi
capped people who can supply a
doctors certificate confirming that they are unable to read printed books in the
normal way. Its catalogue
contains more than 370 books for adults and more than 250 for children, and addi
tions are being made at the
rate of around three a week. Full details can be obtained from Calibre. www.cali
bre.org.uk
Calliper A two-pronged instrument with pointed ends, for the measurement
of diameters, such as that of
the pelvis in obstetrics.
Calliper Splint This is applied to a broken leg in such a way that in wa
lking, the weight of the body
is taken by the hip-bone and not by the foot.
Callosities Areas of gross thickening of the epidermis in response to tr
auma. They usually occur on a
foot due to bony deformity or ill-fitting footwear. (See CORNS AND BUNIONS.)
Callus The new tissue formed around the ends of a broken bone. (See BONE
, DISORDERS OF.)
Caloric Test A test for vestibular function (see EAR). It is performed b
y irrigating the external
auditory meatus of the ear with alternate cold and hot water. This usually stimu
lates the vestibular
apparatus, causing nystagmus (see DIABETES MELLITUS Diabetic eye disease). If th
e vestibular apparatus is
affected by disease, the response may be absent or reduced.
Calorie A unit of energy. Two units are called by this name. The small c
alorie, or gram calorie, is the
amount of heat required to raise one gram of water one degree centigrade in temp
erature.
The large Calorie or kilocalorie, which is used in the study of dietetic
s and physiological processes,
is the amount of heat required to raise one kilogram of water one degree centigr
ade in temperature. The
number of Calories required to carry on the processes necessary for life and bod
y warmth such as the
beating of the heart, the movements of the chest in breathing, and the chemical
activities of the secreting
glands is, for an adult person of ordinary weight, somewhere in the neighbourhoo
d of 1,600. For ordinary
sedentary occupations an individual requires about 2,500 Calories; for light mus
cular work slightly over
3,000 Calories; and for hard continuous labour around 4,000 Calories daily. Unde
Cancer
Canaliculus Canaliculus means a small channel, and is applied to (a) the
minute passage leading from
the lacrimal pore on each eyelid to the lacrimal sac on the side of the nose; (b
) any one of the minute
canals in bone.
Cancellous A term applied to loose bony tissues as found in the ends of
the long bones.
Cancer The general term used to refer to a malignant TUMOUR, irrespectiv
e of the tissue of origin.
Malignancy indicates that (i) the tumour is capable of progressive growth, unrestr
ained by the capsule of
the parent organ, and/or (ii) that it is capable of distant spread via lymphatic
s or the bloodstream,
resulting in development of secondary deposits of tumour known as metastases. Micr
oscopically, cancer
cells appear different from the equivalent normal cells in the affected tissue.
In particular they may show
a lesser degree of differentiation (i.e. they are more primitive), features indica
tive of a faster
proliferative rate and disorganised alignment in relationship to other cells or
blood vessels. The
diagnosis of cancer usually depends upon the observation of these microscopic fe
atures in biopsies, i.e.
tissue removed surgically for such examination. Cancers are classified according
to the type of cell from
which they are derived as well as the organ of origin. Hence cancers arising wit
hin the bronchi, often
collectively referred to as lung cancer, include both adenocarcinomas, derived fro
m epithelium (surface
tissue), and carcinomas from glandular tissue. Sarcomas are cancers of connectiv
e tissue, including bone
and cartilage. The behaviour of cancers and their response to therapy vary widel
y depending on this
classification as well as on numerous other factors such as how large the cancer
is, how fast the cells
grow and how well defined they are. It is entirely wrong to see cancer as a sing
le disease entity with a
universally poor prognosis. For example, fewer than one-half of women in whom br
east cancer (see BREASTS,
DISEASES OF) is discovered will die from the disease, and 75 per cent of childre
n with lymphoblastic
LEUKAEMIA can be cured.
Incidence In most western countries, cancer is the second most important
cause of death after heart
disease and accounts for 2025 per cent of all deaths. In the United Kingdom in 20
03, more than 154,000
people died of
111
malignant disease. There is wide international variation in the most fre
quently encountered types of
cancer, reflecting the importance of environmental factors in the development of
cancer. In the UK as well
as the US, carcinoma of the BRONCHUS is the most common. Since it is usually ino
Carbachol
Cannabis Psychoactive substances obtained from Cannabis sativa or Indian
hemp, they are the oldest
euphoriants. Also called marijuana, these substances do not usually result in ph
ysical DEPENDENCE but
chronic abuse leads to passivity, apathy and inertia. Acute adverse effects incl
ude transient panic
reactions and toxic psychoses. The panic reactions are characterised by anxiety,
helplessness and loss of
control and may be accompanied by florid paranoid thoughts and hallucinations. T
he toxic psychoses are
characterised by the sudden onset of confusion and visual hallucinations. Even a
t lower doses, cannabis
products can precipitate functional psychoses in vulnerable individuals. The acu
te physical manifestations
of short-term cannabis abuse are conjunctival suffusion and tachycardia. The cho
pped leaves are usually
smoked but can be eaten in food or taken as tea. The active ingredient is tetrah
ydrocannibol. There is much
public debate in western countries over the social use of cannabis: it is illega
l to possess or supply the
substance in the United Kingdom, but nevertheless cannabis is quite widely used.
Cannabis is classified as
a Schedule 1 drug under the Misuse of Drugs Act 1971 and has not officially been
used medicinally despite
some claims that it is helpful in ameliorating painful symptoms in certain serio
us chronic diseases such as
multiple sclerosis. A related agent, NABILONE, is a synthetic cannabinoid licenc
ed for use in treating
nausea and vomiting caused by CYTOTOXIC drugs.
Cannula A tube for insertion into the body, designed to fit tightly roun
d a trocar a sharp, pointed
instrument which is withdrawn from the cannula after insertion, so that fluid ma
y run out through the
latter.
Canthus The name applied to the angle at either end of the aperture betw
een the eyelids.
CAPD Chronic ambulatory peritoneal dialysis an outpatient technique for
treating failure of the
KIDNEYS. (See HAEMODIALYSIS.)
Capillaries The minute vessels which join the ends of the arteries to ve
nules, the tiny commencement of
veins. Their walls consist of a single layer of fine, flat, transparent cells, b
ound together at the edges,
and the vessels form a meshwork all
113
through the tissues of the body, bathing the latter in blood with only t
he thin capillary wall
interposed, through which gases and fluids readily pass. These vessels are less
than 0025 mm in width.
Capillary Return A test for the adequacy of blood circulation by pressin
g on the skin and seeing how
114 Carbamazepine
C
Carbamazepine
Carbon
An anticonvulsant drug used to treat most types of EPILEPSY, including s
imple and complex partial
seizures and tonic-clonic seizures secondary to a focal discharge. Monitoring of
concentrations in the
blood may be of help in finding the most effective dose. Carbamazepine has gener
ally fewer side-effects
than other antiepileptic drugs; even so, it should be started at a low dose and
increased incrementally.
The drug is also used to treat TRIGEMINAL NEURALGIA and other types of nerve pai
n, as well as pain from a
PHANTOM LIMB. DEPRESSION resistant to LITHIUM CARBONATE may also benefit from ca
rbamazepine.
A non-metallic element, the compounds of which are found in all living t
issues and which is a
constituent (as carbon dioxide) of air exhaled from the LUNGS. Two isotopes of c
arbon, 11C and 14C, are
used in medicine. Carbon-11 is used in positron-emission tomography (see PET SCA
NNING); carbon-14 is used
as a tracer element in studying various aspects of METABOLISM.
Carbaryl A pesticide used to kill head and crab lice (see PEDICULOSIS).
Available as a lotion, some of
which contains alcohol (not recommended for use on crab lice), the substance may
irritate skin and should
not be used near damaged skin, eyes or ears.
Carbimazole One of the most widely used drugs in the treatment of HYPERT
HYROIDISM. It acts by
interferring with the synthesis of thyroid hormone in the thyroid gland.
Carbohydrate The term applied to an organic substance in which the hydro
gen and oxygen are usually in
the proportion to form water. Carbohydrates are all, chemically considered, deri
vatives of simple forms of
sugar and are classified as monosaccharides (e.g. glucose), disaccharides (e.g.
cane sugar),
polysaccharides (e.g. starch). Many of the cheaper and most important foods are
included in this group,
which comprises sugars, starches, celluloses and gums. When one of these foods i
s digested, it is converted
into a simple kind of sugar and absorbed in this form. Excess carbohydrates, not
immediately needed by the
body, are stored as glycogen in the liver and muscles. In DIABETES MELLITUS, the
most marked feature
consists of an inability on the part of the tissues to assimilate and utilise th
e carbohydrate material.
Each gram of carbohydrate is capable of furnishing slightly over 4 Calories of e
nergy. (See CALORIE; DIET.)
Carbolic Acid Carbolic acid, or phenol, was the precursor of all ANTISEP
TICS. It paralyses and then
destroys most forms of life, particularly organisms such as bacteria. It has bee
n superseded by less
penetrative and harmful antiseptics.
Carbon Dioxide (CO2)
Formed by the body during metabolism and exhaled by the lungs. Seen in s
parkling waters and wines, it
is also used in baths as a stimulant to the skin. Combined with oxygen in cylind
ers, it is used to control
breathing in ANAESTHESIA and in the treatment of victims of CARBON MONOXIDE (CO)
poisoning. Measuring the
partial pressure of the gas by taking blood for blood gas estimation provides in
formation on the adequacy
of breathing. A high partial pressure may indicate impending or actual respirato
ry failure.
Carbonic Anhydrase Inhibitor A drug that curbs the action of an ENZYME i
n the blood controlling the
production of carbonic acid or bicarbonate from CARBON DIOXIDE (CO2). Called car
bonic anhydrase, the enzyme
is present in ERYTHROCYTES and it has a key part in maintaining the acid-base ba
lance in the blood.
Inhibiting drugs include ACETAZOLAMIDE and DORZOLAMIDE, and these are used as we
ak DIURETICS to reduce the
increased intraocular pressure in ocular hypertension or open-angle GLAUCOMA (se
e EYE, DISORDERS OF).
Carbon Monoxide (CO) This is a colourless, odourless, tasteless, nonirri
tating gas formed on incomplete
combustion of organic fuels. Exposure to CO is frequently due to defective gas,
oil or solid-fuel heating
appliances. CO is a component of car exhaust fumes and deliberate exposure to th
ese is a common method of
suicide. Victims of fires often suffer from CO poisoning. CO combines reversibly
with oxygen-carrying sites
of HAEMOGLOBIN (Hb) molecules with an affinity 200 to 300 times greater than oxy
gen itself. The
carboxyhaemoglobin (COHb) formed becomes unavailable for oxygen transportation.
In addition the partial
saturation of the Hb molecule results in tighter oxygen binding, impairing deliv
ery to the tissues. CO also
binds to MYOGLOBIN and respiratory cytochrome enzymes. Exposure to CO at levels
of 500 parts per mil-
Carcinomatosis 115
lion (ppm) would be expected to cause mild symptoms only and exposure to
levels of 4,000 ppm would be
rapidly fatal. Each year around 50 people in the United Kingdom are reported as
dying from carbon monoxide
poisoning, and experts have suggested that as many as 25,000 people a year are e
xposed to its effects
within the home, but most cases are unrecognised, unreported and untreated, even
though victims may suffer
from long-term effects. This is regrettable, given that Napoleons surgeon, Larrey
, recognised in the 18th
century that soldiers were being poisoned by carbon monoxide when billeted in hu
ts heated by woodburning
stoves. In the USA it is estimated that 40,000 people a year attend emergency de
partments suffering from
carbon monoxide poisoning. So prevention is clearly an important element in deal
ing with what is sometimes
termed the silent killer. Safer designs of houses and heating systems, as well as
wider public education
on the dangers of carbon monoxide and its sources, are important. Clinical effec
ts of acute exposure
resemble those of atmospheric HYPOXIA. Tissues and organs with high oxygen consu
mption are affected to a
great extent. Common effects include headaches, weakness, fatigue, flushing, nau
sea, vomiting,
irritability, dizziness, drowsiness, disorientation, incoordination, visual dist
urbances, TACHYCARDIA and
HYPERVENTILATION. In severe cases drowsiness may progress rapidly to COMA. There
may also be metabolic
ACIDOSIS, HYPOKALAEMIA, CONVULSIONS, HYPOTENSION, respiratory depression, ECG ch
anges and cardiovascular
collapse. Cerebral OEDEMA is common and will lead to severe brain damage and foc
al neurological signs.
Significant abnormalities on physical examination include impaired short-term me
mory, abnormal Rhombergs
test (standing unsupported with eyes closed) and unsteadiness of gait including
heel-toe walking. Any one
of these signs would classify the episode as severe. Victims skin may be coloured
pink, though this is
very rarely seen even in severe incidents. The venous blood may look arterial. Pat
ients recovering from
acute CO poisoning may suffer neurological sequelae including TREMOR, personalit
y changes, memory
impairment, visual loss, inability to concentrate and PARKINSONISM. Chronic lowlevel exposures may result
in nausea, fatigue, headache, confusion, VOMITING, DIARRHOEA, abdominal pain and
general malaise. They are
often misdiagnosed as influenza or food poisoning. First-aid treatment is to rem
ove the victim from the
source of exposure, ensure an effective
airway and give 100-per-cent oxygen by tightfitting mask. In hospital, m
anagement is largely
suppportive, with oxygen administration. A blood sample for COHb level determina
tion should be taken as
soon as practicable and, if possible, before oxygen is given. Ideally, oxygen th
erapy should continue until
the COHb level falls below 5 per cent. Patients with any history of unconsciousn
ess, a COHb level greater
than 20 per cent on arrival, any neurological signs, any cardiac arrhythmias or
anyone who is pregnant
should be referred for an expert opinion about possible treatment with hyperbari
c oxygen, though this
remains a controversial therapy. Hyperbaric oxygen therapy shortens the half-lif
e of COHb, increases plasma
oxygen transport and reverses the clinical effects resulting from acute exposure
s. Carbon monoxide is also
an environmental poison and a component of cigarette smoke. Normal body COHb lev
els due to ENDOGENOUS CO
production are 0.4 to 0.7 per cent. Non-smokers in urban areas may have level of
12 per cent as a result
of environmental exposure. Smokers may have a COHb level of 5 to 6 per cent.
Carboxyhaemoglobinaemia The term applied to the state of the blood in ca
rbon monoxide poisoning, in
which this gas combines with the haemoglobin, displacing oxygen from it. (See CA
RBON MONOXIDE (CO).)
Carbuncle See BOILS (FURUNCULOSIS).
Carcinogenesis Carcinogenesis is the means or method whereby the changes
responsible for the induction
of CANCER are brought about.
Carcinogens Agents, such as tobacco smoke, certain chemicals, asbestos f
ibres and high-dose radiation,
that have the property of causing CANCER.
Carcinoma A type of CANCER developing from cells found in the surface la
yer of an organ in the body.
Carcinoma in Situ The first stage of CARCINOMA in which the malignant tu
mour is present only in the
EPITHELIUM, and when surgical excision of the local growth, with its pathologica
l status confirmed in the
laboratory, should ensure a cure.
Carcinomatosis The spread of cancer cells from their original
C
116 Cardia
C
site of growth to other tissues in the body. Such a spread of cancer, wh
ich takes place mainly via
blood and lymph vessels, is usually fatal. CHEMOTHERAPY and RADIOTHERAPY may, ho
wever, check the spread or
sometimes destroy the cancerous growth.
Cardia Cardia is a term applied to the upper opening of the stomach into
which the oesophagus empties.
The cardia lies immediately behind the heart.
Cardiac Arrest Cardiac arrest occurs when the pumping action of the hear
t stops. This may be because
the heart stops beating (see ASYSTOLE) or because the heart muscle starts contra
cting too fast to pump
effectively (ventricular systole, the period when the heart contracts). Coronary
thrombosis is the most
frequent cause of arrest. Irreversible brain damage and death result without pro
mpt treatment. Heart
massage, defibrillation and artificial respiration are customary treatment. Othe
r causes of cardiac arrest
are respiratory arrest, anaphylactic shock and electrocution. Up to one-third of
patients treated in
hospital whose heart rhythm is restored recover to an extent that enables them t
o return home. (See
APPENDIX 1: BASIC FIRST AID Cardiac/respiratory arrest.)
Cardiac Arrhythmia Abnormal rhythm of the heartbeat. Most commonly seen
after someone has had a myocardial infarction, but also present in some normal individuals especial
ly if they have taken a lot
of coffee or other stimulant and in those with a congenital abnormality of the h
eart-muscle conducting
system. The cause is interference in the generation or transmission of electrica
l impulses through the
hearts conducting system. Occasional isolated irregular beats (ectopic beats) do
not necessarily mean that
conduction is faulty. Arrhythmias can be classified as tachycardias (more than 1
00 beats a minute) or
bradycardias (slower than 60 beats a minute). Heartbeats may be regular or irreg
ular. (See HEART, DISEASES
OF.)
Cardiac Catheterisation A diagnostic procedure in which a tube is insert
ed into a blood vessel under
local anaesthetic and threaded through to the chambers of the heart to monitor b
lood flow, blood pressure,
blood chemistry and the output of the heart, and to take a sample of heart tissu
e. The technique is used to
diagnose congenital heart disease and coronary artery disease. Another applicati
on is in the diagnosis and
treatment of valvular disease in the heart.
Cardiac Cycle The various sequential movements of the heart that compris
e the rhythmic relaxation and
expansion of the heart muscles as first the atria contract and force the blood i
Cardiology
Cardiac Disease See HEART, DISEASES OF.
Cardiac Glycosides Drugs whose main actions are to increase the force of
myocardial contraction and
reduce the conductivity of the nerve fibres in the atrioventricular node of the
heart. They are useful in
treating supraventricular tachycardias (rapid heart rhythm) and some forms of he
art failure. Glycosides are
a traditional group of cardiac drugs, originally derived from the leaves of foxg
love plants and used as
digitalis. The active principle has long been synthesised and used as DIGOXIN. T
hey are potentaially toxic
and their use, especially during initial treatment, should be monitored. Side-ef
fects include ANOREXIA,
nausea, vomiting, diarrhoea and abdominal pain; drowsiness, confusion and DEPRES
SION may occur. An
abnormally slow heart rate may develop. The glycosides should be used with speci
al care in the elderly who
are sometimes particularly susceptible to their toxic effects.
Cardiac Massage The procedure used to restart the action of the heart if
it is suddenly arrested. In
many cases the arrested heart can be made to start beating again by rhythmic com
pression of the chest wall.
This is done by placing the patient on a hard surface a table or the floor and t
hen placing the heel of
the hand over the lower part of the sternum and compressing the chest wall firml
y, but not too forcibly, at
the rate of 6080 times a minute. At the same time artificial respiration must be
started by the
mouth-tomouth method. (See APPENDIX 1: BASIC FIRST AID.) Open heart massage is s
ometimes undertaken if an
arrest occurs during a chest operation the heart being directly handled by the r
esuscitator.
Cardiac Muscle
117
by the ventricles of the heart. It is one measure of the hearts efficienc
y. At rest, the heart of a
healthy adult will pump between 2.5 and 4.5 litres of blood every minute. Exerci
se will raise this to as
much as 30 litres a minute but, if this figure is low, it suggests that the hear
t muscle may be diseased or
that the person has suffered severe blood loss.
Cardiac Pacemaker The natural pacemaker is the sinuatrial node, found at
the base of the heart. The
heart normally controls its rate and rhythm; heart block occurs when impulses ca
nnot reach all parts of the
heart. This may lead to ARRHYTHMIA, or even cause the heart to stop (see HEART,
DISEASES OF). Artificial
pacemakers may then be used; in the United Kingdom these are required for around
one person in every 2,000
of the population. Usually powered by mercury or lithium batteries, and lasting
up to 15 years, they are
either fixed to the outside of the chest or implanted in the armpit, and connect
ed by a wire passing
through a vein in the neck to the heart. Normally adjusted to deliver 6575 impuls
es a minute, they also
ensure a regular cardiac rhythm. Patients with pacemakers may be given a driving
licence provided that
their vehicle is not likely to be a source of danger to the public, and that the
y are receiving adequate
and regular medical supervision from a cardiologist. Although there are numerous
possible sources of
electrical interference with pacemakers, the overall risks are slight. Potential
sources include anti-theft
devices, airport weapon detectors, surgical diathermy, ultrasound, and short-wav
e heat treatment.
Nevertheless, many pacemaker patients lead active and fulfilling lives.
Cardiac Pump See HEART, ARTIFICIAL.
Cardiac Tamponade
The muscle, unique to the heart, which comprises the walls of the atria
and ventricles. It consists of
long broadening cells (fibres) with special physiological characteristics which
enable them to keep
contracting and expanding indefinitely.
Compression of the heart due to abnormal accumulation of fluid within th
e fibrous covering of the heart
(PERICARDIUM). The result is irregular rhythm and death if the fluid is not remo
ved.
Cardiac Neurosis
Cardioangiography
Obsessional fear about the state of the heart. It tends to occur after a
heart attack and may result in
the patients experiencing the symptoms of another attack.
Rendering the outline of the heart visible on an X-ray film by injecting
a radio-opaque substance into
it.
Cardiac Output
That branch of medical science devoted to the study of the diseases of t
he heart.
The volume of blood pumped out per minute
Cardiology
C
118 Cardiomegaly
Cardiomegaly Enlargement of the heart (see OF).
HEART, DISEASES
Cardiomyopathy C A general term covering primary disease of the heart mu
scle. (See HEART, DISEASES OF.)
Cardioplegia A procedure whereby the heart is stopped by reducing its te
mperature (hypothermia), by
injecting the muscle with a solution of salts or by electrostimulation. This ena
bles surgeons to operate
safely on the heart.
Cardiopulmonary Bypass A procedure in which the bodys circulation of bloo
d is kept going when the
heart is intentionally stopped to enable heart surgery to be carried out. A HEAR
T-LUNG MACHINE substitutes
for the hearts pumping action and the blood is oxygenated at the same time.
Cardiopulmonary Resuscitation (CPR) The use of life-saving measures of m
outh-tomouth resuscitation and
external cardiac compression massage in a person who has collapsed with CARDIAC
ARREST. Speedy restoration
of the circulation of oxygenated blood to the brain is essential to prevent dama
ge to brain tissues from
oxygen starvation. The brain is irreversibly damaged if it is starved of oxygen
for more than 45 minutes.
Someone whose heart has stopped will be very pale or blue-grey (in particular, r
ound the lips) and
unresponsive; he or she will not be breathing and will have no pulse. It is impo
rtant to determine that the
collapsed person has not simply fainted before starting CPR. The procedure is de
scribed under
cardiac/respiratory arrest in APPENDIX 1: BASIC FIRST AID. In hospital, or when
paramedical staff are
attending an emergency, CPR may include the use of a DEFIBRILLATOR to apply a co
ntrolled electric shock to
the heart via the chest wall.
Cardiospasm The spasmodic contraction of the muscle surrounding the open
ing of the oesophagus into the
stomach: also termed achalasia of the cardia. (See OESOPHAGUS, DISEASES OF.)
Cardiovascular System This refers to the whole circulatory system: the h
eart, the systemic circulation
(the arteries and veins of the body) and the pulmonary circulation (the arteries
and veins of the lungs).
Blood
circulates throughout the cardiovascular system bringing oxygen and nutr
ients to the tissues and
removing carbon dioxide and other waste products.
Cardioversion Cardioversion, or DEFIBRILLATION, is indicated in patients
with ventricular fibrillation
or tachycardia, fast or irregular heartbeat, if other treatments have failed. A
general anaesthetic is
given if the patient is conscious, following which a carefully timed direct-curr
Castration 119
an aromatic volatile oil, usually of vegetable extraction.
A colouring matter of carrots, other plants, butter and yolk of egg, car
otene is the precursor of
vitamin A, which is formed from carotene in the liver. (See VITAMIN and APPENDIX
5: VITAMINS.)
forms a joint with other bones (articular cartilage), and in young perso
ns up to about the age of 16
there is a plate of cartilage (epiphyseal cartilage) running right across the bo
ne about 12 mm (half an
inch) from each end. The latter, by constantly thickening and changing into bone
, causes the increase in
length of the bone. (See also BONE.) In some situations there is found a combina
tion of cartilage and
fibrous tissue, as in the discs between the vertebrae of the spine. This fibro-c
artilage, as it is known,
combines the pliability of fibrous tissue with the elasticity of cartilage. (For
cartilages of the knee,
see KNEE.)
Carotid Body
Caruncle
A small reddish-brown structure measuring 57 254 millimetres, situated one
on each side of the
neck, where the carotid artery divides into the internal and external carotid ar
teries. Its main function
is in controlling breathing so that an adequate supply of oxygen is maintained t
o the tissues of the body.
Oxygen levels are controlled by a reflex operating between the carotid body and
the respiratory centre in
the brain.
Any small fleshy eminence, whether normal or abnormal.
Carneous Mole An ovum which has died in the early months of pregnancy. I
t usually requires no treatment
and evacuates itself.
Carotene
Carpal Tunnel Syndrome A condition characterised by attacks of pain and
tingling in the first three or
four fingers of one or both hands. The attacks usually occur at night. Carpal tu
nnel syndrome is caused by
pressure on the median nerve as it passes under the strong ligament that lies ac
ross the front of the
wrist. The condition may respond to use of a night splint on the hand; otherwise
a corticosteroid injection
under the ligament may help. If not, pressure is relieved by surgical division o
f the compressing ligament.
Carpus The Latin term for the WRIST, composed of eight small bones firml
y joined together with
ligaments, but capable of a certain amount of sliding movement over one another.
120 Casts
C
is routinely performed during HYSTERECTOMY, especially in cases of uteri
ne carcinoma, and is usually
performed when removing an ovarian tumour or malignant cyst. It is essential tha
t the surgeon discusses
with a woman before an operation when it might prove beneficial to remove her ov
aries in addition to
carrying out the main procedure. In men, orchidectomy is routine for testicular
tumours, and is sometimes
carried out when treating prostatic cancer.
Casts Casts of hollow organs are found in various diseases. Membraneous
casts of the air passages are
found in diphtheria and in one form of bronchitis, and are sometimes coughed up
entire. Casts of the
interior of the bowels are passed in cases of mucous colitis associated with con
stipation, and casts of the
microscopic tubules in the kidneys passed in the urine form one of the surest si
gns of glomerulonephritis.
(See KIDNEYS, DISEASES OF.)
Catabolism The breakdown by the body of complex substances to form simpl
er ones, a process that is
accompanied by the release of energy. Among the substances catabolised are nutri
ents, such as CARBOHYDRATE
and PROTEIN in food, and in storage in the body for example, GLYCOGEN.
Catalepsy A physical condition in which part or all of the body becomes
rigid. It is characterised by
the adoption of strange often statue-like poses (CATATONIA), which may pass off
within a few minutes or
may last for several hours (rarely, days). Typically brought on by a sudden ment
al trauma, catalepsy may
occur with prolonged depression or some other serious MENTAL ILLNESS, and occasi
onally with EPILEPSY.
Successful treatment must depend upon due recognition of all precipitating facto
rs and circumstances.
Cataplexy Cataplexy is a condition in which the patient has a sudden att
ack of muscular weakness
affecting the whole body. (See also NARCOLEPSY.)
Cataract An opacity of the lens sufficient to cause visual impairment (s
ee EYE, DISORDERS OF).
Catarrh Inflammation of the mucous membranes, particularly those of the
air passages, associated with a
copious secretion of mucus. Commonly
the result of infection or local allergy, catarrh can affect the nose, m
iddle ear and sinuses.
Catatonia A condition in which an individual takes up odd postures, ofte
n accompanied by muteness or
semi-coma. The arms and legs may be moved passively by someone else into positio
ns that the sufferer then
holds for many hours. Catatonia occurs in SCHIZOPHRENIA. It may also be associat
CD4/CD8 Count
down the TRACHEA into the lungs, usually in the course of administering
anaesthetics (see under
ANAESTHESIA).
Eustachian catheters are small catheters
121
coccygeal spinal nerves. The resulting bundle, fancifully resembling a h
orses tail, runs down inside
the spinal column until the individual fibres leave through their respective ope
nings.
Caul
that are passed along the floor of the nose into the Eustachian tube in
order to inflate the ear.
The piece of AMNION which sometimes covers a child when he or she is bor
n.
Nasal catheters are tubes passed through
Cauliflower Ear
the nose into the stomach to feed a patient who cannot swallow so-called
nasal feeding.
The term applied to the distortion of the external ear produced by repea
ted injury in sport. Initially
it is due to a HAEMATOMA in the auricle (see EAR). To prevent deformity the bloo
d should be drawn off from
this haematoma as soon as possible, and a firm pressure bandage then applied. Su
bsequent protection can be
given to the ear by covering it with a few layers of two-way-stretch strapping w
ound around the head.
Rectal catheters are passed into the RECTUM in order to introduce fluid
into the rectum. Suprapubic
catheters are passed into the bladder through an incision in the lower abdominal
wall just above the pubis,
either to allow urine to drain away from the bladder, or to wash out an infected
bladder. Ureteric
catheters are small catheters that are passed up the ureter into the pelvis of t
he kidney, usually to
determine the state of the kidney, either by obtaining a sample of urine direct
from the kidney or to
inject a radioopaque substance preliminary to X-raying the kidney. (See PYELOGRA
PHY.)
Causalgia A severe burning pain in a limb in which the sympathetic and s
omatic nerves have been
damaged.
Caustics and Cauteries
Urethral catheters are catheters that are
Caustics and cauteries are used to destroy tissues the former by chemica
l action, the latter by their
high temperature. (See ELECTROCAUTERY.)
passed along the urethra into the bladder, either to draw off urine or t
o wash out the bladder.
Cavernous Breathing
It is these last three types of catheters that are most extensively used
.
A peculiar quality of the respiratory sounds heard on AUSCULTATION over
a cavity in the lung.
Cat Scanner
Cavernous Sinus
See CT SCANNER.
A channel for venous blood placed either side of the sphenoid bone at th
e base of the SKULL behind the
eye sockets. Blood drains into it from the eye, the nose, the brain and part of
the cheek, and leaves via
the internal jugular and facial veins. Sometimes the sinus becomes blocked by a
blood clot (thrombus),
usually a complication of a nearby bacterial infection. A potentially serious co
ndition, it should be
treated with thrombolysis and antibiotics.
Cat-Scratch Fever An infection in humans caused by a small gram-negative
BACILLUS (Bartonella
henselae). The domestic cat is a reservoir for the bacteria, and up to 50 per ce
nt of the cat population
may be affected. The disorder manifests itself as a skin lesion 310 days after a
minor scratch; within two
weeks the victims lymph glands enlarge and may produce pus. Fever, headache and m
alaise occur in some
patients. Antibiotics do not seem to be effective. The skin lesion and lymph-gla
nd enlargement subside
spontaneously within 25 months.
Cauda A tail or a tail-like structure. For example, the cauda equina (hor
ses tail) is a collection
of nerve roots arising from the lumbar, sacral and
CD4/CD8 Count An immunological assessment used to monitor for signs of o
rgan rejection after
transplantation; it is also used to check the progress of treatment in patients
with HIV (see AIDS/ HIV).
The count measures the ratio of helper-induced T-lymphocytes to cytotoxicsuppres
sor lymphocytes. (See
LYMPHOCYTE; IMMUNOLOGY.)
C
122 Cefoxitin
Cefoxitin
C
Cefoxitin is a semi-synthetic antibiotic, given by injection, which is u
sed in the treatment of
infections due to gram-negative microorganisms such as Proteus which are resista
nt to many other
antibiotics.
Cell Salvage Transfusion See TRANSFUSION.
Cells The basic structural unit of body tissues. There are around 10 bil
lion cells in the human body
and they are structurally and functionally linked to carry out the bodys many com
plex activities. Every
cell consists essentially of a cell-body of soft albuminous material called cyto
plasm, in which lies a
kernel or nucleus which seems to direct all the activities of the cell. Within t
he nucleus may be seen a
minute body, the nucleolus; and there may or may not be a cellenvelope around al
l. (See also MITOCHONDRIA.)
Each cell nucleus carries a set of identical CHROMOSOMES, the bodys genetic instr
uctions. Cells vary much
in size, ranging in the human body from 00025 mm to about 0025 mm. All animals and
plants consist at
first of a single cell (the egg-cell, or ovum), which begins to develop when fer
tilised by the sperm-cell
derived from the opposite sex. Development begins by a division into two new cel
ls, then into four, and so
on till a large mass is formed. These cells among them stem cells (see STEM CELL
) which have the
potential to develop into a variety of specialised cells then arrange themselves
into layers, and form
various tubes, rods, and masses which represent in the embryo the organs of the
fully developed animal.
(See FETUS.) When the individual organs have been laid down on a scaffolding of
cells, these gradually
change in shape and in chemical composition. The cells in the nervous system sen
d out long processes to
form the nerves; those in the muscles become long and striped in appearance; and
those which form fat
become filled with fat droplets which distend the cells. Further, they begin to
produce, between one
another, the substances which give the various tissues their special character.
Thus, in the future bones,
some cells deposit lime salts and others form cartilage, while in tendons they p
roduce long white fibres of
a gelatinous substance. In some organs the cells change little: thus the liver c
onsists of columns of large
cells
packed together, while many cells, like the white blood corpuscles, reta
in their primitive characters
almost entire. Thus cells are the active agents in forming the body, and they ha
ve a similar function in
repairing its wear and tear. Tumours, and especially malignant tumours, have a h
ighly cellular structure,
the cells being of an embryonic type, or, at best, forming poor imitations of th
e tissues in which they
grow (see TUMOUR).
Cellulitis Inflammation taking place in cellular tissue, and usually ref
erring to infection in the
subcutaneous tissue. A related word, cellulite, which has no medical meaning, is
used in the slimming
business to refer to excess fatty tissue in the arms, buttocks and thighs. (See
ABSCESS; ERYSIPELAS.)
Cellulose A carbohydrate substance forming the skeleton of most plant st
ructures. It is colourless,
transparent, insoluble in water and is practically unaffected by digestion. In v
egetable foods it therefore
adds to the bulk, but it is of no value as a food-stuff. It is found in practica
lly a pure state in
cotton-wool.
Cement See TEETH.
Central Nervous System This comprises the nervous tissue of the brain an
d spinal cord, but does not
include the cranial and spinal nerves and the autonomic nervous system. This lat
ter group makes up the
peripheral nervous system. (See BRAIN and SPINAL CORD; NERVOUS SYSTEM.)
Central Venous Pressure The pressure of blood within the right atrium of
the HEART as measured by a
catheter and manometer.
Cephalosporins These are broad-spectrum antibiotics. Most are semi-synth
etic derivatives of
cephalosporin C, an antibiotic originally derived from a sewage outfall in Sardi
nia. First-generation
examples still in use include cephalexin and cefadroxil. They are orally active
and, along with
second-generation cefaclor, have a similar antimicrobial spectrum. They are used
for resistant urinary
infections and urinary infections in pregnancy. Cephalosporins have a similar ph
armacology to that of
penicillin, and about 10 per cent of patients allergic to
Cerebral Palsy
penicillin will also be hypersensitive to cephalosporins. They are effec
tive in treating SEPTICAEMIA,
PNEUMONIA, MENINGITIS, biliary-tract infections and PERITONITIS. Second-generati
on cefuroxime and
cefamandole are less vulnerable to penicillinases and are useful for treating res
istant bacteria and
Haemophilus influenzae and Neisseria gonorrhoea. Third-generation cephalosporins
include cefotaxime,
ceftazidime and others; these are more effective than the second-generation in t
reating some gram-negative
infections, especially those causing septicaemia.
Cereal Any grass-like plant bearing an edible seed. The important cereal
s are wheat, oats, barley,
maize, rice and millet. Along with these are usually included tapioca (derived f
rom the cassava plant),
sago (derived from the pith of the sago palm) and arrowroot (derived from the ro
ot of a West Indian plant),
all of which consist almost entirely of starch. Semolina, farola and macaroni ar
e preparations of wheat.
per cent 1012 1012 6575 058 2
Water Protein Carbohydrate Fat Mineral matter
Composition of cereals Cereals consist predominantly of carbohydrate. Th
ey are therefore an excellent
source of energy. On the other hand, their deficiency in protein and fat means t
hat to provide a balanced
diet, they should be supplemented by other foods rich in protein and fat. per ce
nt Water 120 72 123 110
125 124
Wheat Oatmeal Barley Rye Maize Rice (polished) Millet 123 Buck wheat 130
Carbohydrate 712 659 695 723 689 794
Protein 110 142 101 102 97 69
Fat 17 73 19 23 54 04
104 102
39 683 22 613
Cellulose Ash 22 19 35 19 38 24 21 21 20 15 04 05 29 22 111 22
Composition of certain cereals
Cerebellar Ataxia Uncoordinated movements, including an unsteady gait, c
aused by damage to or disease
of the cerebellum (see BRAIN). Brain tumours, MULTIPLE SCLEROSIS (MS) and stroke
can result
123
in ataxia as can excessive consumption of alcohol, and degeneration of t
he cerebellum as a result of
an inherited disease. Affected victims may have slurred speech, hand tremors and
Chelating Agents
Cetavlon See CETRIMIDE.
Cetrimide Also known as cetavlon, cetrimide is the official name for a m
ixture of alkyl ammonium
bromides. It is a potent antiseptic, and as a 1 per cent solution is used for cl
eaning and disinfecting
wounds, and in the first-aid treatment of burns. As it is also a detergent, it i
s particularly useful for
cleaning the skin, and also for cleansing and disinfecting greasy and infected b
owls and baths.
Chagas Disease Chagas disease, or American trypanosomiasis, is a disease w
idespread in Central and
South America, and caused by the Trypanosoma cruzi. The disease is transmitted b
y the biting bugs,
Panstrongylus megistus and Triatoma infestans. It occurs in an acute and a chron
ic form. The former, which
is most common in children, practically always affects the heart, and the progno
sis is poor. The chronic
form is commonest in adolescents and young adults and the outcome depends upon t
he extent to which the
heart is involved. There is no effective drug treatment. (See also SLEEPING SICK
NESS.)
Chalazion See EYE, DISORDERS OF.
Chalicosis A disorder of the lungs found among stonecutters, and due to
the inhalation of fine
particles of stone.
Chalk-Stones See GOUT.
Chancre The primary lesion of SYPHILIS.
Chancroid A soft or non-syphilitic venereal sore, caused by a micro-orga
nism known as Haemophilus
ducreyi. It is usually acquired by sexual contact, and responds well to treatmen
t with antibiotics. The
disease is rare in the UK.
Change of Life See CLIMACTERIC; MENOPAUSE.
Chapped Hands Chapped hands occur in cold weather, when reduced sweat an
d sebaceous activity leads to
125
decreased natural protection of the skin. Prolonged immersion in soapy w
ater, followed by exposure to
cold air, results in cracking of the skin. Prevention consists of minimising exp
osure to detergents and
soapy water, and wearing rubber gloves for all routine household duties.
Chapped Lips See LIPS.
Charcoal Activated charcoal is a finely powdered material with a huge su
rface area (1,000 m2/g)
prepared from vegetable matter by carbonisation. It is capable of binding a vari
126 Chemosis
as mercury. The main chelating agents are DIMERCAPROL, PENICILLAMINE, de
sferrioxamine and sodium
calciumedetate, used for example, in iron poisoning.
C Chemosis Swelling of the conjunctiva of the EYE, usually caused by inf
lammation from injury or
infection.
Chemotaxis The ability of certain cells to attract or repel others.
Chemotherapy The prevention or treatment of disease by chemical substanc
es. The term is generally used
in two senses: the use of antibacterial and other drugs to treat infections; and
the administration of
ANTIMETABOLITES and other drugs to treat cancer. The discovery by Paul Ehrlich i
n 1910 of the action of
Salvarsan in treating syphilis led to the introduction of sulphonamides in 1935,
followed by PENICILLIN
during World War II, which revolutionised the treatment of common infections. Ma
ny ANTIBACTERIAL DRUGS have
been developed since then: these include CEPHALOSPORINS, cephamycins, TETRACYCLI
NES, AMINOGLYCOSIDES,
MACROLIDES and CLINDAMYCIN as well as antituberculous drugs such as STREPTOMYCIN
and METRONIDAZOLE.
Unfortunately, overuse of chemotherapeutic drugs in medicine and in animal husba
ndry has stimulated
widespread resistance among previously susceptible pathogenic microorganisms. Ch
emotherapy also plays an
important role in treating tropical diseases, especially MALARIA, SLEEPING SICKN
ESS and LEPROSY.
Recently chemotherapy has become increasingly effective in the treatment
of cancer. Numerous drugs,
generally CYTOTOXIC, are available; great care is required in their selection an
d to minimise side-effects.
Certain tumours are highly sensitive to chemotherapy especially testicular tumou
rs, LEUKAEMIA, LYMPHOMA
and various tumours occurring in childhood (e.g. Wilms tumour see NEPHROBLASTOMA)
and may even be
cured.
Chenodeoxycholic Acid One of the bile acids (see BILE), used in the trea
tment of cholesterol
gall-stones for patients with mild symptoms when other modern techniques are uns
uitable. (See GALL-BLADDER,
DISEASES OF.)
Chest The chest, or THORAX, is the upper part of the trunk. It is enclos
ed by the breastbone (sternum)
and the 12 ribs which join the sternum by way of cartilages and are attached to
the spine behind. At the
top of the thorax, the opening in between the first ribs admits the windpipe (TR
ACHEA), the gullet
(OESOPHAGUS) and the large blood vessels. The bottom of the thorax is separated
from the abdomen below by
the muscular DIAPHRAGM which is the main muscle of breathing. Other muscles of r
espiration, the intercostal
muscles, lie in between the ribs. Overlying the ribs are layers of muscle and so
Chilblain
127
the sternum forming a sort of keel in front. It may be related to breath
ing problems in early life.
chickenpox, is said to be derived from the resemblance of the eruption t
o boiled chickpeas.
Rickety chest is uncommon now and is
Causes The disease occurs in epidemics affecting especially children und
er the age of ten years. It is
due to the varicella zoster virus, and the condition is an extremely infectious
one from child to child.
Although an attack confers life-long immunity, the virus may lie dormant and man
ifest itself in adult life
as HERPES ZOSTER or shingles.
caused by RICKETS in early life. There is a hollow down each side caused
by the pull of muscles on the
softer ribs in childhood. The line of knobs produced on each side where the ribs
join their costal
cartilages is known as the rickety rosary.
Pectus excavatum , or funnel chest, is quite a common abnormality where
the central tendon of the
diaphragm seems to be too short so that the lower part of the sternum is displac
ed inwards and the lower
ribs are prominent. When severe, it may displace the heart further to the left s
ide.
Local abnormalities in the shape of the chest occur when there is a defo
rmity in the spine such as
scoliosis which alters the angles of the ribs. The chest wall may be locally fla
ttened when the underlying
lung is reduced in size locally over a prolonged period. (See SPINE AND SPINAL C
ORD, DISEASES AND INJURIES
OF.) This may be seen over a scarred area of
lung such as that observed in pulmonary TUBERCULOSIS.
Cheyne-Stokes Breathing A type of breathing which gets very faint for a
short time, then gradually
deepens until full inspirations are taken for a few seconds, and then gradually
dies away to another quiet
period, again increasing in depth after a few seconds and so on in cycles. It is
seen in some serious
neurological disorders, such as brain tumours and stroke, and also in the case o
f persons with advanced
disease of the heart or kidneys. When well marked it is a sign that death is imp
ending, though milder
degrees of it do not carry such a serious implication in elderly patients.
Chiasma This is an X-shaped crossing. The optic chiasma is where the ner
ve fibres from the nasal half
of each retina cross over the mid line to join the optic tract from the other si
de.
Child Adoption Adoption was relatively uncommon until World War II, with
only 6,000 adoption orders
annually in the UK. This peaked at nearly 25,000 in 1968 as adoption became more
socially acceptable and
the numbers of babies born to lone mothers rose in a climate hostile to single p
arenthood. Adoption
declined as the availability of babies fell with the introduction of the Abortio
n Act 1968, improving
contraceptive services and increasing acceptability of single parenthood. Howeve
r, with 10 per cent of
couples suffering infertility, the demand continued, leading to the adoption of
those previously perceived
as difficult to place i.e. physically, intellectually and/or emotionally disable
d children and
adolescents, those with terminal illness, and children of ethnic-minority groups
. Recent controversies
regarding homosexual couples as adoptive parents, adoption of children with or a
t high risk of HIV/AIDS,
transcultural adoption, and the increasing use of intercountry adoption to fulfi
l the needs of childless
couples have provoked urgent consideration of the ethical dilemmas of adoption a
nd its consequences for the
children, their adoptive and birth families and society generally. Detailed stat
istics have been
unavailable since 1984 but in general there has been a downward trend with relat
ively more older children
being placed. Detailed reasons for adoption (i.e. interfamily, step-parent, inte
rcountry, etc.) are not
available but approximately one-third are adopted from local-authority care. In
the UK all adoptions
(including interfamily and step-parent adoption) must take place through a regis
tered adoption agency which
may be local-authority-based or provided by a registered voluntary agency. All l
ocal authorities must act
as agencies, the voluntary agencies often providing specialist services to promo
te and support the adoption
of more difficult-to-place children. Occasionally an adoption allowance will be
awarded. Adoption orders
cannot be granted until a child has resided with its proposed adopters for 13 we
eks. In the case of newborn
infants the
Child Health
mother cannot give formal consent to placement until the baby is six wee
ks old, although informal
arrangements can be made before this time. In the UK the concept of responsibili
ty of birth parents to
their children and their rights to continued involvement after adoption are ackn
owledged by the Children
Act 1989. However, in all discussions the childs interests remain paramount. The
Act also recognises
adopted childrens need to have information regarding their origins. BAAF British
Agencies for Adoption
and Fostering is the national organisation of adoptive agencies, both local auth
ority and voluntary
sector. The organisation promotes and provides training service, development and
research; has several
specialist professional subgroups (i.e. medical, legal, etc.); and produces a qu
arterly journal. Adoption
UK is an effective national support network of adoptive parents who offer free i
nformation, a listening
ear and, to members, a quarterly newsletter. National Organisation for Counsellin
g Adoptees and their
Parents (NORCAP) is concerned with adopted children and birth parents who wish t
o make contact. The
Registrar General operates an Adoption Contact Register for adopted persons and
anyone related to that
person by blood, half-blood or marriage. Information can be obtained from the Of
fice of Population Censuses
and Surveys. For the addresses of these organisations, see Appendix 2.
Childbirth See PREGNANCY AND LABOUR.
Child Health Paediatrics is the branch of medicine which deals with dise
ases of children, but many
paediatricians have a wider role, being employed largely outside acute hospitals
and dealing with child
health in general.
History Child health services were originally designed, before the NHS c
ame into being, to find or
prevent physical illness by regular inspections. In the UK these were carried ou
t by clinical medical
officers (CMOs) working in infant welfare clinics (later, child health clinics)
set up to fill the gap
between general practice and hospital care. The services expanded greatly from t
he mid 1970s; inspections
have evolved into a regular screening and surveillance system by general practit
ioners and health visitors,
129
while CMOs have mostly been replaced by consultant paediatricians in com
munity child health (CPCCH).
Screening Screening begins at birth, when every baby is examined for con
genital conditions such as
dislocated hips, heart malformations, cataract and undescended testicles. Blood
is taken to find those
babies with potentially brain-damaging conditions such as HYPOTHYROIDISM and PHE
NYLKETONURIA. Some NHS
trusts screen for the life-threatening disease CYSTIC FIBROSIS, although in futu
re it is more likely that
finding this disease will be part of prenatal screening, along with DOWNS (DOWN)
SYNDROME and SPINA
BIFIDA. A programme to detect hearing impairment in newborn babies has been pilo
ted from 2001 in selected
districts to find out whether it would be a useful addition to the national scre
ening programme. Children
from ethnic groups at risk of inherited abnormalities of HAEMOGLOBIN (sickle cel
l disease; thalassaemia
see under ANAEMIA) have blood tested at some time between birth and six months o
f age.
Illness prevention At two months, GPs screen babies again for these abno
rmalities and start the process
of primary IMMUNISATION. The routine immunisation programme has been dramaticall
y successful in preventing
illness, handicap and deaths: as such it is the cornerstone of the public health
aspect of child health,
with more potential vaccines being made available every year. Currently, infants
are immunised against
pertussis (see WHOOPING COUGH), DIPHTHERIA, TETANUS, POLIOMYELITIS, haemophilus
(a cause of MENINGITIS,
SEPTICAEMIA, ARTHRITIS and epiglottitis) and meningococcus C (SEPTICAEMIA and me
ningitis see
NEISSERIACEAE) at two, three and four months. Selected children from high-risk g
roups are offered BCG
VACCINE against tuberculosis and hepatitis vaccine. At about 13 months all are o
ffered MMR VACCINE
(measles, mumps and rubella) and there are pre-school entry boosters of diphtheria
, tetanus, polio,
meningococcus C and MMR. Pneumococcal vaccine is available for particular cases
but is not yet part of the
routine schedule.
Health promotion and education Throughout the UK, parents are given thei
r childs personal health
record to keep with them. It contains advice on health promotion, including immu
nisation, developmental
milestones (when did he or she first smile, sit up, walk and so on), and graphs
called centile
C
Children Act
doctors, therapists and other professionals in training. (See CHILD ABUS
E.)
School health services Once children have reached school age, the emphas
is changes. The prime need
becomes identifying those with problems that may interfere with learning includi
ng those with special
needs as defined above, but also those with behavioural problems. Teachers and p
arents are advised on how
to manage these problems, while health promotion and health education are direct
ed at children. Special
problems, especially as children reach secondary school (aged 1118) include accid
ents, substance abuse,
psychosexual adjustment, antisocial behaviour, eating disorders and physical con
ditions which loom large in
the minds of adolescents in particular, such as ACNE, short stature and delayed
puberty. There is no
longer, in the UK, a universal school health service as many of its functions ha
ve been taken over by
general practitioners and hospital and community paediatricians. However, most a
reas still have school
nurses, some have school doctors, while others do not employ specific individual
s for these tasks but share
out aspects of the work between GPs, health visitors, community nurses and consu
ltant paediatricians in
child health. Complementing their work is the community dental service whose rol
e is to monitor the whole
child populations dental health, provide preventive programmes for all, and denta
l treatment for those who
have difficulty using general dental services for example, children with complex
disability. All children
in statefunded schools are dentally screened at ages five and 15.
Successes and failures Since the inception of the NHS, hospital services
for children have had enormous
success: neonatal and infant mortality rates have fallen by twothirds; deaths fr
om PNEUMONIA have fallen
from 600 per million children to a handful; and deaths from MENINGITIS have fall
en to one-fifth of the
previous level. Much of this has been due to the revolution in the management of
pregnancy and labour, the
invention of neonatal resuscitation and neonatal intensive care, and the provisi
on of powerful antibiotics.
At the same time, some children acquire HIV infection and AIDS from their affect
ed mothers (see AIDS/HIV);
the prevalence of atopic (see ATOPY) diseases (ASTHMA, eczema see DERMATITIS, HA
Y FEVER) is rising; more
children attend hos131
pital clinics with chronic CONSTIPATION; and little can be done for most
viral diseases. Community
child health services can also boast of successes. The routine immunisation prog
ramme has wiped out
SMALLPOX, DIPHTHERIA and POLIOMYELITIS and almost wiped out haemophilus and meni
ngococcal C meningitis,
measles and congenital RUBELLA syndrome. WHOOPING COUGH outbreaks continue but t
132 Chills
subsidiary legislation, rules, case law and official guidance. An equiva
lent act is in force in
Scotland.
Chills C
See COLD, COMMON.
Chimera Chimera is an organism, whether plant, animal or human being, in
which there are at least two
kinds of tissue differing in their genetic constitution.
Chinese Avian Influenza A variety of influenza in chickens occurring in
southern China that in 1997
appeared to jump the species barrier and infect humans. Some cases of the human
version of the infection
occurred in Hong Kong. There were fears of a serious epidemic which, because of
a lack of natural
resistance among humans, might have led to its worldwide spread. This has not so
far occurred.
Chiropody Chiropody (also termed podiatry) is that part of medical scien
ce which is concerned with the
health of the feet. Its practitioners are specialists capable of providing a ful
ly comprehensive
foot-health service. This includes the palliation of established deformities and
dysfunction, both as
short-term treatment for immediate relief of painful symptoms and as long-term m
anagement to secure optimum
results. This requires the backing of effective appliances and footwear services
. It also involves curative
footcare, including the use of various therapeutic techniques, including minor s
urgery and the prescription
and provision of specialised and individual appliances. Among conditions routine
ly treated are walking
disorders in children, injuries to the feet of joggers and athletes, corns, buni
ons and hammer toes, ulcers
and foot infections. Chiropody also has a preventative role which includes inspe
ction of childrens feet
and the detection of foot conditions requiring treatment and advice and also foo
t-health education. The
chiropodist is trained to recognise medical conditions which manifest themselves
in the feet, such as
circulatory disorders, DIAand diseases causing BETES MELLITUS ulceration. The on
ly course of training in
the United Kingdom recognised for the purpose of state registration by the Healt
h Professionals Council is
the Society of Chiropodists three-year fulltime course. The course includes instr
uction
and examination in the relevant aspects of anatomy and physiology, local
analgesia, medicine and
surgery, as well as in podology and therapeutics. The Council holds the register
of podiatrists. (See
APPENDIX 2: ADDRESSES: SOURCES OF INFORMATION, ADVICE, SUPPORT AND SELFHELP.)
Chiropractor A person who practises chiropractic mainly a system of phys
ical manipulations of minor
Choking
in women on the contraceptive pill. It mainly affects the face.
Chloral Hydrate This drug is now rarely used but chloral betaine (Welldo
rm) is occasionally used in the
elderly and in newborns with fits or cerebral irritation after a difficult deliv
ery.
Chlorambucil One of several ALKYLATING AGENTS widely used in cancer chem
otherapy, chlorambucil is an
oral drug commonly used to treat chronic lymphocytic LEUKEMIA, non-Hodgkins lymph
omas, Hodgkins disease
(see LYMPHOMA) and ovarian cancer (see OVARIES, DISEASES OF). Apart from suppres
sion of bone-marrow
activity, sideeffects are few.
Chloramphenicol An antibiotic derived from a soil organism, Streptomyces
venezuelae. It is also
prepared synthetically. A potent broad-spectrum antibiotic, chloramphenicol may,
however, cause serious
side-effects such as aplastic ANAEMIA, peripheral NEURITIS, optic neuritis and,
in neonates, abdominal
distension and circulatory collapse. The drug should therefore be reserved for t
he treatment of
life-threatening infections such as Haemophilus influenzae, SEPTICAEMIA or MENIN
GITIS, typhoid fever (see
ENTERIC FEVER) and TYPHUS FEVER, when the causative organism proves resistant to
other drugs. However,
because it is inexpensive, it is used widely in developing countries. This antib
iotic is available as drops
for use in eye and ear infection, where safety is not a problem.
disease in which greenish growths appear under the skin, and in which a
change takes place in the blood
resembling that in leukaemia.
Chlorophyll The green colouring matter of plants. Its main use is as a c
olouring agent, principally for
soaps, oils and fats. It is also being found of value as a deodorant dressing to
remove, or diminish, the
unpleasant odour of heavily infected sores and wounds.
Chloroquine Chloroquine, which is a 4-aminoquinoline, was introduced dur
ing World War II for the
treatment of MALARIA. The drug is also used for PROPHYLAXIS against malaria wher
e the risk of
chloroquine-resistant falciparum is still low. It has also been found of value i
n the treatment of the skin
condition known as chronic discoid lupus erythematosus, and of rheumatoid arthri
tis.
Chlorpromazine Chlorpromazine is chemically related to the antihistamine
drug, PROMETHAZINE
HYDROCHLORIDE. One of the first antipsychotic drugs to be marketed, it is used e
xtensively in psychiatry on
account of its action in calming psychotic activity without producing undue gene
ral depression or clouding
of consciousness. The drug is used particularly in SCHIZOPHRENIA and mania. It c
arries a risk of contact
sensitisation, so should be handled with care, and the drug has a wide range of
side-effects.
Chlorpropamide
Chlordane An insecticide which has been used sucessfully against flies a
nd mosquitoes resistant to DDT
(see DICHLORODIPHENYL TRICHLOROETHANE), and for the control of ticks and mites.
It requires special
handling as it is toxic to humans when applied to the skin.
An oral hypoglycaemic agent, chlorpropamide was for many years used to t
reat diabetes (see DIABETES
MELLITUS). It has been largely superseded by more effective oral agents with few
er side-effects, such as
gliclazide.
Chlortetracycline See TETRACYCLINES.
Chlordiazepoxide A widely used anti-anxiety drug. (See QUILLISERS; BENZO
DIAZEPINES.)
133
TRANChlorhexidine An antiseptic which has a bacteriostatic action against ma
ny bacteria.
Chlorine See SODIUM HYPOCHLORITE.
Chloroma Chloroma, or green cancer, is the name of a
Choking Choking is the process which results from an obstruction to brea
thing situated in the larynx
(see AIR PASSAGES). It may occur as the result of disease causing swelling round
the glottis (the entrance
to the larynx), or of some nervous disorders that interfere with the regulation
of the muscles which open
and shut the larynx. Generally, however, it is due to the irritation of a piece
of food or other substance
introduced by the mouth, which provokes coughing but only
C
134 Cholagogues
C
partly interferes with breathing. As the mucous membrane lining the uppe
r part of the latter is
especially sensitive, coughing results in order to expel the cause of irritation
. At the same time, if the
foreign body is of any size, lividity of the face appears, due to partial suffoc
ation (see ASPHYXIA).
Cholecystectomy
Treatment The choking person should take
Cholecystography
slow, deep inspirations, which do not force the particle further in (as
sudden catchings of the breath
between the coughs do), and which produce more powerful coughs. If the coughing
is weak, one or two strong
blows with the palm of the hand over either shoulder blade, timed to coincide wi
th coughs, aid the effect
of the coughing. If this is ineffective, the Heimlich manoeuvre may be used. Thi
s involves hugging the
person from behind with ones hands just under the diaphragm. A sudden upward comp
ressive movement is made
which serves to dislodge any foreign body. In the case of a baby, sit down with
left forearm resting on
thigh. Place the baby chest-down along the forearm, holding its head and jaw wit
h the fingers and thumb.
The infants head should be lower than its trunk. Gently deliver three or four blo
ws between the shoulder
blades with the free hand. The resuscitator should not attempt blind finger-swee
ps at the back of the
mouth; these can impact a foreign body in the larynx. If normal breathing (in ad
ult or child) cannot be
quickly restored, seek urgent medical help. Sometimes an emergency TRACHEOSTOMY
is necessary to restore the
air supply to the lungs. (See APPENDIX 1: BASIC FIRST AID.)
Cholagogues Substances which increase the flow of BILE by stimulating ev
acuation of the gall-bladder
(see LIVER). The great majority of these act only by increasing the activity of
the digestive organs, and
so producing a flow of bile already stored up in the gall-bladder. Substances wh
ich stimulate the liver to
secrete more bile are known as CHOLERETIC.
Cholangiography The process whereby the bile ducts (see BILE and the gal
l-bladder (see LIVER) are
rendered radio-opaque and therefore visible on an X-ray film. DUCT)
Cholangitis Inflammation of the bile ducts (see GALL-BLADDER, DISEASES O
F).
BILE DUCT;
Removal of the gall-bladder (see operation.
LIVER)
by
Cholecystitis Inflammation of the gall-bladder (see BLADDER, DISEASES OF
).
GALLThe process whereby the gall-bladder (see LIVER) is rendered radio-opaqu
e and therefore visisble on an
X-ray film.
Cholecystokinin The hormone (see HORMONES) released from the lining memb
rane of the DUODENUM when food
is taken, and which initiates emptying of the gall-bladder (see LIVER).
Cholelithiasis The presence of gall-stones in the bile ducts and/or in t
he gall-bladder. (See
GALL-BLADDER, DISEASES OF.)
Cholelithotomy The removal of gall-stones from the gallbladder or bile d
ucts (see GALL-BLADDER,
DISEASES OF), when CHOLECYSTECTOMY or LITHOTRIPSY are inappropriate or not possi
ble. It involves a
cholecystomy, an operation to open the gall-bladder.
Cholera Bacterial infection caused by Vibrio cholerae. The patient suffe
rs profuse watery DIARRHOEA,
and resultant dehydration and electrolyte imbalance. Formerly known as the Asiat
ic cholera, the disease has
occurred in epidemics and pandemics for many centuries. When it entered Europe i
n 1853, Dr John Snow, a
London anaesthetist, carried out seminal epidemiological work in Soho, London, w
hich established that the
source of infection was contaminated drinking water derived from the Broad Stree
t pump. Several smaller
epidemics involved Europe in the latter years of the 19th century, but none has
arisen in Britain or the
United States for many years. In 1971, the El Tor biotype of V. cholerae emerged
, replacing much of the
classical infection in Asia and, to a much lesser extent, Europe; parts of Afric
a were seriously affected.
Recently a non-01 strain has arisen and is causing much disease in Asia. Cholera
remains a major health
problem (this is technically the seventh pandemic) in many countries of Asia, Af
rica and South America. It
is one of three quarantinable infections. Incubation period varies from a few ho
urs to
Cholesterol
five days. Watery diarrhoea may be torrential and the resultant dehydrat
ion and electrolyte imbalance,
complicated by cardiac failure, commonly causes death. The victims skin elasticit
y is lost, the eyes are
sunken, and the radial pulse may be barely perceptible. Urine production may be
completely suppressed.
Diagnosis is by detection of V. cholerae in a faecal sample. Treatment consists
of rapid rehydration.
Whereas the intravenous route may be required in a severe case, in the vast majo
rity of patients oral
rehydration (using an appropriate solution containing sodium chloride, glucose,
sodium bicarbonate, and
potassium) gives satisfactory results. Proprietary rehydration fluids do not alw
ays contain adequate sodium
for rehydration in a severe case. ANTIBIOTICS, for example, tetracycline and dox
ycycline, reduce the period
during which V. cholerae is excreted (in children and pregnant women, furazolido
ne is safer); in an
epidemic, rapid resistance to these, and other antibiotics, has been clearly dem
onstrated. Prevention
consists of improving public health infrastructure in particular, the quality of
drinking water. When
supplies of the latter are satisfactory, the infection fails to thrive. Though t
here have recently been
large epidemics of cholera in much of South America and parts of central Africa
and the Indian
subcontinent, the risk of tourists and travellers contracting the disease is low
if they take simple
precautions. These include eating safe food (avoid raw or undercooked seafood, a
nd wash vegetables in clean
water) and drinking clean water. There is no cholera vaccine at present availabl
e in the UK as it provides
little protection and cannot control spread of the disease. Those travelling to
countries where it exists
should pay scrupulous attention to food and water cleanliness and to personal hy
giene.
Choleretic The term applied to a drug that stimulates the flow of BILE.
Cholestasis A reduction or stoppage in the flow of BILE into the intesti
ne caused either by a blockage
such as a stone in the BILE DUCT or by liver disease disturbing the production o
f bile. The first type is
called extrahepatic biliary obstruction and the second, intrahepatic cholestasis
. The patient develops
jaundice and itching and passes dark urine and pale faeces. Cholestasis may occa
sionally occur during
pregnancy.
Cholesterol A
LIPID
that is an important constituent of
135
body cells and so widely distributed throughout the body. It is especial
136 Choline
C
oily fish such as mackerel and herring tend to lower it. There is a tend
ency in western society to
eat too much animal fat, and current health recommendations are for everyone to
decrease saturated-fat
intake, increase unsaturated-fat intake, increase daily exercise, and avoid obes
ity. This advice is
particulary important for people with high blood-cholesterol levels, with diabet
es mellitus, or with a
history of coronary thrombosis (see HEART, DISEASES OF). As well as a low-choles
terol diet, people with
high cholesterol values or arterial disease may be given cholesterol-reducing dr
ugs such as STATINS, but
this treatment requires full clinical assessment and ongoing medical monitoring.
Recent research involving
the worlds largest trial into the effects of treatment to lower concentrations of
cholesterol in the blood
showed that routine use of drugs such as statins reduced the incidence of heart
attacks and strokes by
one-third, even in people with normal levels of cholesterol. The research also s
howed that statins
benefited women and the over-70s.
Choline One of the many constituents of the vitamin B complex. Lack of i
t in the experimental animal
produces a fatty liver. It is found in egg-yolk, liver, and meat. The probable d
aily human requirement is
500 mg, an amount amply covered by the ordinary diet. Choline can be synthesised
by the body (see APPENDIX
5: VITAMINS).
Cholinergic
the symptoms, as can the drugs used to treat PARKINSONISM. Types of chor
ea include HUNTINGTONS CHOREA,
an inherited disease, and SYDENHAMS CHOREA, which is autoimmune.
There is also a degenerative form senile chorea.
Choriocarcinoma A form of cancer affecting the CHORION, in the treatment
of which particularly
impressive results are being obtained from the use of methotrexate.
Chorion This is the more external of the two fetal membranes. (See PLACE
NTA.)
Chorionic Gonadotrophic Hormone A hormone produced by the PLACENTA durin
g pregnancy. It is similar to
the pituitary GONADOTROPHINS, which are blocked during pregnancy. Large amounts
appear in a womans urine
when she is pregnant and are used as the basis for pregnancy tests. Human gonado
trophins are used to treat
delayed puberty and premenstrual tension.
Choroid See EYE.
Choroiditis See UVEITIS.
exertion, wheezing and tightness of the chest follow. Bloodstained and/or infect
ed sputum are also
indicative of established disease. Among the symptoms and signs of patients with
advanced obstruction of
airflow in the lungs are: RHONCHI (abnormal musical sounds heard through a STETH
OSCOPE when the patient
breathes out). marked indrawing of the muscles between the ribs and development
of a barrel-shaped chest.
loss of weight. CYANOSIS in which the skin develops a blue tinge because of redu
ced oxygenation of blood in
the blood vessels in the skin. bounding pulse with changes in heart rhythm. OEDE
MA of the legs and arms.
decreasing mobility. Some patients with COPD have increased ventilation of the a
lveoli in their lungs, but
the levels of oxygen and carbon dioxide are normal so their skin colour is norma
l. They are, however,
breathless so are dubbed pink puffers. Other patients have reduced alveolar ventil
ation which lowers
their oxygen levels causing cyanosis; they also develop COR PULMONALE, a form of
heart failure, and become
oedematous, so are called blue bloaters.
Investigations include various tests of lung function, including the pat
ients response to
bronchodilator drugs. Exercise tests may help, but radiological assessment is no
t usually of great
diagnostic value in the early stages of the disorder.
Treatment depends on how far COPD has progressed. Smoking must be stoppe
d also an essential
preventive step in healthy individuals. Early stages are treated with bronchodil
ator drugs to relieve
breathing symptoms. The next stage is to introduce steroids (given by inhalation
). If symptoms worsen,
physiotherapy breathing exercises and postural drainage is valuable and annual v
accination against
INFLUENZA is strongly advised. If the patient develops breathlessness on mild ex
ertion, has cyanosis,
wheezing and permanent cough and tends to HYPERVENTILATION, then oxygen therapy
Cimex Lectularius
should be considered. Antibiotic treatment is necessary if overt infecti
on of the lungs develops.
Complications Sometimes rupture of the pulmonary bullae (thin-walled air
spaces produced by the
breakdown of the walls of the alveoli) may cause PNEUMOTHORAX and also exert pre
ssure on functioning lung
tissue. Respiratory failure and failure of the right side of the heart (which co
ntrols blood supply to the
lungs), known as cor pulmonale, are late complications in patients whose primary
problem is emphysema.
Prognosis This is related to age and to the extent of the patients respon
se to bronchodilator drugs.
Patients with COPD who develop raised pressure in the heart/lung circulation and
subsequent heart failure
(cor pulmonale) have a bad prognosis.
Chronic Sick and Disabled Act 1970 UK legislation that provides for the
identification and care of
individuals who have an incurable chronic or degenerative disorder. The patients
are usually distinguished
from elderly people with chronic disorders. Local authorities identify relevant
individuals and arrange for
appropriate services. The legislation does not, however, compel doctors and nurs
es in the community to
inform local authorities of potential beneficiaries. This may be because the ind
ividuals concerned dislike
being on a register of disabled, or because questions of confidentiality prevent
health staff from
reporting the persons condition.
Chyle The milky fluid which is absorbed by the lymphatic vessels of the
intestine. The absorbed portion
consists of fats in very fine emulsion, like milk, so that these vessels receive
the name of lacteals (L.
lac, milk). This absorbed chyle mixes with the lymph and is discharged into the
thoracic duct, a vessel,
which passes up through the chest to open into the jugular vein on the left side
of the neck, where the
chyle mixes with the blood.
Chyluria The passage of CHYLE in the urine. This results in the passing
of a milky-looking urine. It is
one of the manifestations of FILARIASIS, where it is due to obstruction of the L
YMPHATICS by the causative
parasite.
139
Chyme Partly digested food as it issues from the stomach into the intest
ine. It is very acid and grey
in colour, containing salts and sugars in solution, and the animal food softened
into a semi-liquid mass.
It is next converted into CHYLE.
Chymopapain An ENZYME obtained from the paw-paw, which is being used in
the treatment of prolapsed
INTERVERTEBRAL DISC. When injected into the disc it dissolves the cartilage tiss
ue.
Chymotrypsin An ENZYME produced by the PANCREAS which digests protein. I
t is used as an aid in
operations for removal of a cataract (see ZONULOLYSIS), and also by inhalation t
o loosen and liquefy
secretions in the windpipe and bronchi.
Cicatrix Another word for scar.
Ciclosporin A A drug used to prevent the rejection of transplanted organ
s such as the heart and
kidneys. (See TRANSPLANTATION.)
Cilia A term applied to minute, lash-like processes which are seen with
the aid of the microscope upon
the cells covering certain mucous membranes for example, the TRACHEA (or windpip
e) and nose and which
maintain movement in the fluid passing over these membranes. They are also found
on certain bacteria which
have the power of rapid movement.
Ciliary Body That part of the EYE that connects the iris and the choroid
. The ciliary ring is next to
the choroid; the ciliary processes comprise many ridges behind the iris, to whic
h the lenss suspensory
ligament is attached; and the ciliary muscle contracts to change the curvature o
f the lens and so adjust
the accommodation of the eye.
Cimetidine Cimetidine is a drug (known as an H2 receptor antagonist) tha
t is widely used in the
treatment of PEPTIC ULCER. It acts by reducing the hyperacidity of the gastric j
uice by antagonising
histamine receptors in the stomach.
Cimex Lectularius See BED BUG.
C
140 Cinchona
Cinchona
C
The general name for several trees in the bark of which QUININE is found
. This bark is also known as
Jesuits bark, having been first brought to notice by Spanish priests in South Ame
rica, and first brought
to Europe by the Countess of Cinchon, wife of the Viceroy of Peru, in 1640. The
red cinchona bark contains
the most quinine; quinine is usually prepared from this. Various extracts and ti
nctures are made direct
from cinchona bark, and used in place of quinine.
Ciprofloxacin A quinolone antibiotic (see QUINOLONES) used to treat typh
oid and paratyphoid infections
(see ENTERIC FEVER).
Circle of Willis A circle of arteries at the base of the brain, formed b
y the junction of the basilar,
posterior cerebral, internal carotid and anterior cerebral arteries. Congenital
defects may occur in these
arteries and lead to the formation of aneurysm (see ANEURYSM).
Circulatory System of the Blood The course of the circulation is as foll
ows: the veins pour their
blood, coming from the head, trunk, limbs and abdominal organs, into the right a
trium of the HEART. This
contracts and drives the blood into the right ventricle, which then forces the b
lood into the LUNGS by way
of the pulmonary artery. Here it is contained in thin-walled capillaries, over w
hich the air plays freely,
and through which gases pass readily out and in. The blood gives off carbon diox
ide (CO2) and takes up
oxygen (see RESPIRATION), and passes on by the pulmonary veins to the left atriu
m of the heart. The left
atrium expels it into the left ventricle, which forces it on into the aorta, by
which it is distributed all
over the body. Passing through capillaries in the various tissues, it enters ven
ules, then veins, which
ultimately unite into two great veins, the superior and the inferior vena cava,
these emptying into the
right atrium. This complete circle is accomplished by any particular drop of blo
od in about half a minute.
In one part of the body there is a further complication. The veins coming from t
he bowels, charged with
food material and other products, split up, and their blood undergoes a second c
apillary circulation
through the liver. Here it is relieved of some food material and purified, and t
hen passes into the
inferior vena cava, and so to the right atrium. This is known as the portal circ
ulation.
The circle is maintained always in one direction by four valves, situate
d one at the outlet from each
cavity of the heart. The blood in the arteries going to the body generally is br
ight red, that in the veins
dull red in colour, owing to the former being charged with oxygen and the latter
ed strength. It is,
however, liable to be broken by falls on the hand or on the shoulder, and is the
most frequently fractured
bone in the body. (See BONE, DISORDERS OF.)
Claw-Foot Claw-foot, or PES CAVUS, is a familial deformity of the foot c
haracterised by an abnormally
high arch of the foot accompanied by shortening of the foot, clawing of the toes
, and inversion, or turning
inwards, of the foot and heel. Its main effect is to impair the resilience of th
e foot resulting in a stiff
gait and aching pain. Milder cases are treated with special shoes fitted with a
sponge rubber insole. More
severe cases may require surgical treatment.
Claw-Hand A (contraction) deformity of the hand and fingers, especially
of the ring and little fingers.
The condition is generally due to paralysis of the ULNAR NERVE. A somewhat simil
ar condition is produced by
contraction of the fibrous tissues in the palm of the hand, partly due to rheuma
tic changes and partly to
injury caused by the constant pressure of a tool against the palm of the hand. (
See DUPUYTRENS
CONTRACTURE.)
Claw-Toes See CLAW-FOOT.
Cleft Foot A rare congenital abnormality characterised by the absence of
one or more toes and a deep
central cleft that divides the foot into two. It is sometimes known as lobster f
oot, or lobster claw. It
may be accompanied by other congenital defects, such as CLEFT HAND, absent perma
nent teeth, CLEFT PALATE
(and/or lip), absence of the nails, and defects of the eye.
C
Clinical Clinical means literally belonging to a bed, but the word is used
to denote anything
associated with the practical study or observation of sick people as in clinical
medicine, clinical
thermometers.
Clinical Audit A MEDICAL professionals.
AUDIT
carried out by health
Clinical Governance A concept, introduced in a UK government White Paper
in 1997, aimed at ensuring
that all NHS organisations have in place proper processes for continuously monit
oring and improving
clinical audit. All clinicians and managers are now expected to understand their
individual and collective
responsibilities for assuring accountability for the quality of patient care. Cl
inical governance is now
included in the NHS legislation based on the 1997 White Paper. (See also MEDICAL
AUDIT; HEALTH CARE
COMMISSION; NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE (NICE).)
Clinical Guidelines Systematically developed statements which assist cli
nicians and patients to decide
on appropriate treatments for specific conditions. The guidelines are attractive
to health managers and
patients because they are potentially able to reduce variation in clinical pract
ice. This helps to ensure
that patients receive the right treatment of an acceptable standard. In England
and Wales, the NATIONAL
INSTITUTE FOR CLINICAL EXCELLENCE (NICE) is developing national guidelines with
advice from health-care
professionals and patients to improve clinical effectiveness of NHS care. Some d
octors have reservations
about guidelines because (1) health-care managers might use them primarily to co
ntain costs; (2)
inflexibility would discourage clinical innovations; (3) they could encourage li
tigation by patients. (See
also HEALTH CARE COMMISSION; MEDICAL LITIGATION.)
Clinical Psychology Psychology is the scientific study of behaviour. It
may be applied in various
settings including education, industry and health care. Clinical psychology is c
oncerned with the practical
application of research findings in the fields of physical and mental health. Tr
aining in clinical
Clinical Trials
psychology involves a degree in psychology followed by postgraduate trai
ning. Clinical psychologists
are specifically skilled in applying theoretical models and objective methods of
observation and
measurement, and in therapeutic interventions aimed at changing patients dysfunct
ional behaviour,
including thoughts and feelings as well as actions. Dysfunctional behaviour is e
xplained in terms of normal
processes and modified by applying principles of normal learning, adaption and s
ocial interaction. Clinical
psychologists are involved in health care in the following ways: (1) Assessment
of thoughts, emotions and
behaviour using standardised methods. (2) Treatment based on theoretical models
and scientific evidence
about behaviour change. Behaviour change is considered when it contributes to ph
ysical, psychological or
social functioning. (3) Consultation with other health-care professionals about
problems concerning
emotions, thinking and behaviour. (4) Research on a wide variety of topics inclu
ding the relationship
between stress, psychological functioning and disease; the aetiology of problem
behaviours; methods and
theories of behaviour change. (5) Teaching other professionals about normal and
dysfunctional behaviour,
emotions and functioning. Clinical psychologists may specialise in work in parti
cular branches of patient
care, including surgery, psychiatry, geriatrics, paediatrics, mental handicap, o
bstetrics and gynaecology,
cardiology, neurology, general practice and physical rehabilitation. Whilst the
focus of their work is
frequently the patient, at times it may encompass the behaviour of the health-ca
re professionals.
Clinical Risk Management Initially driven by anxiety about the possibili
ty of medical negligence cases,
clinical risk management has evolved into the study of IATROGENIC DISEASE. The f
irst priority of risk
managers is to ensure that all therapies in medicine are as safe as possible. Al
lied to this is a
recognition that errors may occur even when error-prevention strategies are in p
lace. Lastly, any accidents
that occur are analysed, allowing a broader understanding of their cause. Risk m
anagement is generally
centred on single adverse events. The threat of litigation is taken as an opport
unity to expose unsafe
conditions of practice and to put pressure on those with the authority to implem
ent change. These might
include senior clinicians, hospital management, the purchasing authorities, and
even the Secretary of State
for Health. Attention is
143
focused on organisational factors rather than on the individuals involve
d in a specific case.
Clinical Signs The physical manifestations of an illness elicited by a d
octor when examining a patient
for example, a rash, lump, swelling, fever or altered physical function such as
reflexes.
Clinical Symptoms The experiences of a patient as communicated to a doct
or, for example, pain,
weakness, cough. They may or may not be accompanied by confirmatory CLINICAL SIG
NS.
Clinical Trials (See EVIDENCE-BASED MEDICINE.) Clinical trials aim to ev
aluate the relative effects of
different health-care interventions. They are based on the idea that there must
a fair comparison of the
alternatives in order to know which is better. Threats to a fair comparison incl
ude the play of chance and
bias, both of which can cause people to draw the wrong conclusions about how eff
ective a treatment or
procedure is. An appreciation of the need to account for chance and bias has led
to development of methods
where new treatments are compared to either a PLACEBO or to the standard treatme
nt (or both) in a
controlled, randomised clinical trial. Controlled means that there is a comparison
group of patients not
receiving the test intervention, and randomised implies that patients have been as
signed to one or other
treatment group entirely by chance and not because of their doctors preference. I
f possible, trials are
double-blind that is, neither the patient nor the investigator knows who is receiv
ing which
intervention until after the trial is over. All such trials must follow proper e
thical standards with the
procedure fully explained to patients and their consent obtained. The conduct, e
ffectiveness and
duplication of clinical trials have long been subjects of debate. Apart from occ
asional discoveries of
deliberately fraudulent research (see RESEARCH FRAUD AND MISCONDUCT), the struct
ure of some trials are
unsatisfactory, statistical analyses are sometimes disputed and major problems h
ave been the usually
unwitting duplication of trials and non-publication of some trials, restricting
access to their findings.
Duplication occurs because no formal international mechanism exists to enable re
search workers to discover
whether a clinical trial they are planning is already underway elsewhere or has
been completed but never
published, perhaps because the
C
144 Clitoris
C
results were negative, or no journal was willing to publish it, or the a
uthors or funding authorities
decided not to submit it for publication. In the mid 1980s a proposal was made f
or an international
register of clinical trials. In 1991 the NHS launched a research and development
initiative and, liaising
with the COCHRANE COLLABORATION, set out to collect systematically data from pub
lished randomised clinical
trials. In 1994 the NHS set up a Centre for Reviews and Dissemination which, amo
ng other responsibilities,
maintains a database of research reviews to provide NHS staff with relevant info
rmation. These efforts are
hampered by availability of information about trials in progress and unpublished
completed trials. With a
view to improving accessibility of relevant information, the publishers of Curre
nt Science, in 1998,
launched an online metaregister of ongoing randomised controlled trials. Subsequ
ently, in October 1999, the
editors of the British Medical Journal and the Lancet argued that the case for a
n international register of
all clinical trials prior to their launch was unanswerable. The public, they said,
has the right to know
what research is being funded. Researchers and research funders dont want to wast
e resources repeating
trials already underway. Given the widening recognition of the importance to pati
ents and doctors of the
practice of EVIDENCE-BASED MEDICINE, the easy availability of information on pla
nned, ongoing and completed
clinical trials is vital. The register was finally set up in 2005.
Clitoris A small, sensitive organ comprising erectile tissue at the top
of the female genitalia where
the labial folds meet below the pubic bone. Clitoral tissue extends into the ant
erior roof of the vagina.
During sexual excitement the clitoris enlarges and hardens and may be the focus
of orgasm. (See
CIRCUMCISION.)
Clofazimine A drug used in the treatment of LEPROSY.
Clofibrate See HYPERLIPIDAEMIA.
Clomiphene An anti-oestrogen drug that stimulates ovulation, or the prod
uction of ova, through the
medium of the PITUITARY GLAND. When used in the treatment of female infertility,
one of its hazards is
that, if given in too-big doses, it may produce multiple births.
Clomipramine One of the tricyclic
ANTIDEPRESSANT DRUGS.)
Clonazepam A drug to treat EPILEPSY, including STATUS EPILEPTICUS, and M
YOCLONUS. (See also
TRANQUILLISERS.)
Clone A group of cells genetically identical to each other that have ari
sen from one cell by asexual
reproduction (see CLONING).
Clonic A word applied to short spasmodic movements.
Clonidine A drug used for
HYPERTENSION, MIGRAINE, GILLES DE LA TOURETTES SYNDROME, and
menopausal flushing. It can cause drowsiness so caution is needed when d
riving or using machinery.
Cloning Cloning from the Greek klon, meaning a cutting such as is used t
o propagate plants is
essentially a form of asexual reproduction. The initial stages were first succes
sfully achieved in rabbits.
In essence the technique consists of destroying the nucleus of the egg and repla
cing it with the nucleus
from a body cell of the same species either a male or a female. This provides th
e egg with a full
complement of CHROMOSOMES and it starts to divide and grow just as it would if i
t had retained its nucleus
and been fertilised with a spermatozoon. The vital difference is that the embryo
resulting from this
cloning process owes nothing genetically to the female egg. It is identical in e
very respect with the
animal from which the introduced nucleus was obtained. In 1997 the first mammal
to be cloned from the
tissue of an adult animal was born. A technique that scientists have been trying
to perfect for decades,
the success of the Roslin Institute, near Edinburgh, in producing Dolly, a cloned
sheep, has profound
implications. Already some scientists are talking of cloning humans, although th
is has great medical, legal
and ethical consequences. The key to the scientists success in producing Dolly wa
s the ability to
coordinate the fusion of a donor cell (from an adult) containing all its DNA wit
h a recipient egg from
which DNA had been removed. The difficulty of the technique is shown by the fact
that, out of 277 fused
pairs of cells where the donor cell was from adult tissue, Dolly was the only su
rvivor and she has
developed premature
Cluster Headaches
arthritis. Research suggests that cloning may be accompanied by a higher
than normal incidence of
congenital defects. Since Dolly was born, other animal clones have been produced
and American researchers
have cloned the first human embryo which grew to six cells with the aim of provi
ding stem cells for
therapeutic use. As a result the UK government passed emergency legislation to o
utlaw human cloning for
reproductive purposes.
Clonus A succession of intermittent muscular relaxations and contraction
s usually resulting from a
sustained stretching stimulus. An example is the clonus stimulated in the calf m
uscle by maintaining
sustained upward pressure on the sole of the foot. The condition is often a sign
of disease in the brain or
spinal cord.
Clormethiazole A useful hypnotic, particularly for elderly patients, bec
ause of its freedom from
hangover effect. It is especially beneficial in the acute withdrawal symptoms of
alcoholism and is used to
treat STATUS EPILEPTICUS. The drugs sedative effects are an adjunct to regional a
naesthesia and may also
be of help in ECLAMPSIA. Dependence may occur occasionally and therefore the len
gth of period for which the
drug is used should be limited. Side-effects include sneezing, conjunctival irri
tation and occasional
headache.
Clostridium The genus, or variety, of micro-organisms that produce spore
s which enable them to survive
under adverse conditions. They normally grow in soil, water and decomposing plan
t and animal matter, where
they play an important part in the process of PUTREFACTION. Among the important
members of the group, or
genus, are Clostridium welchii, Cl. septicum and Cl. oedematiens, the causes of
gas gangrene (see
GANGRENE); Cl. tetani, the cause of TETANUS; and Cl. botulinum, the cause of BOT
ULISM.
Clot The term applied to any semi-solid mass of blood, lymph or other bo
dy fluid. Clotting in the blood
is due to the formation of strings of FIBRIN produced by the action of a ferment
. Milk clots in a similar
manner in the stomach when exposed to the action of the enzyme rennin. Clotting
occurs naturally when blood
is shed and comes into contact with tissues outside the blood vessels. It occurs
also at times in
145
diseased vessels (THROMBOSIS), producing serious effects upon the tissue
s supplied or drained by these
vessels. Clots sometimes form in the heart when the circulation is failing. (See
COAGULATION; EMBOLISM.)
Clotrimazole A drug of the IMIDAZOLES group used to treat fungal infecti
146 CMV
drugs such as SUMATRIPTAN or by breathing 100 per cent oxygen.
CMV See CYTOMEGALOVIRUS (CMV).
C
Coagulation Coagulation of the blood is the process whereby bleeding (or
haemorrhage) is normally
arrested in the body. Blood starts to clot as soon as the skin (or other tissue)
has been cut. Coagulation
is part of the process of HAEMOSTASIS which is the arrest of bleeding from an in
jured or diseased blood
vessel. Haemostasis depends on the combined activities of vascular, platelet (se
e PLATELETS) and PLASMA
elements which are offset by processes to restrict the accumulation of platelets
and FIBRIN to the damaged
area. The three-stage process of coagulation is complex, involving many differen
t substances. There are two
cascading pathways of biochemical reactions for activating coagulation of blood.
The extrinsic pathway is
the main physiological mechanism, which is triggered when blood vessels are dama
ged, usually by trauma or
surgery. The intrinsic pathway is activated by internal disruption of the wall o
f a blood vessel. The basic
pattern is broadly the same for both and is summarised simply as follows: prothr
ombin + calcium +
thromboplastin thrombin + fibrinogen fibrin Prothrombin and calcium are normally
present in the blood.
Thromboplastin is an enzyme which is normally found in the blood platelets and i
n tissue cells. When
bleeding occurs from a blood vessel, there is always some damage to tissue cells
and to the blood
platelets. As a result of this damage, thromboplastin is released and comes into
contact with the
prothrombin and calcium in the blood. In the presence of thromboplastin and calc
ium, prothrombin is
converted into thrombin, which in turn interacts with fibrinogen a protein alway
s present in the blood
to form fibrin. Fibrin consists of needle-shaped crystals which, with the assist
ance of the blood
platelets, form a fine network in which the blood corpuscles become enmeshed. Th
is meshwork, or CLOT as it
is known, gradually retracts until it forms a tight mass which, unless the tissu
e injury is very severe or
a major artery has been damaged, prevents any further bleeding. It will thus be
seen that clotting, or
coagulation, does not occur in the healthy blood vessel because there is no thro
mboplastin present. There
is now evidence suggesting that there is an anti-thrombin substance present in the blood in small amounts, and that this substance an
tagonises any small amounts of
thrombin that may be formed as a result of small amounts of thromboplastin being
released. The clotting or
coagulation time is the time taken for blood to clot and can be measured under c
ontrolled conditions to
ensure that it is normal (38 minutes). In certain diseases HAEMOPHILIA, for examp
le clotting time is
Cod-Liver Oil
used from time immemorial by the South American Indians, who chew them m
ixed with a little lime. Their
effect is to dull the mucous surfaces of mouth and stomach, with which the saliv
a, produced by chewing
them, comes into contact thus blunting, for long periods, all feeling of hunger.
The cocaine, being
absorbed, stimulates the central nervous system so that all sense of fatigue and
breathlessness vanishes
for a time. It was by the use of coca that the Indian post-runners of South Amer
ica were able to achieve
their extraordinary feats of endurance. The continued use of the drug, however,
results in emaciation, loss
of memory, sleeplessness and general breakdown. DEPENDENCE on cocaine or a deriv
ative, crack, is now a
serious social problem in many countries.
Uses Before the serious effects that result from its habitual use were r
ealised, the drug was sometimes
used by hunters, travellers and others to relieve exhaustion and breathlessness
in climbing mountains and
to dull hunger. Derivatives of cocaine are used as locally applied analgesics vi
a sprays or injections in
dentistry and for procedures in the ear, nose and throat. Because of its serious
side-effects and the risk
of addiction, cocaine is a strictly controlled Class A drug which can be prescri
bed only by a medical
practitioner with a Home Office licence to do so.
Cocci Spherical BACTERIA that cause a variety of infections. Staphylococ
ci, streptococci and
meningococci (see NEISSERIACEAE) are examples.
Coccydynia The sensation of severe pain in the COCCYX.
Coccyx The lower end of the SPINAL COLUMN, resembling a birds beak and co
nsisting of four fused
nodules of bone; these represent vertebrae and correspond to the tail in lower a
nimals. Above the coccyx
lies a much larger bone, the SACRUM, and together they form the back wall of the
PELVIS, which protects the
organs in the lower ABDOMEN.
Cochlea That part of the inner ear concerned with hearing. (See EAR.)
Cochlear Implants A cochlear implant is an electronic device, inserted u
nder a general anaesthetic,
which stimulates the auditory system, restoring partial
147
hearing in profound sensory deafness. Although there are many types of c
ochlear implant, they all
consist of a microphone, a signal processor, a signal coupler (transmitter and r
eceiver), and an array of
electrodes. Most are multi-channel implants. The microphone and signal processor
are worn outside the body,
like a conventional hearing aid: they receive sound and convert it into an elect
ronic signal which is
transmitted through the skin to the receiver. Here the signal is transmitted to
the array of electrodes
which stimulates the cochlear nerve. Although cochlear implants do not provide n
ormal hearing, most
profoundly deaf patients who receive a cochlear implant are able to detect a var
iety of sounds, including
environmental sounds and speech. The duration of hearing-loss and age at implant
ation are among the many
factors which influence the results (see DEAFNESS).
Cochrane Collaboration A non-profit-making international organisation wh
ich systematically finds,
appraises and reviews available evidence, mainly from randomised CLINICAL TRIALS
, about the consequences of
health care. The aim is to help people make well-informed decisions about health
care. The main work is
done by around 50 review groups, the members of which share an interest in gener
ating reliable, up-to-date
evidence on the prevention, treatment and rehabilitation of particular health pr
oblems or groups of
problems. The UK Cochrane Centre opened in Oxford in 1992 and the International
Collaboration launched a
year later. Its origins lay in the work of a UK epidemiologist, Dr Archie Cochra
ne, who in 1979 published a
monograph calling for a systematic collection of randomised controlled trials on
the effect of health care.
The main output of the Cochrane Collaboration is published electronically as the
Cochrane Library, updated
quarterly, with free access in many countries. (See CLINICAL TRIALS, EVIDENCE-BA
SED MEDICINE and Appendix
2.)
Codeine One of the active principles of OPIUM, codeine is an analgesic (
see ANALGESICS) which in the
form of codeine phosphate is used to suppress persistent coughs and to relieve p
ain such as headaches and
musculoskeletal discomfort. Side-effects include constipation, nausea and sleepi
ness. Dependence is rare.
Cod-Liver Oil Cod-liver oil is derived from the fresh liver of the cod (
Gadus callarius). It is a rich
source of
C
Cholestyramine
clusions drawn about a particular disease or drug treatment.
149
Coitus is sexual intercourse.
such as asthma, bronchitis or ear infections. Most colds are self-limiti
ng, resolving in a week or ten
days, but some patients develop secondary bacterial infections of the sinuses, m
iddle ear (see EAR),
trachea, or LUNGS.
Coitus interruptus (see CONTRACEPTION).
Treatment Symptomatic treatment with
Coitus
Colchicine A drug used to treat GOUT in the acute stage. Its use is limi
ted by the development of
toxicity at higher doses, but in patients with heart failure it may be preferabl
e to NON-STEROIDAL
ANTIINFLAMMATORY DRUGS (NSAIDS), which tend to cause fluid retention. Colchicine
can be given to patients
receiving ANTICOAGULANTS. The drug does have side-effects on the gastrointestina
l system.
Colchicum The bulb of Colchicum autumnale, or meadowsaffron, has long be
en used as a remedy for GOUT.
How it acts is not quite certain.
Uses Its main use is in gout, for which colchicine, the active principle
of colchicum, in doses of 05
mg every one or two hours until the pain is relieved, followed by 05 mg thrice da
ily for about a week, is
the form generally employed.
Cold, Common An infection by any one of around 200 viruses, with about h
alf the common-cold infections
being caused by RHINOVIRUSES. Certain CORONAVIRUSES, ECHOVIRUSES and COXSACKIE V
IRUSES are also culprits.
The common cold traditionally also called a chill is one of several viral infect
ions that cause
respiratory symptoms and systemic illness. Others include PNEUMONIA and GASTROEN
TERITIS. Colds are commoner
in winter, perhaps because people are more likely to be indoors in close contact
with others. Also called
acute coryza or upper respiratory infection, the common cold is characterised by
inflammation of any or all
of the airways NOSE, sinuses (see SINUS), THROAT, LARYNX, TRACHEA and bronchi (s
ee BRONCHUS). Most
common, however, is the head cold, which is confined to the nose and throat, with
initial symptoms
presenting as a sore throat, runny nose and sneezing. The nasal discharge may be
come thick and yellow a
sign of secondary bacterial infection while the patient often develops watery ey
es, aching muscles, a
cough, headache, listlessness and the shivers. PYREXIA (raised temperature) is u
150 Colic
triglycerides in the blood and thereby, like clofibrate and STATINS, hel
ping to reduce the incidence of
coronary artery heart disease. (See HEART, DISEASES OF; HYPERLIPIDAEMIA.)
C Colic
This term is generally used for an attack of spasmodic pain in the abdom
en.
Simple colic often results from the build-up of indigestible material in
the alimentary tract, leading
to spasmodic contractions in the muscular lining. Other causes include habitual
constipation, with
accumulation of faecal material; simple colic also occurs as an accompaniment of
neurological disorders.
Major risks include sudden obstruction of the bowel from twisting, INTUSSUSCEPTI
ON, or as a result of a
tumour or similar condition. (See also INTESTINE, DISEASES OF.)
Lead colic (traditional names include painters colic, colica pictonum, De
vonshire colic, dry
belly-ache) is due to the absorption of lead into the system. (See LEAD POISONIN
G.) Biliary colic and renal
colic are the terms applied to that violent pain which is produced, in the one c
ase where a biliary
calculus or gall-stone passes down from the gallbladder into the intestine, and
in the other where a renal
calculus descends from the kidney along the ureter into the bladder. (See GALL-B
LADDER, DISEASES OF and
KIDNEYS, DISEASES OF.)
Treatment This consists of means to relieve the spasmodic pain with warm
th and analgesics, and removal,
where possible, of the underlying cause.
Infantile colic is a common condition in babies under three months, some
times continuing for a little
longer. The babies cry persistently and appear to their parents to have abdomina
l pain, although this
remains unproven. Swaddling and massage can help, as can simply stimulating the
child with movement and
noise (rocking and singing). Medication is usually unhelpful, although the most
severely affected deserve
help because of the deleterious effect of infantile colic on family life.
Coliform Description of a gram-negative bacterium found in the faeces. I
t covers the bacterial groups
Enterobacter, Escherichia, and Klebsiella.
Colistin A POLYMYXIN antibiotic active against many gram-negative organi
sms, including Pseudomonas
aeruginosa. It is not absorbed by mouth and therefore needs to be given by injec
tion to obtain a systemic
effect; this is rarely indicated, however, as it has serious adverse effects. Co
listin is used by mouth in
bowelsterilisation regimens before surgery in patients. It is given by inhalatio
n of a nebulised solution
as an adjunct to some standard antibiotic therapy, and is included in some topic
al preparations, chiefly
for skin, eye and ear infections.
Colitis Inflammation of the colon, the first part of the large intestine
. The subject suffers from
diarrhoea, usually passing blood and mucus, abdominal pain or discomfort, and fe
ver. Colitis can be caused
by various micro-organisms: for example, CAMPYLOBACTER, CLOSTRIDIUM and SHIGELLA
bacteria, viruses or
amoeba. Anxiety and antibiotic drugs may also cause colitis, the latter by direc
tly irritating the lining
of the gut. Colitis is classified as an INFLAMMATORY BOWEL DISEASE (IBD) and ULC
ERATIVE COLITIS is a
particularly troublesome form, the cause of which is not known. CROHNS DISEASE ma
y also cause colitis and
is included in the umbrella designation IBD (see also IRRITABLE BOWEL SYNDROME (
IBS)).
Collagen The most abundant protein in the body. It is the major structur
al component of many parts of
the body and occurs in many different forms. Thus it exists as thick fibres in s
kin and tendons. It is also
an important constituent of the heart and blood vessels. With calcium salts it p
rovides the rigid structure
of bone. It also occurs as a delicate structure in the cornea of the eye, and in
what is known as the
basement membrane of many tissues including the glomeruli of the kidneys and the
capsule of the lens of the
eye. It plays a part in many diseases, hereditary and otherwise. Among the inher
ited abnormalities of
collagen are those responsible for aneurysms of the CIRCLE OF WILLIS and for OST
EOGENESIS IMPERFECTA. On
boiling it is converted into gelatin.
Collagen Diseases A group of diseases affecting CONNECTIVE TISSUE. The t
erm is really outdated since
there is no evidence that collagen is primarily involved. Fibrinoid NECROSIS and
VASCULITIS are two
Colposcopy
characteristics, and autoimmunity reaction may occur in the connective tis
sue. The latter affects
blood vessels and causes secondary damage in the connective tissue. Such conditi
ons are sometimes described
as collagen vascular diseases, examples being RHEUMATOID ARTHRITIS, SYSTEMIC LUP
US ERYTHEMATOSUS (SLE), and
SCLERODERMA.
Collapse See SHOCK.
Collar-Bone See CLAVICLE.
Colles Fracture Colles fracture is a fracture of the lower end of the radi
us close to the wrist,
caused usually by a fall forwards on the palm of the hand, in which the lower fr
agment is displaced
backwards. (See BONE, DISORDERS OF.)
Collodions Collodions consist basically of a thick, colourless, syrupy l
iquid, made by dissolving
guncotton (pyroxylin) in a mixture of ether and alcohol or with acetone. When pa
inted on the skin the
solvent evaporates, leaving behind a tough protective film that is useful for co
vering wounds. Flexible
collodion or collodion as it is often known contains 16 per cent of pyroxylin, wi
th colophony, castor
oil and alcohol (90 per cent) in solvent ether. It should be kept in a well-seal
ed container. Being
relatively elastic, it does not crack through the movements of the skin.
Colloid A type of suspension, for instance milk, in which insoluble part
icles are suspended in a fluid.
In medical parlance a colloid preparation is one containing PLASMA proteins and
is used to treat patients
in SHOCK. The follicles of the thyroid gland also contain a colloid substance.
Coloboma Coloboma simply means a defect, but its use is usually restrict
ed to congenital defects of the
eye. These may involve the lens, the iris, the retina or the eyelid.
Colon The first part of the large INTESTINE.
Colonic Irrigation Washing out the large bowel with an ENEMA of water or
other medication.
151
Colonoscope An
ENDOSCOPE for viewing the COLON. It is made of fibreglass
interior of the which ensures flexibility, and incorporates a system of
lenses for magnification and a
lighting system.
Colonoscopy, Virtual A procedure that links COMPUTED TOMOGRAPHY of the C
OLON (see also INTESTINE) with
techniques that produce three-dimensional views of the mucosa of the large bowel
152 Coma
by means of the binocular instrument known as the colposcope. It is used
to screen for cancer of the
cervix and in investigation of child sexual abuse.
CERVIX UTERI
C Coma
A state of profound unconsciousness in which the patient cannot be rouse
d and reflex movements are
absent. Signs include long, deep, sighing respirations, a rapid, weak pulse, and
low blood pressure.
Usually the result of a STROKE, coma may also be due to high fever, DIABETES MEL
LITUS, glomerulonephritis
(see KIDNEYS, DISEASES OF), alcohol, EPILEPSY, cerebral TUMOUR, MENINGITIS, inju
ry to the head, overdose of
INSULIN, CARBON MONOXIDE (CO) poisoning, or poisoning from OPIUM and other NARCO
TICS. Though usually of
relatively short duration (and terminating in death, unless yielding to treatmen
t) it may occasionally last
for months or even years. (See UNCONSCIOUSNESS; GLASGOW COMA SCALE.)
Coma Position See RECOVERY POSITION FIRST AID.
and APPENDIX 1: BASIC
Coma Scale See GLASGOW COMA SCALE.
Comedones See ACNE.
Commensal Micro-organisms which live in or on the body (e.g. in the gut
or respiratory tract, or on the
skin) without doing any harm to the individual.
Comminuted Fracture See BONE, DISORDERS OF.
Commission for Health Improvement See HEALTHCARE COMMISSION.
Commissure Commissure means a joining, and is a term applied to strands
of nerve fibres which join one
side of the brain to the other; to the band joining one optic nerve to the other
; to the junctions of the
lips at the corners of the mouth, etc.
Committee on Safety of Medicines (CSM) An independent advisory committee
launched in 1971 in the
United Kingdom composed of doctors, pharmacists and other specialists. It advise
s the MEDICINES CONTROL
AGENCY in the UK on the safety, efficacy and pharmaceutical quality of M
EDICINES for which licences are
sought and also reviews reports of ADVERSE REACTIONS TO DRUGS, including spontan
eous Yellow Card reports
from doctors or pharmacists who suspect that a patient has suffered an adverse r
eaction from a medicine.
Its predecessor, the Committee for Safety of Drugs, was set up in 1963 in respon
se to the THALIDOMIDE
disaster.
When incompatibility
occurs there is usually a rapid antibody attack on the invading antigen with a s
evere local or system
reaction in the individual receiving the antigenic substance. (See IMMUNITY.)
Compensation In medical parlance, a term applied to the counterbalancing
of some defect of structure or
function by some other special bodily development. The body possesses a remarkab
le power of adapting itself
even to serious defects, so that disability due to these passes off after a time
. The term is most often
applied to the ability possessed by the heart to increase in size, and therefore
in power, when the need
for greater pumping action arises in consequence of a defective valve or some ot
her abnormality in the
circulation (see also HEART, DISEASES OF; CIRCULATORY SYSTEM OF THE BLOOD). A he
art in this condition is,
however, more liable to be prejudicially affected by strains and diseaseprocesse
s, and the term failure of
compensation is applied to the symptoms that result
This is the title used for a diverse group of health-related therapies a
nd disciplines which are not
considered to be a part of mainstream medical care. Other terms sometimes used t
o describe them include
natural medicine, nonconventional medicine and holistic medicine. CAM embraces those
herapies which
may either be provided alongside conventional medicine (complementary) or which
may, in the view of their
practitioners, act as a substitute for it. Alternative disciplines purport to pr
ovide diagnostic
information as well as offering therapy. However, there is a move now to integra
te CAM with orthodox
medicine and this view is supported by the Foundation for Integrated Medicine in
the UK in its report, A
way forward for the next five years? A discussion paper (1997). The University o
f Exeter Centre for
Complementary Health Studies report, published in 2000, estimated that there are
probably more than 60,000
practitioners of complementary and alternative medicine in the UK. In addition t
here are about 9,300
therapist members of organisations representing practitioners who have statutory
qualifications, including
doctors, nurses (see NURSING), midwives, osteopaths and physiotherapists; chirop
ractors became fully
regulated by statute in
Compression Syndrome
June 2001. There are likely to be many thousands more health staff with
an active interest or
involvement in the practice of complementary medicine for example, the 10,000 me
mbers of the Royal
College of Nursings Complementary Therapy Forum. It is possible that up to 20,000
statutory health
professionals regularly practise some form of complementary medicine including h
alf of all general
practices providing access to CAMs most commonly manipulation therapies. The rep
ort from the Centre at
Exeter University estimates that up to 5 million patients consulted a practition
er specialising in
complementary and alternative medicine in 1999. Surveys of users of complementar
y and alternative
practitioners show a relatively high satisfaction rating and it is likely that m
any patients will go on to
use such therapists over an extended period. The Exeter Centre estimates that, w
ith the increments of the
last two years, up to 1520 million people, possibly 33 per cent of the population
of the country, have now
sought such treatment. The 1998 meeting of the British Medical Association (BMA)
agreed to investigate the
scientific basis and efficacy of acupuncture and the quality of training and sta
ndards of confidence in its
practitioners. In the resulting report (July 2000) the BMA recommended that guide
lines on CAM use for
general practitioners, complementary medicine practitioners and patients were ur
gently needed, and that the
Department of Health should select key CAM therapies, including acupuncture, for
appraisal by the National
Institute for Clinical Medicine (NICE). The BMA also reiterated its earlier reco
mmendation that the main
CAM therapies, including acupuncture, should be included in familiarisation cour
ses on CAM provided within
medical schools, and that accredited postgraduate education should be provided t
o inform GPs and other
clinicians about the possible benefits of CAM for patients.
Complement System This is part of the bodys defence mechanism that compri
ses a series of 20 serum
peptides (see PEPTIDE). These are sequentially activated to produce three signif
icant effects: firstly, the
release of small peptides which provoke inflammation and attract phagocytes (see
PHAGOCYTE); secondly, the
deposition of a substance (component C3b) on the membranes of invading bacteria
or viruses, attracting
phagocytes to destroy the microbes; thirdly, the activation of substances that d
amage cell
155
membranes called lytic components which hasten the destruction of foreign
cells. (See
IMMUNOLOGY.)
Complex The term applied to a combination of various actions or symptoms
. It is particularly applied to
a set of symptoms occurring together in mental disease with such regularity as t
element, or spermatozoon, and the female element, or ovum, fuse together. Only o
ne-third of these
conceptions survive to birth, whilst 15 per cent are cut short by spontaneous ab
ortion or stillbirth. The
remainder over one-half are lost very early during pregnancy without trace. (See
also FETUS.)
Concussion of the Brain See BRAIN INJURIES.
Conditioned Reflex The development of a specific response by an individu
al to a specific stimulus. The
bestknown conditioned reflex is the one described by Ivan Pavlov, in which dogs
that became accustomed to
being fed when a bell was sounded salivated on hearing the bell, even if no food
was given. The conditioned
reflex is an important part of behavioural theory.
Condom A thin rubber or plastic sheath placed over the erect PENIS befor
e sexual intercourse. It is the
most effective type of barrier contraception and is also valuable in preventing
the transfer between sexual
partners of pathogenic organisms such as gonococci, which cause GONORRHOEA, and
human immuno-deficiency
virus, which may lead to AIDS (see AIDS/HIV). Sheaths are most effective when pr
operly used and with
spermicides. The female condom might be suitable for contraception when a woman
misses a day or two of her
contraceptive pill; if there is DYSPAREUNIA; when the perineum needs protection,
for example, after
childbirth; or in cases of latex allergy to traditional condoms. Used properly w
ith spermicide, it provides
an effective barrier both to infections and to spermatozoa. Failure may result i
f the penis goes alongside
the condom, if it gets pushed up into the vagina, or if it falls out. (See CONTR
ACEPTION.)
Condyle A rounded prominence at the end of a bone: for example, the prom
inences at the outer and inner
sides of the knee on the thigh-bone (or FEMUR). The projecting part of a condyle
is sometimes known as an
epicondyle, as in the
Connective Tissue
case of the condyle at the lower end of the HUMERUS where the epicondyle
s form the prominences on the
outer and inner side of the elbow.
Condyloma A localised, rounded swelling of mucous membrane around the op
ening of the bowel, and the
genital organs, sometimes known as genital warts or ano-genital warts. There are two
main forms:
condyloma latum, which is syphilitic in origin; and condyloma accuminatum, which
often occurs in
association with sexually transmitted disease, but is only indirectly due to it,
being primarily a virus
infection.
Cone (1) A light-sensitive cell in the retina of the EYE that can also d
istinguish colours. The other
type of light-sensitive cell is called a rod. There are around six million cones
in the human retina and
these are thought to comprise three types that are sensitive to the three primar
y colours of red, blue, and
green. (2) A cone biopsy is a surgical technique in which a conical or cylindric
al section of the lower
part of the neck of the womb is excised.
Confidentiality The ethical principle that doctors do not reveal informa
tion to other people (or to
organisations) that their patients have given to them in confidence. Normally th
e doctor must get
permission to release confidential information to an employer (or other authorit
ative body), insurance
company or lawyer. The doctor does have to provide such information if required
by a court of law. (See
ETHICS.)
Congenital Congenital deformities, diseases, etc. are those which are ei
ther present at birth, or
which, being transmitted direct from the parents, show themselves some time afte
r birth.
Congenital Adrenal Hyperplasia See ADRENOGENITAL SYNDROME DISORDERS.
and
GENETIC
Congestion The accumulation of blood or other body fluid in a particular
part of the body. The
condition may be due to some failure in the circulation, but as a rule is one of
the early signs of
INFLAMMATION (see also ABSCESS; PNEUMONIA).
Conjoined Twins Identical twins who are united bodily but are
157
possessed of separate personalities. Their frequency is not known, but i
t has been estimated that
throughout the world, six or more conjoined twins are born every year who are ca
Continuity of Care
Constitution Constitution, or DIATHESIS, means the general condition of
the body, especially with
reference to its liability to certain diseases.
Consultant In Britains health service a consultant is the senior career p
ost for a fully accredited
specialist. He or she normally sees patients referred by general practitioners h
ence the historical term
consultant or emergency cases admitted direct to hospital. NHS consultants are als
o allowed to do a
certain amount of private practice if they wish. After qualification and a twoye
ar period of general
supervised training, doctors enter onto a specialist training scheme, working in
hospitals for 58 years
before being accredited; many also do research or spend some time working abroad
. All must pass difficult
higher examinations. In 2004, the number of consultant hospital medical and dent
al staff in Great Britain
was 30,650 (some of these worked part-time, so the whole-time equivalent [w.t.e.
] figure was 25,640). The
total number of hospital medical and dental staff was 86,996 (w.t.e. 78,462).
Consumption See TUBERCULOSIS.
Contact a Family A charity which helps families with disabled children t
o obtain good-quality
information, support and most of all contact with other families with children w
ho have the same
disorder. This includes children with specific and rare conditions and those wit
h special educational
needs. The charity has many local parent groups throughout the UK and publishes
a comprehensive directory
with brief descriptions of each condition followed by contact addresses, phone n
umbers and web addresses.
It also has a central helpline and a team of parent advisers. See www.cafamily.o
rg.uk
159
tact lenses instead of glasses. Therapeutic lenses are those used in the
treatment of eye disease:
bandage lenses are used in certain corneal diseases; contact lenses can be soaked
in a particular drug
and then put on the eye so that the drug slowly leaks out on to the eye. Contact
lenses may be hard, soft
or gas permeable. Hard lenses are more optically accurate (because they are rigi
d), cheaper and more
durable than soft. The main advantage of soft lenses is that they are more comfo
rtable to wear.
Gas-permeable lenses are so-called because they are more permeable to oxygen tha
n other lenses, thus
allowing more oxygen to reach the cornea. Disposable lenses are soft lenses desi
gned to be thrown away
after a short period of continuous use; their popularity rests on the fact that
they need not be cleaned.
The instructions on use should be followed carefully because the risk of complic
ations, such as corneal
infection, are higher than with other types of contact lenses. Contraindications
consists of a rubber sheath which is placed over the erect penis before intromis
sion and removed after
ejaculation. The failure rate, if properly used, is about 4 per cent. DIAPHRAGM
OR CAP A rubber dome that
is inserted into the vagina before intercourse and fits snugly over the cervix.
It should be used with an
appropriate spermicide and is removed six hours after intercourse. A woman must
be measured to ensure that
she is supplied with the correct size of diaphragm, and the fit should be checke
d annually or after more
than about 7 lbs. change in weight. The failure rate, if properly used, is about
2 per cent.
Non-barrier methods These do not provide a physical barrier between sper
m and cervix and so do not
protect against sexually transmitted diseases, including HIV. COITUS INTERRUPTUS
This involves the mans
withdrawing his penis from the vagina before ejaculation. Because some sperm may
leak before full
ejaculation, the method is not very reliable. SAFE PERIOD This involves avoiding
intercourse around the
time when the woman ovulates and is at risk of pregnancy. The safe times can be
predicted using temperature
charts to identify the rise in temperature before ovulation, or by careful asses
sment of the quality of the
cervical mucus. This method works best if the woman has regular menstrual cycles
. If used carefully it can
be very effective but requires a highly disciplined couple to succeed. It is app
roved by the Catholic
church. SPERMICIDAL GELS, CREAMS, PESSARIES, ETC.
These are supposed to prevent pregnancy by killing sperm before they rea
ch the cervix, but they are
unreliable and should be used only in conjunction with a barrier method. INTRAUT
ERINE (COIL) This is
CONTRACEPTIVE
DEVICE
a small metal or plastic shape, placed inside the uterus, which prevents
pregnancy by disrupting
implantation. Some people regard it as a form of abortion, so it is not acceptab
le to all religious groups.
There is a risk of pelvic infection and eventual infertil-
Contre-Coup
ity in women who have used coils, and in many countries their use has de
clined substantially. Coils
must be inserted by a specially trained health worker, but once in place they pe
rmit intercourse at any
time with no prior planning. Increased pain and bleeding may be caused during me
nstruation. If severe, such
symptoms may indicate that the coil is incorrectly sited, and that its position
should be checked. HORMONAL
METHODS Steroid hormones have dominated contraceptive developments during the pa
st 40 years, with more than
200 million women worldwide taking or having taken the pill. In the past 20 years,
new developments have
included modifying existing methods and devising more effective ways of deliveri
ng the drugs, such as
implants and hormonereleasing devices in the uterus. Established hormonal contra
ception includes the
combined oestrogen and progesterone and progesterone-only contraceptive pills, a
s well as longer-acting
depot preparations. They modify the womans hormonal environment and prevent pregn
ancy by disrupting
various stages of the menstrual cycle, especially ovulation. The combined oestro
gen and progesterone pills
are very effective and are the most popular form of contraception. Biphasic and
triphasic pills contain
different quantities of oestrogen and progesterone taken in two or three phases
of the menstrual cycle. A
wide range of preparations is available and the British National Formulary conta
ins details of the commonly
used varieties. The main side-effect is an increased risk of cardiovascular dise
ase. The lowest possible
dose of oestrogen should be used, and many preparations are phasic, with the dos
e of oestrogen varying with
the time of the cycle. The progesterone-only, or mini, pill does not contain any o
estrogen and must be
taken at the same time every day. It is not as effective as the combined pill, b
ut failure rates of less
than 1-per-100 woman years can be achieved. It has few serious side-effects, but
may cause menstrual
irregularities. It is suitable for use by mothers who are breast feeding. Depot
preparations include
intramuscular injections, subcutaneous implants, and intravaginal rings. They ar
e useful in cases where the
woman cannot be relied on to take a pill regularly but needs effective contracep
tion. Their main
side-effect is their prolonged action, which means that users cannot suddenly de
cide that they would like
to become pregnant. Skin patches containing a contraceptive that is absorbed thr
ough the skin have recently
been launched.
161
There is a growing demand by men worldwide for hormonal contraception. D
evelopment of a male pill,
however, has been slow because of the potentially dangerous side-effects of usin
g high doses of
TESTOSTERONE (the male hormone) to suppress spermatogenesis. Progress in researc
h to develop a suitable
Cordotomy
assault on someone else. Treatment using a COGNITIVE BEHAVIOUR approach
may help those with conversion
disorders.
Convolutions See BRAIN.
Convulsions Rapidly alternating contractions and relaxations of the musc
les, causing irregular
movements of the limbs or body generally, usually accompanied by unconsciousness
.
Causes The most common reason for convulsions is EPILEPSY, and the under
lying cause of the latter often
remains uncertain. In newborns, convulsions may be due to HYPOXIA following a di
fficult labour, or to low
levels of sugar or calcium in the blood (HYPOGLYCAEMIA; HYPOCALCAEMIA). A sudden
rise of body temperature
during infective illness may induce convulsions in an infant or young child. Dis
eases of the brain, such as
meningitis, encephalitis and tumours, or any disturbance of the brain due to ble
eding, blockage of a blood
vessel, or irritation of the brain by a fracture of the skull, may also be respo
nsible for convulsions (see
BRAIN, DISEASES OF). Asphyxia, for example from choking, may also bring on convu
lsions. Treatment Newborns
with hypoglycaemia or hypocalcaemia are treated by replacing the missing compoun
d. Infants with febrile
convulsions may be sponged with tepid water and fever reduced with paracetamol.
In epilepsy, unless it is
particularly severe, the movements seldom need to be restrained. If convulsions
persist beyond a few
minutes it may be necessary to give BENZODIAZEPINES, either intravenously or rec
tally. In the UK,
paramedics are trained to do this; likewise many parents of epileptic children a
re capable of administering
the necessary treatment. If however this fails to stop the convulsions immediate
ly, hospital admission is
needed for further treatment. Once fits are under control, the cause of the conv
ulsions must be sought and
the necessary long-term treatment given.
Cooleys Anaemia See THALASSAEMIA.
Coombs Test A sensitive test that detects ANTIBODIES to the bodys red cell
s (see ERYTHROCYTE). There
are two methods: one the direct method identifies those antibodies that are boun
d to the
163
cells; the other, indirect, method identifies those circulating unattach
ed in the serum.
Coordination The governing power exercised by the brain as a whole, or b
y certain centres in the
nervous system, to make various muscles contract in harmony and so produce defin
ite actions (instead of
meaningless movements). Coordination is intimately bound up with the complex sen
se of localisation, which
enables a person with their eyes shut to tell, by sensations received from the b
ones, joints and muscles,
the position of the various parts of their body. The power is impaired in variou
s diseases, such as
LOCOMOTOR ATAXIA. It is tested by making the patient shut their eyes, moving the
ir hand in various
directions, and then telling them to bring the point of the forefinger steadily
to the tip of the nose or
by other simple movements.
Copper Copper is an essential nutrient for humans, and all tissues in th
e human body contain traces of
it. The total amount in the adult body is 100 150 mg. Many essential enzyme syste
ms are dependent on
traces of copper; on the other hand, there is no evidence that dietary deficienc
y of copper ever occurs in
humans. Infants are born with an ample store, and the normal diet for an adult c
ontains around 2 mg of
copper a day. It is used in medicine as the two salts, sulphate of copper (blue
stone) and nitrate of
copper. The former is, in small doses, a powerful astringent, and in larger dose
s an irritant. Both are
caustics when applied externally. Externally, either is used to rub on unhealthy
ulcers and growths to
stimulate the granulation tissue to more rapid healing.
Coprolalia An inherited condition, usually beginning in childhood. It pr
esents with motor tics and with
irrepressible, explosive, occasionally obscene, verbal ejaculations. (See GILLES
DE LA TOURETTES
SYNDROME.)
Copulation The act of coitus or sexual intercourse, when the man inserts
his erect penis into the
womans vagina and after a succession of thrusting movements ejaculates his semen.
Cordotomy The surgical operation of cutting the anterolateral tracts of
the SPINAL CORD to relieve
C
164 Cornea
otherwise intractable pain. It is also sometimes known as tractotomy.
Cornea See EYE.
C
Corneal Graft Also known as keratoplasty. If the cornea (see EYE) become
s damaged or diseased and
vision is impaired, it can be removed and replaced by a corneal graft. The graft
is taken from the cornea
of a human donor. Some of the indications for corneal grafting include keratocon
us (conicalshaped cornea),
corneal dystrophies, severe corneal scarring following HERPES SIMPLEX, and alkal
i burns or other injury.
Because the graft is a foreign protein, there is a danger that the recipients imm
une system may set up a
reaction causing rejection of the graft. Rejection results in OEDEMA of the graf
t with subsequent poor
vision. Once a corneal graft has been taken from a donor, it should be used as q
uickly as possible. Corneas
can be stored for days in tissue-culture medium at low temperature. A small numb
er of grafts are autografts
in which a patients cornea is repositioned. The Department of Health has drawn up
a list of suitable
eye-banks to which people can apply to bequeath their eyes, and an official form
is now available for the
bequest of eyes. (See also DONORS; TRANSPLANTATION.)
Corneal Reflex Instinctive closing of the eyelids when the surface of th
e cornea (see EYE) is lightly
touched with a fine hair.
Corns and Bunions A corn is a localised thickening of the cuticle or epi
dermis (see SKIN) affecting the
foot. The thickening is of a conical shape; the point of the cone is directed in
wards and is known as the
eye of the corn. A general thickening over a wider area is called a callosity. Bun
ion is a condition
found over the joint at the base of the big toe, in which not only is there thic
kening of the skin, but the
head of the metatarsal bone also becomes prominent. Hammer-toe is a condition of
the second toe, often
caused by short boots, in which the toe becomes bent at its two joints in such a
way as to resemble a
hammer. Corns and bunions are caused by badly fitting shoes, hence the importanc
e of children and adults
wearing properly fitted footwear. Corns can be pared after softening in warm wat
er, or painted with
salicylic acid collodion or other proprietary preparations. Bad corns may need t
reatment by a chiropodist
(see CHIROPODY).
Bunions may require surgical treatment. Regular foot care is important i
n patients with DIABETES
MELLITUS.
Corticosteroids
requires the heart to be stopped temporarily, with blood circulation and
oxygenation taken over by a
HEART-LUNG MACHINE.
Coronary Care Unit (CCU) A specialised hospital unit equipped and staffe
d to provide intensive care
(see INTENSIVE THERAPY UNIT (ITU)) for patients who have had severe heart attack
s or undergone surgery on
the heart.
Coronary Thrombosis See HEART, DISEASES OF.
Coronaviruses
165
material. The follicle and its luteal cells constitute the corpus luteum
. The corpus luteum begins to
disappear after ten days, unless the discharged ovum is fertilised and pregnancy
ensues. In pregnancy the
corpus luteum persists and grows and secretes the hormone, PROGESTERONE.
Corrigans Pulse The name applied to the collapsing pulse found with incom
petence of the hearts aortic
valve. It is so-called after Sir Dominic John Corrigan (180280), the famous Dubli
n physician, who first
described it.
Coronaviruses so-called because in electron micrographs the spikes proje
cting from the virus resemble
a crown are a group of viruses which have been isolated from people with common
colds (see COLD, COMMON)
and have also been shown to produce common colds under experimental conditions.
Their precise significance
in the causation of the common cold is still undetermined.
Corrosives
Coroner
A support device worn around the trunk to help in the treatment of backa
che and spinal injuries or
disorders.
An independent legal officer of the Crown who is responsible for decidin
g whether to hold a POST-MORTEM
EXAMINATION and an inquest in cases of sudden or unexpected or unnatural death.
He or she presides over an
inquest, if held sometimes with the help of a jury. Coroners are usually lawyers
or doctors (some are
double-qualified) who have been qualified for at least five years. In Scotland t
he coroner is known as the
procurator fiscal.
Corpulence See OBESITY.
Cor Pulmonale Another name for pulmonary heart disease, which is charact
erised by hypertrophy and
failure of the right VENTRICLE of the heart as a result of disease of the LUNGS
or disorder of the
pulmonary circulation.
Corpuscle Corpuscle means a small body. (See BLOOD.)
Corpus Luteum The mass of cells formed in the ruptured Graafian follicle
in the ovary (see OVARIES)
from which the ovum is discharged about 15 days before the onset of the next men
strual period (see
MENSTRUATION). When the ovum escapes, the follicle fills up with blood; this is
soon replaced by cells
which contain a yellow fatty
Corrosives are poisonous substances which corrode or eat away the skin o
r the mucous surfaces of mouth,
gullet and stomach with which they come into contact. Examples are strong minera
l acids like sulphuric,
nitric and hydrochloric acids, caustic alkalis, and some salts like chlorides of
mercury and zinc. (See
POISONS.)
Corset
Cortex The tissues that form the outer part of an organ and which are po
sitioned just below the capsule
or outer membrane. Examples are the cerebal cortex of the BRAIN and the renal co
rtex of the KIDNEYS.
Corticosteroids The generic term for the group of hormones produced by t
he ADRENAL GLANDS, with a
profound effect on mineral and glucose metabolism. Many modifications have been
devised of the basic
steroid molecule in an attempt to keep useful therapeutic effects and minimise u
nwanted side-effects. The
main corticosteroid hormones currently available are CORTISONE, HYDROCORTISONE,
PREDNISONE, PREDNISOLONE,
methyl prednisolone, triamcinolone, dexamethasone, betamethasone, paramethasone
and deflazacort. They are
used clinically in three quite distinct circumstances. First they constitute rep
lacement therapy where a
patient is unable to produce their own steroids for example, in adrenocortical i
nsufficiency or
hypopituitarism. In this situation the dose is physiological namely, the equival
ent of the normal adrenal
output under similar circumstances and is not
C
166 Corticotropin
C
associated with any side-effects. Secondly, steroids are used to depress
activity of the adrenal cortex
in conditions where this is abnormally high or where the adrenal cortex is produ
cing abnormal hormones, as
occurs in some hirsute women. The third application for corticosteroids is in su
ppressing the
manifestations of disease in a wide variety of inflammatory and allergic conditi
ons, and in reducing
antibody production in a number of AUTOIMMUNE DISORDERS. The inflammatory reacti
on is normally part of the
bodys defence mechanism and is to be encouraged rather than inhibited. However, i
n the case of those
diseases in which the bodys reaction is disproportionate to the offending agent,
such that it causes
unpleasant symptoms or frank illness, the steroid hormones can inhibit this unde
sirable response. Although
the underlying condition is not cured as a result, it may resolve spontaneously.
When corticosteroids are
used for their anti-inflammatory properties, the dose is pharmacological; that i
s, higher often much
higher than the normal physiological requirement. Indeed, the necessary dose may
exceed the normal
maximum output of the healthy adrenal gland, which is about 250300 mg cortisol pe
r day. When doses of this
order are used there are inevitable risks and sideeffects: a drug-induced CUSHIN
GS SYNDROME will result.
Corticosteroid treatment of short duration, as in angioneurotic OEDEMA of the la
rynx or other allergic
crises, may at the same time be life-saving and without significant risk (see UR
TICARIA). Prolonged therapy
of such connective-tissue disorders, such as POLYARTERITIS NODOSA with its atten
dant hazards, is generally
accepted because there are no other agents of therapeutic value. Similarly the a
bsence of alternative
medical treatment for such conditions as autoimmune haemolytic ANAEMIA establish
es steroid therapy as the
treatment of choice which few would dispute. The use of steroids in such chronic
conditions as RHEUMATOID
ARTHRITIS, ASTHMA and DERMATITIS needs careful assessment and monitoring. Althou
gh there is a risk of
ill-effects, these should be set against the misery and danger of unrelieved chr
onic asthma or the
incapacity, frustration and psychological trauma of rheumatoid arthritis. Patien
ts should carry cards
giving details of their dosage and possible complications. The incidence and sev
erity of side-effects are
related to the dose and duration of treatment. Prolonged daily treatment with 15
mg of
prednisolone, or more, will cause hypercortisonism; less than 10 mg pred
nisolone a day may be tolerated
by most patients indefinitely. Inhaled steroids rarely produce any illeffect apa
rt from a propensity to
oral thrush (CANDIDA infection) unless given in excessive doses. General side-ef
fects may include weight
gain, fat distribution of the cushingoid type, ACNE and HIRSUTISM, AMENORRHOEA,
Cough 167
tice of medicine has been influenced by patients social circumstances and
more recently by communityand government-driven national priorities. One critical aspect of these widening
influences has been the
cost of medical care which, as medicine becomes more complex, has been rising sh
arply. Thus health
economics has become an integral part of the provision of health care. Cost-of-i
llness studies now appear
commonly in medical publications. Such studies aim to identify and measure all t
he costs of a particular
disease, including, where feasible, the direct, indirect and intangible dimensio
ns. The information
obtained is intended to help the development of health policies, nationally and
internationally. The
application of information from such studies is, however, proving controversial.
Firstly, doctors still see
their clinical responsibilities to patients as a priority. Secondly, cost-of-car
e studies are often
criticised for excluding broader economic aspects of health care for example, an
alyses of the
cost-effectiveness of prevention as well as the treatment of illness. This requi
res assessment of potential
and actual outcomes as well as the costs of illnesses. Even so, the increasing c
omplexity of medicine, with
its commensurately rising costs affecting both state- and privately funded medic
al care, makes it
inevitable that the cost of maintaining a populations good health will be a growi
ng factor in the
provision of health care that seems bound to impinge on how doctors are enabled
to treat their individual
patients.
Cot Death See SUDDEN INFANT DEATH SYNDROME (SIDS).
Co-Trimoxazole This drug a mixture of trimethoprim and the sulphonamide,
sulphamethoxazole should
be used only in the prophylaxis or treatment of pneumocystis PNEUMONIA, and in a
cute exacerbations of
chronic BRONCHITIS, urinary tract infections and otitis media (see EAR, DISEASES
OF), where indicated.
Cotton Wool
med by the British
Pharmacopoeia, is a
ssypium herbaceum).
used in medicine in
g services and it is
vital that those providing them have been properly trained.
Cowpers Glands Also known as the bulbourethral glands, these are a pair o
f glands whose ducts open
into the urethra at the base of the PENIS. They secrete a fluid that is one of t
he constituents of the
SEMEN which carries the spermatozoa and is ejaculated into the VAGINA during coi
tus (sexual intercourse).
Cowpox Cowpox is a disease affecting the udders of cows, on which it pro
duces vesicles (see VESICLE;
PAPULE). It is communicable to humans, and there has for centuries been a tradit
ion that persons who have
caught this disease from cows do not suffer afterwards from SMALLPOX. This forme
d the basis for Jenners
experiments on VACCINATION.
COX-2 Inhibitors This stands for cyclo-oxygenase 2 inhibitors a class of
drugs used in treating
ARTHRITIS of which the most well-used is celecoxib. Their main claim is that the
y are less likely to
cause gastrointestinal disturbance than NONSTEROIDAL (NSAIDS). In
ANTI-INFLAMMATORY
DRUGS
2001, the National Institute for Clinical Excellence (NICE) recommended
that they should not be used
routinely in rheumatoid arthritis or osteoarthritis but only in patients with a
history of peptic ulcer or
gastrointestinal bleeding. They should also be considered in persons over the ag
e of 65 taking other drugs
which could cause gastrointestinal bleeding, those who are very debilitated, and
those who are taking
maximum doses of NSAIDs. In 2005, rofecoxib was withdrawn because of concerns ab
out cardiac side-effects.
Creatinine Clearance
Coxalgia Pain in the hip-joint; also referred to as coxodynia.
Coxa Vara
usually responds to a daily shampoo with cetrimide solution. Warm olive
oil gently massaged into the
scalp and left overnight, after which the scales can be washed off, also helps w
ith the condition.
A condition in which the neck of the thighbone is bent so that the lower
limbs are turned outwards and
lameness results.
Cramp
Coxsackie Viruses
Cranial Nerves
A group of viruses so-called because they were first isolated from two p
atients with a disease
resembling paralytic POLIOMYELITIS, in the village of Coxsackie in New York Stat
e. Thirty distinct types
have now been identified. They constitute one of the three groups of viruses inc
luded in the family of
ENTEROVIRUSES, and are divided into two groups: A and B. Despite the large numbe
r of types of group A virus
(24) in existence, evidence of their role in causing human disease is limited. S
ome, however, cause aseptic
MENINGITIS, non-specicifc upper respiratory infection and MYOCARDITIS, and other
s cause a condition known
as HERPANGINA. HAND, FOOT AND MOUTH DISEASE is another disease caused by the A g
roup. All six types of
group B virus have been associated with outbreaks of aseptic meningitis, and the
y are also the cause of
BORNHOLM DISEASE. Epidemics of type B2 infections tend to occur in alternate yea
rs. (See VIRUS.)
CPR See CARDIOPULMONARY RESUSCITATION (CPR).
Crab-Louse Another name for Pediculus pubis, a louse that infests the pu
bic region. (See PEDICULOSIS.)
Cracked-Pot Sound
169
See MUSCLES, DISORDERS OF.
Cranial nerves are those arising from the BRAIN.
Craniotomy The removal of part of the SKULL to provide surgical access f
or an operation on the BRAIN.
This may be to obtain a BIOPSY, to remove a tumour or to drain an infection or a
blood clot. Following the
operation the bone is replaced, along with the membranes, muscle and skin.
Cranium The part of the skull enclosing the brain as distinguished from
the face.
Cream The oily or fatty part of milk from which butter is prepared. Vari
ous medicinal preparations are
known also as cream for example, cold cream, which is a simple ointment containi
ng rosewater, beeswax,
borax, and almond oil scented with oil of rose.
Creatine A nitrogenous substance, methyl-guanidineacetic acid. The adult
human body contains about 120
grams 98 per cent of which is in the muscles. Much of the creatine in muscles is
combined with phosphoric
acid as phosphocreatine, which plays an important part in the chemistry of muscu
lar contraction.
A peculiar resonance heard sometimes on percussion of the chest over a c
avity in the lung, resembling
the jarring sound heard on striking a cracked pot or bell. It is also heard on p
ercussion over the skull in
patients with diseases of the brain such as haemorrhages and tumours, and in cer
tain cases of fracture of
the skull.
An ENZYME which is proving to be of value in the investigation and diagn
osis of muscular dystrophy (see
MUSCLES, DISORDERS OF Myopathy), in which it is found in the blood in greatly in
creased amounts.
Cradle
Creatinine is the anhydride of CREATINE and is 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 ta
ke the weight of the bedclothes
off the legs.
Creatinine Clearance
Cradle Cap Crusta lactea, or cradle cap as it is technically known, is a
form of SEBORRHOEA of the
scalp which is not uncommon in nursing infants. It
Creatine Kinase
Creatinine
A method of assessing the function of the kidney (see KIDNEYS) by compar
ing the amount of creatinine
a product of body metabolism which is normally excreted by the kidneys in the bl
ood with the amount
appearing in the urine.
C
172 Crotamiton
(See
APPENDIX 2: ADDRESSES: SOURCES OF INFORMATION, ADVICE, SUPPORT AND SELFH
ELP Colitis; Crohns
disease.)
Crotamiton C A topical cream used to treat pruritus (itch). Crotch See P
ERINEUM.
Croup Also known as laryngo-tracheo-bronchitis, croup is a household ter
m for a group of diseases
characterised by swelling and partial blockage of the entrance to the LARYNX, oc
curring in children and
characterised by crowing inspiration. There are various causes but by far the co
mmonest is acute
laryngo-tracheobronchitis (see under LARYNX, DISORDERS OF). Croup tends to occur
in epidemics, particularly
in autumn and early spring, and is almost exclusively viral in origin commonly d
ue to parainfluenza or
other respiratory viruses. It is nearly always mild and sufferers recover sponta
neously; however, it can be
dangerous, particularly in young children and infants, in whom the relatively sm
all laryngeal airway may
easily be blocked, leading to suffocation.
Symptoms Attacks generally come on at night, following a cold caught dur
ing the previous couple of
days. The breathing is hoarse and croaking (croup), with a barking cough and har
sh respiratory noise. The
natural tendency for the laryngeal airway to collapse is increased by the childs
desperate attempts to
overcome the obstruction. Parental anxiety, added to that of the child, only exa
cerbates the situation.
After struggling for up to several hours, the child finally falls asleep. The co
ndition may recur.
CRP Stands for C-Reactive Protein, and refers to a blood measurement whi
ch is a marker of inflammation
so offering a clue as to whether infection might be present or, in inflammatory
illnesses, being used to
track the progress of the condition.
Cruciate Ligaments Two strong ligaments in the interior of the knee-join
t, which cross one another like
the limbs of the letter X. They are so attached as to become taut when the lower
limb is straightened, and
they prevent over-extension or bending forwards at the knee. The cruciate ligame
nts are sometimes strained
or torn as a result of sporting injuries or vehicular accidents; surgery may be
needed to repair the
damage, but the knee will be permanently weakened.
Crural Crural means connected with the leg.
Crush Syndrome A condition in which kidney failure occurs in patients wh
o have been the victims of
severe crushing accidents (see also KIDNEYS). The fundamental injury is damage t
o muscle. The limb swells.
The blood volume falls. Blood UREA rises; there is also a rise in the POTASSIUM
content of the blood.
Urgent treatment in an intensive therapy unit is required and renal dialysis may
well be necessary. The
patient may survive; or die with renal failure. Post-mortem examination shows de
generation of the tubules
of the kidney, and the presence in them of pigment casts.
Crusta Lactea See CRADLE CAP.
Treatment Most children with croup should be looked after at home if the
environment is suitable.
Severe episodes may require hospital observation, with treatment by oxygen if ne
eded and usually with a
single dose of inhaled steroid or oral PREDNISONE. For the very few children who
se illness progresses to
respiratory obstruction, intubation and ventilation may be needed for a few days
. There is little evidence
that putting the child in a mist tent or giving antibiotics is of any value. Of
greater importance is the
reassurance of the child, and careful observation for signs of deterioration, to
gether with the exclusion
of other causes such as foreign-body inhalation and bacterial tracheitis.
Crutch (1) An aid to support the weight of the body for a person unable
to bear weight on one of his or
her legs. Made of wood or metal, usually long enough to reach from the persons ar
mpit to the ground, it
has a concave surface that fits under the arm and a cross-bar for the hand. An e
lbow crutch provides
weight-bearing support using the forearm and elbow and is usually recommended wh
en the leg can take some
weight. (2) See PERINEUM.
Crutch Palsy Crutch palsy is weakness or paralysis of muscles
CS Gas
in the wrist and hand, due to pressure exerted by the CRUTCH head on the
nerves that control the
affected muscles. It usually occurs because the crutch is too long for the indiv
idual, and/or if he or she
attempts too much walking. The nerve damage is temporary and symptoms disappear
if the crutch is properly
used or left aside for a time.
Cryoanalgesia The induction of analgesia (see ANALGESICS) by the use of
cold that is produced by means
of a special probe. The use of cold for the relief of pain dates back to the ear
ly days of mankind: two
millennia ago, Hippocrates was recommending snow and ice packs as a preoperative
analgesic. The modern
probe allows a precise temperature to be induced in a prescribed area. Among its
uses is in the relief of
chronic pain which will not respond to any other form of treatment. This applies
particularly to chronic
facial pain.
173
two main forms in which it is now used are and refrigeration ANAESTHESIA
.
HYPOTHERMIA
Cryptococcosis Cryptococcosis is a rare disease due to infection with a
yeast known as Cryptococcus
neoformans. Around 510 cases are diagnosed annually in the United Kingdom. It usu
ally involves the lungs
in the first instance, but may spread to the MENINGES and other parts of the bod
y, including the skin. As a
rule, the disease responds well to treatment with AMPHOTERICIN B, clotrimazole,
and flucytosine.
Cryptococcus A genus of yeasts. Cryptococcus neoformans is widespread in
nature, and is present in
particularly large numbers in the faeces of pigeons. It occasionally infects hum
ans, as a result of the
inhalation of dust contaminated by the faeces of pigeons causing the disease kno
wn as CRYPTOCOCCOSIS.
Cryoprecipitate
Cryptorchidism
When frozen plasma is allowed to thaw slowly at 4 C, a proportion of the
plasma protein remains
undissolved in the cold thawed plasma and stays in this state until the plasma i
s warmed. It is this cold,
insoluble precipitate that is known as cryoprecipitate. It can be recovered quit
e easily by centrifuging.
Its value is that it is a rich source of factor VIII, which is used in the treat
ment of HAEMOPHILIA.
An undescended testis (see TESTICLE). The testes normally descend into t
he scrotum during the seventh
month of gestation; until then, the testis is an abdominal organ. If the testes
do not descend before the
first year of life, they usually remain undescended until puberty and even then,
descent is not achieved
in some instances. Fertility is impaired when one testis is affected and is usua
lly absent in the bilateral
cases. The incidence of undescended testis in full-term children at birth is 35 p
er cent, falling to less
than 2 per cent at one month and 07 per cent at one year. Because of the high ris
k of infertility,
undescended testes should be brought down as early as possible and at the latest
by the age of two.
Sometimes medical treatment with HUMAN CHORIONIC GONADOTROPHIN is helpful but fr
equently surgical
interference is necessary. This is the operation of orchidopexy.
Cryopreservation Maintenance at very low temperatures of the viability o
f tissues or organs that have
been excised from the body.
Cryoscopy The method of finding the concentration of blood, urine, etc.,
by observing their
freezingpoint.
Cryosurgery The use of cold in surgery. Its advantages include little as
sociated pain, little or no
bleeding, and excellent healing with little or no scar formation. Hence its rela
tively wide use in eye
surgery, some abdominal surgery, skin cancers and treatment of HAEMORRHOIDS. The
coolants used include
liquid nitrogen with which temperatures as low as 196 C can be obtained, carbon di
oxide (78 C) and
nitrous oxide (88 C).
Cryotherapy The treatment of disease by refrigeration. The
CSF See CEREBROSPINAL FLUID.
CS Gas A noxious gas used for riot control which causes irritation of th
e eyes and respiratory tract.
Symptoms usually subside within 20 minutes but, if they persist, the victim shou
ld be removed to a
wellventilated area, contaminated clothing removed, the affected skin washed wi
th soap and water and the
eyes irrigated with water or physiological saline. (CONTACT LENSES should be rem
oved and washed, if hard;
dis
C
174 CSM
carded, if soft.) If respiratory complications develop, the victim shoul
d be admitted to hospital.
CSM C
See COMMITTEE ON SAFETY OF MEDICINES (CSM).
CT Scan See COMPUTED TOMOGRAPHY.
CT Scanner The machine which combines the use of a computer and Xrays t
o produce crosssectional
images of the body (see COMPUTED TOMOGRAPHY).
Culdoscopy Culdoscopy is a method of examining the pelvic organs in wome
n by means of an instrument
comparable to a CYSTOSCOPE, inserted into the pelvic cavity through the VAGINA.
The instrument used for
this purpose is known as a culdoscope.
Curette A spoonshaped instrument with a cutting edge, used for scooping
out the contents of any body
cavity for example, the uterus or for removing certain skin lesions, such as ver
rucae.
Cushings Syndrome Described in 1932 by Harvey Cushing, the American neuro
surgeon, Cushings syndrome
is due to an excess production of CORTISOL. It can thus result from a tumour of
the ADRENAL GLANDS
secreting cortisol, or from a PITUITARY GLAND tumour secreting ACTH and stimulat
ing both adrenal cortexes
to hypertrophy and secrete excess cortisol. It is sometimes the result of ectopi
c production of ACTH from
nonendocrine tumours in the LUNGS and PANCREAS. The patient gains weight and the
obesity tends to have a
characteristic distribution over the face, neck, and shoulder and pelvic girdles
. Purple striae develop
over the abdomen and there is often increased hairiness or hirsutism. The blood
pressure is commonly raised
and the bone softens as a result of osteoporosis. The best test to establish the
diagnosis is to measure
the amount of cortisol in a 24hourly specimen of urine. Once the diagnosis has
been established, it is
then necessary to undertake further tests to determine the cause.
Cutaneous Cutaneous means belonging to the SKIN.
Cuticle See SKIN.
Cuts See WOUNDS.
Cyanide Poisoning Cyanide inhibits cellular RESPIRATION by binding rapid
ly and reversibly with the
ENZYME, cytochrome oxidase. Effects of poisoning are due to tissue HYPOXIA. Cyan
ide is toxic by inhalation,
ingestion and prolonged skin contact, and acts extremely quickly once absorbed.
Following inhalation of
hydrogen cyanide gas, death can occur within minutes. Ingestion of inorganic cya
nide salts may produce
Cyesis 175
Cyanides Salts of hydrocyanic or prussic acid. They are highly poisonous
, and are also powerful
antiseptics. (See CYANIDE POISONING; WOUNDS.)
Cyanocobalamin The name given by the British Pharmacopoeia Commission to
vitamin B12, found to be an
effective substitute for liver in the treatment of pernicious ANAEMIA. It has no
w been replaced by
HYDROXOCOBALAMIN as the standard treatment for this condition (see also COBALAMI
NS).
Cyanosis A condition in which the skin usually of the face and extremiti
es takes on a bluish tinge.
It accompanies states in which the blood is not properly oxygenated in the lungs
, 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 passages, or to disease in the lungs, or to a feeble circulation, as in
heart disease. (See CHRONIC
OBSTRUCTIVE PULMONARY DISEASE (COPD); METHAEMOGLOBINAEMIA.)
Cybernetics The science of communication and control in the animal and i
n the machine.
Cyclamates Artificial sweetening agents which are about 30 times as swee
t as cane sugar. After being in
use since 1965, they were banned by government decree in 1969 because of adverse
reports received from the
USA.
Cyclical Oedema This is a syndrome in women, characterised by irregular
intermittent bouts of
generalised swelling. Sometimes the fluid retention is more pronounced before th
e menstrual period (see
MENSTRUATION). The eyelids are puffy and the face and fingers feel stiff and blo
ated. The breasts may feel
swollen and the abdomen distended, and ankles may swell. The diurnal weight gain
may exceed 4 kg. The
underlying disturbance is due to increased loss of fluid from the vascular compa
rtment, probably from
leakage of protein from the capillaries increasing the tissue osmotic pressure.
Recent evidence suggests
that a decrease in the urinary excretion of DOPAMINE may contribute, as this has
a natriuretic action (see
NATRIURESIS). This may explain why drugs that are dopamine antagonists, such as
chlorpromazine, may
precipitate or aggravate cyclical oedema. Conversely, bro
mocriptine, a dopamine agonist, may improve the oedema.
Cyclizine Hydrochloride One of the ANTIHISTAMINE DRUGS which is mainly u
sed for the prevention of
sickness, including seasickness.
CycloOxygenase2 Selective Inhibitors See COX2 INHIBITORS.
Cyclophosphamide A derivative of NITROGEN MUSTARDS used to treat various
forms of malignant disease,
including HODGKINS DISEASE and chronic lymphocytic LEUKAEMIA. (See also ALKYLATIN
G AGENTS; CYTOTOXIC.)
Cycloplegia Paralysis of the ciliary muscle of the EYE, which results in
the loss of the power of
ACCOMMODATION in the eye.
Cyclopropane One of the most potent of the anaesthetics given by inhalat
ion (see ANAESTHESIA). Its
advantages are that it acts quickly, causes little irritation to the lungs, and
its effects pass off
quickly.
Cycloserine An antibiotic derived from an actinomycete, used to treat ce
rtain infections of the
genitourinary tract, and and in combination with other drugs to treat TUBERCULOS
IS resistant to firstline
drugs.
Cyclothymia The state characterised by extreme swings of mood from elati
on to depression, and vice
versa. (See also MANIC DEPRESSION; MENTAL ILLNESS.)
Cyclotron A machine in which positively charged atomic particles are so
accelerated that they acquire
energies equivalent to those produced by millions of volts. From the medical poi
nt of view, its interest is
that it is a source of neutrons. (See RADIOTHERAPY.)
Cyesis Another term for pregnancy (see AND LABOUR).
PREGNANCY
C
Cysts
Treatment This consists basically of regular physiotherapy and postural
drainage, antibiotics and the
taking of pancreatic enzyme tablets and vitamins. Some children need STEROID tre
atment and all require
nutritional support. The earlier treatment is started, the better the results. W
hereas two decades ago,
only 12 per cent of affected children survived beyond adolescence, today 75 per
cent survive into adult
life, and an increasing number are surviving into their 40s. Patients with ends
tage disease can be treated
by heartlung transplantation (with their own heart going to another recipient).
Research is underway on
the possible use of GENE THERAPY to control the disorder. Parents of children wi
th cystic fibrosis, seeking
help and advice, can obtain this from the Cystic Fibrosis Trust.
Cystitis Inflammation of the URINARY BLADDER. The presenting symptom is
usually dysuria that is, a
feeling of discomfort when urine is passed and frequently a stinging or burning
pain in the URETHRA. There
is also a feeling of wanting to pass water much more often than usual, even thou
gh there is very little
urine present when the act is performed. The condition may be associated with a
dragging ache in the lower
abdomen, and the urine usually looks dark or stronger than normal. It is frequen
tly associated with
haematuria, which means blood in the urine and is the result of the inflammation
. Cystitis is a common
problem; more than half the women in Britain suffer from it at some time in thei
r lives. The cause of the
disease is a bacterial infection of the bladder, the germs having entered the ur
ethra and ascended into the
bladder. The most common organism responsible is called Escherichia coli. This o
rganism normally lives in
the bowel where it causes no harm. It is therefore likely to be present on the s
kin around the anus so that
there is always a potential for infection. The disease is much more common in wo
men because the urethra,
vagina and anus are very close together and the urethra is much shorter in the f
emale than it is in the
male. It also explains why women commonly suffer cystitis after sexual intercour
se and honeymoon cystitis
is a very common presentation of bladder inflammation. In most cases the inflamm
ation is more of a nuisance
than a danger but the infection can spread up to the kidneys and cause PYELITIS
which is a much more
serious disorder. In cases of cystitis the urine should be cultured to grow the
responsible organism. The
177
relevant antibiotic can then be prescribed. Fluids should be taken freel
y not only for an acute attack
of cystitis but also to prevent further attacks, because if the urine is dilute
the organism is less likely
to grow. Bicarbonate of soda is also helpful as this reduces the acidity of the
urine and helps to relieve
the burning pain, and inhibits the growth of the bacteria. Careful hygiene, in o
178 Cytarabine
C
irritation or another cause, some cavity which ought naturally to contai
n a little fluid becomes
distended, or the natural outlet from the cavity becomes blocked. Wens are cause
d by the blockage of the
outlet from sebaceous glands in the skin, so that an accumulation of fatty matte
r takes place. RANULA is a
clear swelling under the tongue, due to a collection of saliva in consequence of
an obstruction to a
salivary duct. Cysts in the breasts are, in many cases, the result of blockage i
n milk ducts, due to
inflammation; they should be assessed to exclude cancer (see BREASTS, DISEASES O
F). Cysts also form in the
kidney as a result of obstruction to the free outflow of the urine.
Developmental cysts Of these, the most important are the huge cysts that
originate in the OVARIES. The
cause is doubtful, but the cyst probably begins at a very early period of life,
gradually enlarges, and
buds off smaller cysts from its wall. The contents are usually a clear gelatinou
s fluid. Very often both
ovaries are affected, and the cysts may slowly reach a great size often, however
, taking a lifetime to do
so. A similar condition sometimes occurs in the KIDNEYS, and the tumour may have
reached a great size in an
infant even before birth (congenital cystic kidney). Dermoid cysts are small cav
ities, which also originate
probably early in life, but do not reach any great size until fairly late in lif
e. They appear about parts
of the body where clefts occur in the embryo and close up before birth, such as
the corner of the eyes, the
side of the neck, and the middle line of the body. They contain hair, fatty matt
er, fragments of bone,
scraps of skin, even numerous teeth.
cells of the body, with particular reference to the CHROMOSOMES.
Cytokines A family of PROTEIN molecules that carry signals locally betwe
en cells. Cytokines are
released by cells when activated by antigens (see ANTIGEN), behaving as enhancin
g mediators for immune
response. These proteins include INTERLEUKINS (produced by LEUCOCYTES), lymphoki
nes (produced by
lymphocytes see LYMPHOCYTE), INTERFERON, and tumour necrosis factor, one of whos
e many functions is
killing tumour cells.
Cytology The study of CELLS.
Cytomegalovirus (CMV)
An drug used mainly to induce remission of acute myeloblastic LEUKAEMIA.
A potent suppressant of
myeloblasts, its use requires monitoring by a HAEMATOLOGIST. (See CYTOTOXIC.)
A commonly occurring virus of the herpes virus group the name derived fr
om the swollen appearance of
Cytotoxic 179
Cytotoxic Cytotoxic means destructive to living cells. Cytotoxic drugs p
ossess anticancer properties
but also have the potential to damage normal tissue. Their use is twofold: to el
iminate a cancer and so
prolong life; or to alleviate distressing symptoms, especially in patients whose
prospects of a cure are
poor. In many cases CHEMOTHERAPY with cytotoxic drugs is combined with surgery,
RADIOTHERAPY or both.
Chemotherapy may be used initially to reduce the size of the primary TUMOUR (a p
rocess called neoadjuvant
therapy) before using radiotherapy or surgery to eliminate it. Cytotoxic drugs m
ay also be used as adjuvant
treatment to prevent or destroy secondary spread of the primary tumour that has
either been removed by
surgery or treated with radiotherapy. All chemotherapy causes sideeffects: the
ONCOLOGIST a specialist
in cancer treatment has to strike a balance between hopedfor benefits and accept
able (for the patient)
toxic effects, which include nausea and vomiting, BONE MARROW suppression, ALOPE
CIA (hair loss) and
teratogenic effects (see TERATOGENESIS). Cytotoxic drugs are used either singly
or in combination, when an
enhanced response is the aim. Chemotherapy of cancer is a complex process and sh
ould be supervised by an
oncologist in cooperation with physicians, surgeons, radiotherapists and radiol
ogists as appropriate. The
cytotoxic drugs include: (1) The alkylating agents which act by damaging DNA, th
us interfering with cell
reproduction. Cyclophosphamide, ifosfamide, chlorambucil, kelphalan, busulphan,
thiotepa and mustine are
examples of alkylating agents.
(2) There are a number of cytotoxic antibiotics used in the treatment of
cancer doxorubicin,
bleomycin, dactinomycin, mithramycin and amsacrine are examples. They are used p
rimarily in the treatment
of acute leukaemia and lymphomas. (3) Antimetabolites these drugs combine irreve
rsibly with vital enzyme
systems of the cell and hence prevent normal cell division. Methotrexate, cytara
bine, fluorouracil,
mercaptopurine and azathioprine are examples. (4) Another group of cytotoxic dru
gs are the vinca alkaloids
such as vincristine, vinblastine and vindesima. (5) Platinum compounds such as c
arboplatin, cisplatin and
oxaliplatin are effective. All of them are given intravenously, but the latter t
wo tend to have more
unpleasant sideeffects. Carboplatin and cisplatin are useful in the treatment o
f solid tumours.
Carboplatin, a derivative of cisplatin, is given intravenously in ovarian cancer
and in smallcell lung
cancer. Better tolerated than cisplatin, the drug causes less nausea and vomitin
g, nephrotoxicity,
neurotoxicity and ototoxicity. Where platinumcontaining therapy has failed, intr
avenous treatment with
paclitaxel may be tried. With only a limited success rate, it is relatively toxi
c and should be carefully
supervised; responses, however, are sometimes prolonged. Also of increasing impo
rtance in treating cancer
are interferons. These are naturally occurring proteins with complex effects on
immunity and cell function.
Although toxic, with numerous adverse effects, they have shown some antitumour
effect against certain
lymphomas and solid tumours.
C
swathed in bandages or otherwise protected from the action of the air. Bodies ar
e also preserved by
injecting the blood vessels with strong antiseptics such as perchloride of mercu
ry.
Cremation or incineration of the body is now the commonest method of dis
posal of the dead in the UK,
where land for burials is increasingly scarce; today it accounts for around 75 p
er cent of disposals. The
process of incineration takes 12 hours. Something in the range of 23 to 32 kg (57 lb
s) of ash result
from the combustion of the body, and there is no admixture with that from the fu
el. Cremation of a body
means that it is almost impossible to conduct any meaningful forensic tests shou
ld any subsequent doubts be
raised about the cause of death. So, before cremation can take place, two doctor
s have to sign the
cremation forms. The first is usually the doctor who was caring for the patient
at the time of death an
important exception being cases of sudden death, when the coroner holds an inque
st into the cause and
authorises the necessary approval for cremation. In 1999, fewer than 3,500 death
s were certified following
a post-mortem, out of a total number of deaths in England and Wales of more than
556,000. When the coroner
is not involved, the second doctor must have been qualified for five years; he o
r she must be unconnected
with the patients care and not linked professionally with the first doctor. (For
example, if the first
doctor is a general practitioner as in the majority of cases they are the second
doctor should be from
another practice.) Before signing the cremation certificate the second doctor mu
st conduct an external
examination of the dead person and discuss the circumstances of death with the f
irst doctor. The two
cremation forms are then inspected by crematorium medical referees who must be s
atisfied that the cause of
death has definitely been ascertained. The present death and cremation certifica
tion system has been in
place in the UK for many years the legislative framework for cremation was set u
p in 1902 and death
certification procedures were last reviewed by the government-appointed Brodrick
committee
D
the adenoids (see NOSE, DISORDERS OF). Recent studies, however, suggest that in
many children these
operations may provide only transiin 1971, with no fundamental changes proposed. The case of Harold Shipma
n, a general practitioner
convicted of murdering more than 15 patients, and suspected of murdering many mo
re, has revealed serious
weaknesses in the certification system. A comprehensive review of the present pr
ocedures was in place at
the time of writing (2004).
Dead Fingers
Dead Space Gas exchange only occurs in the terminal parts of the pulmona
ry airways (see LUNGS). That
portion of each breath that is taken into the lungs but does not take part in ga
s exchange is known as dead
space. Anatomical dead space describes air in the airways up to the terminal BRO
NCHIOLES. Physiological
dead space also includes gas in alveoli (air sacs) which are unable to take part
in gas exchange because of
structural abnormalities or disease.
Deafness Impairment of hearing, which affects about 2 million adults in
the UK. In infants, permanent
deafness is much less common: about 12 per 1,000. It is essential, however, that
deafness is picked up
early so that appropriate treatment and support can be given to improve hearing
and/or ensure that the
child can learn to speak. In most people, deafness is a result of sensorineural
hearing impairment,
commonly known as nerve deafness. This means that the abnormality is located in
the inner ear (the
cochlea), in the auditory nerve, or in the brain itself. The prevalence of this
type of hearing impairment
rises greatly in elderly people, to the extent that more than 50 per cent of the
over-70s have a moderate
hearing impairment. In most cases no definite cause can be found, but contributo
ry factors include
excessive exposure to noise, either at work (e.g. shipyards and steelworks) or a
t leisure (loud music).
Anyone who is exposed to gunfire or explosions is also likely to develop some he
aring impairment: service
personnel, for example. Conductive hearing impairment is the other main classifi
cation. Here there is an
abnormality of the external or middle ear, preventing the normal transmission of
sound waves to the inner
ear. This is most commonly due to
Death, Signs of
ent relief and make no difference to long-term outcome. Advice and infor
mation on deafness and hearing
aids may be obtained from the Royal National Institute for Deaf People and other
organisations.
Deamination The process of removal of the amino group, NH2, from amino a
cids not required for building
up body PROTEIN. This is carried out mainly in the liver by means of an enzyme,
deaminase. The fatty acid
residue is either burnt up to yield energy, or is converted into glucose.
Death, Causes of The final cause of death is usually the failure of the
vital centres in the brain that
control the beating of the heart and the act of breathing. The important practic
al question, however, is
what disease, injury or other agent has led to this failure. Sometimes the cause
may be obvious for
example, pneumonia, coronary thrombosis, or brain damage in a road accident. Oft
en, however, the cause can
be uncertain, in which case a POST-MORTEM EXAMINATION is necessary. The two most
common causes of death in
the UK are diseases of the circulatory system (including strokes and heart disea
se) and cancer. Overall
annual death rates among women in the UK at the start of the 21st century were 7
.98 per 1,000 population,
and among men, 5.58 per 1,000. Comparable figures at the start of the 20th centu
ry were 16.3 for women and
18.4 for men. The death rates in 1900 among infants up to the age of four were 4
7.9 per 1,000 females and
57 per 1,000 males. By 2003 these numbers had fallen to 5.0 and 5.8 respectively
. All these figures give a
crude indication of how the health of Britains population has improved in the pas
t century. Death rates
and figures on the causes of deaths are essential statistics in the study of EPI
DEMIOLOGY which, along with
information on the incidence of illnesses and injuries, provides a temporal and
geographical map of
changing health patterns in communities. Such information is valuable in plannin
g preventive health
measures (see PUBLIC HEALTH) and in identifying the natural history of diseases
knowledge that often
contributes to the development of preventive measures and treatments for those d
iseases.
Death, Signs of There are some minor signs, such as: relaxation
183
of the facial muscles (which produces the staring eye and gaping mouth o
f the Hippocratic
countenance), as well as a loss of the curves of the back, which becomes flat by
contact with the bed or
table; discoloration of the skin, which takes on a wax-yellow hue and loses its
pink transparency at the
finger-webs; absence of blistering and redness if the skin is burned (Christisons
sign); and failure of a
ligature tied round the finger to produce, after its removal, the usual change o
f a white ring, which,
after a few seconds, becomes redder than the surrounding skin in a living person
. The only certain sign of
death, however, is that the heart has stopped beating. To ensure that this is pe
rmanent, it is necessary to
listen over the heart with a stethoscope, or directly with the ear, for at least
five minutes. Permanent
stoppage of breathing should also be confirmed by observing that a mirror held b
efore the mouth shows no
haze, or that a feather placed on the upper lip does not flutter. In the vast ma
jority of cases there is no
difficulty in ensuring that death has occurred. The introduction of organ transp
lantation, however, and of
more effective mechanical means of resuscitation, such as ventilators, whereby a
n individuals heart can be
kept beating almost indefinitely, has raised difficulties in a minority of cases
. To solve the problem in
these cases the concept of brain death has been introduced. In this context it has
to be borne in mind
that there is no legal definition of death. Death has traditionally been diagnos
ed by the irreversible
cessation of respiration and heartbeat. In the Code of Practice drawn up in 1983
by a Working Party of the
Health Departments of Great Britain and Northern Ireland, however, it is stated
that death can also be
diagnosed by the irreversible cessation of brain-stem function. This is described
as brain death. The
brain stem consists of the mid-brain, pons and medulla oblongata which contain t
he centres controlling the
vital processes of the body such as consciousness, breathing and the beating of
the heart (see BRAIN). This
new concept of death, which has been widely accepted in medical and legal circle
s throughout the world,
means that it is now legitimate to equate brain death with death; that the essen
tial component of brain
death is death of the brain stem; and that a dead brain stem can be reliably dia
gnosed at the bedside. (See
GLASGOW COMA SCALE.) Four points are important in determining the time that has
elapsed since death.
HYPOSTASIS, or congestion, begins to appear as livid spots on the back, often mi
staken for bruises, three
hours or more after death. This is due to the
D
The surgical removal of foreign material and damaged tissue from a wound
.
Death Certificate A certificate required by law to be signed by a medica
l practitioner stating the main
and any contributary causes of a persons death.
Death Rate The death (mortality rate) is the number of deaths per 100,00
0 or sometimes 10,000 or
1,000 of the population per year. In 2001 the population of the UK was 59.8 mill
ion, of
Debility A state of weakness.
Decay, Dental See TEETH, DISORDERS OF
Caries of the teeth.
Decibel The unit of hearing. One decibel is the least intensity of sound
at which a given note can be
heard. The usual abbreviation for decibel is dB.
Decidua The soft coat which lines the interior of the womb during pregna
ncy and which is cast off at
birth.
Decoction A preparation made by boiling various plants in water and stra
ining the fluid.
Decompensation A failing condition of the heart in a case of valvular di
sease (see HEART, DISEASES OF).
Decongestants Drugs which relieve nasal congestion and stuffiness. They
may be given orally or by nasal
spray, and most are SYMPATHOMIMETIC DRUGS which cause vasoconstriction in the na
sal mucosa. Too frequent
use reduces their effectiveness, and there is a danger of rebound worsening if the
y are used for more
than 1014 days. A safer option for babies is simple sodium chloride drops. Warm m
oist air is also a
traditional effective decongestant.
Decubitus Decubitus refers to the positions taken up in
Dehydration
185
bed by patients suffering from various conditions such as pneumonia, PER
ITONITIS, or severe exhaustion.
Such patients are liable to develop bed sores, or decubitus ulcer (see ULCER).
SCALDS; CHEST, DEFORMITIES OF; TALIPES; FLAT-FOOT; JOINTS, DISEASES OF;
KNOCK-KNEE; LEPROSY; PALATE,
MALFORMATIONS OF; PARALYSIS; RICKETS; SCAR; SKULL; SPINE AND SPINAL CORD, DISEAS
ES AND INJURIES OF.)
Decussation
Degeneration
Any point in the nervous system at which nerve fibres cross from one sid
e to the other: for example,
the decussation of the pyramidal tracts in the medulla (see BRAIN), where the mo
tor fibres from one side of
the brain cross to the other side of the spinal cord.
A change in structure or in chemical composition of a tissue or organ, b
y which its vitality is lowered
or its function interfered with. Degeneration is of various kinds, the chief bei
ng fatty, where cells
become invaded by fat globules; calcareous, where calcium is deposited in tissue
so that it becomes chalky
in consistency; and mucoid, where it becomes semi-liquefied. Causes of degenerat
ion are, in many cases,
very obscure. In some cases heredity plays a part, with particular organs for ex
ample, the kidneys
tending to show fibroid changes in successive generations. Fatty, fibroid, and c
alcareous degenerations are
part of the natural change in old age; defective nutrition may bring them on pre
maturely, as may excessive
and long-continued strain upon an organ like the heart. Various poisons, such as
alcohol, play a special
part in producing the changes, and so do the poisons produced by various disease
s, particularly SYPHILIS
and TUBERCULOSIS.
Deep Vein Thrombosis (DVT) See THROMBOSIS; VEINS, DISEASES OF.
Defaecation Opening the bowels. (See DIARRHOEA.)
CONSTIPATION;
Defibrillation If a heart is fibrillating (see VENTRICULAR FIBRILLATION)
, the application of a large
electric shock via paddles applied to the chest wall causes simultaneous electri
cal depolarisation of all
the cardiac cells, and may allow the hearts natural pacemaker to re-establish sin
us rhythm. One paddle is
placed below the right clavicle and the other over the cardiac apex. Care must b
e taken that no one is in
contact with the patient or the bed when the shock is given, to avoid electrocut
ion.
186 Dj Vu
D
cent of a mans body weight is water, and 50 per cent of a womans; those pr
oportions need to be
maintained within quite narrow limits to ensure proper functioning of body tissu
es. Body fluids contain a
variety of mineral salts (see ELECTROLYTES) and these, too, must remain within n
arrow concentration bands.
Dehydration is often accompanied by loss of salt, one of the most important mine
rals in the body. The start
of dehydration is signalled by a person becoming thirsty. In normal circumstances,
the drinking of water
will relieve thirst and serious dehydration does not develop. In a temperate cli
mate an adult will lose 1.5
litres or more a day from sweating, urine excretion and loss of fluid through th
e lungs. In a hot climate
the loss is much higher up to 10 litres if a person is doing hard physical work.
Even in a temperate
climate, severe dehydration will occur if a person does not drink for two or thr
ee days. Large losses of
fluid occur with certain illnesses for example, profuse diarrhoea; POLYURIA in d
iabetes or kidney failure
(see KIDNEYS, DISEASES OF); and serious blood loss from, say, injury or a badly
bleeding ULCER in the
gastrointestinal tract. Severe thirst, dry lips and tongue, TACHYCARDIA, fast br
eathing, lightheadedness
and confusion are indicative of serious dehydration; the individual can lapse in
to COMA and eventually die
if untreated. Dehydration also results in a reduction in output of urine, which
becomes dark and
concentrated. Prevention is important, especially in hot climates, where it is e
ssential to drink water
even if one is not thirsty. Replacement of salts is also vital, and a diet conta
ining half a teaspoon of
table salt to every litre of water drunk is advisable. If someone, particularly
a child, suffers from
persistent vomiting and diarrhoea, rehydration therapy is required and a salt-an
dglucose rehydration
mixture (obtainable from pharmacists) should be taken. For those with severe deh
ydration, oral fluids will
be insufficient and the affected person needs intravenous fluids and, sometimes,
admission to hospital,
where fluid intake and output can be monitored and rehydration measures safely c
ontrolled.
Dj Vu A feeling of having already experienced an event which the person is
doing or seeing at the
moment. French for already seen, dj vu is quite common but no satisfactory explanati
on for the
phenomenon has yet been discovered.
Delhi Boil Delhi boil is a form of chronic body sore occurring in Easter
n countries, caused by a
protozoan parasite, Leishmania tropica. (See LEISHMANIASIS.)
Delinquency Behaviour by a young person that would be judged a crime if
carried out by an adult.
Delinquency may also include non-criminal activities for example, running away f
Dengue 187
Delivery The final expulsion of the child in the act of birth. (See PREG
NANCY AND LABOUR.)
Delta Waves Abnormal electrical waves observed in the electroencephalogr
am (see ELECTROENCEPHALOGRAPHY
(EEG)). The frequency of the normal alpha waves is 10 per second; that of the de
lta waves is 7 or fewer per
second. They occur in the region of tumours of the brain, and in the brains of p
atients with EPILEPSY.
Deltoid The powerful triangular muscle attached above to the collar-bone
and shoulder-blade, and below,
by its point, to the humerus, nearly halfway down the outer side of the upper ar
m. Its action is to raise
the arm from the side, and it covers and gives roundness to the shoulder. (See a
lso MUSCLE.)
Delusions An irrational and usually unshakeable belief (ide fixe) peculia
r to some individuals. They
fail to respond to reasonable argument and the delusion is often paranoid in cha
racter with a belief that a
person or persons is/are persecuting them. The existence of a delusion, of such
a nature as to influence
conduct seriously, is one of the most important signs in reaching a decision to
arrange for the compulsory
admission of the patient to hospital for observation. (See MENTAL ILLNESS.)
Dementia An acquired and irreversible deterioration in intellectual func
tion. Around 10 per cent of
people aged over 65 and 20 per cent of those aged 75 or over are affected to som
e extent. The disorder is
due to progressive brain disease. It appears gradually as a disturbance in probl
emsolving and agility of
thought which may be considered to be due to tiredness, boredom or DEPRESSION. A
s memory failure develops,
the affected person becomes bewildered, anxious and emotional when dealing with
new surroundings and
complex conversations. In professional skilled workers this is frequently first
recognised by family and
friends. Catastrophic reactions are usually brief but are commonly associated wi
th an underlying depression
which can be mistaken for progressive apathy. The condition progresses relentles
sly with loss of recent
memory extending to affect distant memory and failure to recognise even friends
and family. Physical
aggression, unsocial behaviour, deteriorating personal cleanliness
and incoherent speech commonly develop. Similar symptoms to those in dem
entia can occur in curable
conditions including depression, INTRACRANIAL tumours, SUBDURAL haematoma, SYPHI
LIS, vitamin B1 deficiency
(see APPENDIX 5: VITAMINS) and repeated episodes of cerebral ISCHAEMIA. This las
t may lead to multi-infarct
dementia.
Treatment If organic disease is identified, it should, where possible, b
e treated; otherwise the
treatment of dementia is alleviation of its symptoms. The affected person must b
Dependence
Dentist
189
See DNA.
drug to avoid distressing withdrawal or abstinence symptoms. Thus, deter
minants and the problematic
consequences of drug dependence may be biological, psychological or social and u
sually interact. Different
drugs cause different rates of dependence: TOBACCO is the most common substance
of addiction; HEROIN and
COCAINE cause high rates of addiction; whereas ALCOHOL is much lower, and CANNAB
IS lower again. Smoking in
the western world reached a peak after World War II with almost 80 per cent of t
he male population smoking.
The reports on the link between smoking and cancer in the early 1960s resulted i
n a decline that has
continued so that only around a quarter of the adult populations of the UK and U
SA smokes. Globally,
tobacco consumption continues to grow, particularly in the developing world with
multinational tobacco
companies marketing their products aggressively. Accurate figures for illegal dr
ug-taking are hard to
obtain, but probably approximately 4 per cent of the population is dependent on
alcohol and 2 per cent on
other drugs, both legal and illegal, at any one time in western countries.
Dependence
How does dependence occur? More
Physical or psychological reliance on a substance or an individual. A ba
by is naturally dependent on
its parents, but as the child develops, this dependence lessens. Some adults, ho
wever, remain partly
dependent, making abnormal demands for admiration, love and help from parents, r
elatives and others. The
dependence that most concerns modern society is one in which individuals become
dependent on or addicted to
certain substances such as alcohol, drugs, tobacco (nicotine), caffeine and solv
ents. This is often called
substance abuse. Some people become addicted to certain foods or activities: exa
mples of the latter include
gambling, computer games and use of the Internet. The 28th report of the World H
ealth Organisation Expert
Committee on Drug Dependence in 1993 defined drug dependence as: A cluster of phy
siological, behavioural
and cognitive phenomena of variable intensity, in which the use of a psychoactiv
e drug (or drugs) takes on
a high priority. The necessary descriptive characteristics are preoccupation wit
h a desire to obtain and
take the drug and persistent drugseeking behaviour. Psychological dependence occ
urs when the substance
abuser craves the drugs desirable effects. Physical dependence occurs when the us
er has to continue taking
the
than 40 distinct theories or models of drug misuse have been put forward
. One is that the individual
consumes drugs to cope with personal problems or difficulties in relations with
others. The other main
model emphasises environmental influences such as drug availability, environment
al pressures to consume
drugs, and sociocultural influences such as peer pressure. By contrast to these
models of why people misuse
drugs, models of compulsive drug use where individuals have a compulsive addicti
on have been amenable
to testing in the laboratory. Studies at cellular and nerve-receptor levels are
attempting to identify
mechanisms of tolerance and dependence for several substances. Classical behavio
ur theory is a key model
for understanding drug dependence. This and current laboratory studies are being
used to explain the
reinforcing nature of dependent substances and are helping to provide an explana
tory framework for
dependence. Drug consumption is a learned form of behaviour. Numerous investigat
ors have used conditioning
theories to study why people misuse drugs. Laboratory studies are now locating t
he reward pathways in the
brain for opiates and stimulants where positive reinforcing mechanisms involve p
articular sectors of the
See DENTAL SURGEON.
Dentition See TEETH.
Denture A plate or frame bearing false teeth. It may be complete (replac
ing all the teeth in one jaw)
or partial.
Deodorants Substances which remove or lessen objectionable odours. Some,
which have a powerful odour,
simply cover other smells, but the most effective act by giving off oxygen, so a
s to convert the
objectionable substances into simple and harmless ones.
Varieties Volatile oils of plants, such as eucalyptus and turpentine, ch
lorine water and chlorinated
lime, peroxide of hydrogen and charcoal have been used as deodorants. There are
now many commercial
products available.
Deoxyribonucleic Acid
D
190 Depigmentation
D
brain. There is a consensus among experts in addiction that addictive be
haviour is amenable to
effective treatment, and that the extent to which an addict complies with treatm
ent makes it possible to
predict a positive outcome. But there is a long way to go before the mechanisms
of drug addiction are
properly understood or ways of treating it generally agreed.
Effects of drugs Cannabis, derived from the plant Cannabis sativa, is a
widely used recreational drug.
Its two main forms are marijuana, which comes from the dried leaves, and hashish
which comes from the
resin. Cannabis may be used in food and drink but is usually smoked in cigarette
s to induce relaxation and
a feeling of well-being. Heavy use can cause apathy and vagueness and may even c
ause psychosis. Whether or
not cannabis leads people to using harder drugs is arguable, and a national deba
te is underway on whether
its use should be legalised for medicinal use. Cannabis may alleviate the sympto
ms of some disorders for
example, MULTIPLE SCLEROSIS (MS) and there are calls to allow the substance to b
e classified as a
prescribable drug. About one in ten of Britains teenagers misuses volatile substa
nces such as toluene at
some time, but only about one in 40 does so regularly. These substances are give
n off by certain glues,
solvents, varnishes, and liquid fuels, all of which can be bought cheaply in sho
ps, although their sale to
children under 16 is illegal. They are often inhaled from plastic bags held over
the nose and mouth.
Central-nervous-system excitation, with euphoria and disinhibition, is followed
by depression and lethargy.
Unpleasant effects include facial rash, nausea and vomiting, tremor, dizziness,
and clumsiness. Death from
COMA and acute cardiac toxicity is a serious risk. Chronic heavy use can cause p
eripheral neuropathy and
irreversible cerebellar damage. (See SOLVENT ABUSE (MISUSE).) The hallucinogenic
or psychedelic drugs
include LYSERGIC ACID DIETHYLAMIDE (LSD) or acid, magic mushrooms, ecstasy (MDMA
), and phencyclidine (PCP
or angel dust, mainly used in the USA). These drugs have no medicinal uses. Taken
by mouth, they produce
vivid trips, with heightened emotions and perceptions and sometimes with hallucina
tions. They are not
physically addictive but can cause nightmarish bad trips during use and flashbac
ks (vivid reruns of trips)
after use, and can probably trigger psychosis and even death, especially if drug
s are mixed or taken with
alcohol. Stimulant drugs such as amphetamine and cocaine act like adrenaline and
speed up the
central nervous system, making the user feel confident, energetic, and p
owerful for several hours. They
can also cause severe insomnia, anxiety, paranoia, psychosis, and even sudden de
ath due to convulsions or
tachycardia. Depression may occur on withdrawal of these drugs, and in some user
s this is sufficiently
deterrent to cause psychological dependence. Amphetamine (speed) is mainly synthes
ised illegally and may
be eaten, sniffed, or injected. Related drugs, such as dexamphetamine sulphate (
Dexedrine), are prescribed
pills that enter the black market. ECSTASY is another amphetamine derivative tha
t has become a popular
recreational drug; it may have fatal allergic effects. Cocaine and related drugs
are used in medicine as
local anaesthetics. Illegal supplies of cocaine (snow or ice) and its derivative, cra
ck, come mainly
from South America, where they are made from the plant Erythroxylon coca. Cocain
e is usually sniffed
(snorted) or rubbed into the gums; crack is burnt and inhaled. Opiate drugs are de
rived from the opium
poppy, Papaver somniferum. They are described as narcotic because they induce sl
eep. Their main medical use
is as potent oral or injectable analgesics such as MORPHINE, DIAMORPHINE, PETHID
INE HYDROCHLORIDE, and
CODEINE. The commonest illegal opiate is heroin, a powdered form of diamorphine
that may be smoked,
sniffed, or injected to induce euphoria and drowsiness. Regular opiate misuse le
ads to tolerance (the need
to take ever larger doses to achieve the same effect) and marked dependence. A l
ess addictive oral opiate,
METHADONE HYDROCHLORIDE, can be prescribed as a substitute that is easier to wit
hdraw. Some 75,000150,000
Britons now misuse opiates and other drugs intravenously, and pose a huge public
-health problem because
injections with shared dirty needles can carry the blood-borne viruses that caus
e AIDS/HIV and HEPATITIS B.
Many clinics now operate schemes to exchange old needles for clean ones, free of
charge. Many addicts are
often socially disruptive. For help and advice see APPENDIX 2: ADDRESSES: SOURCE
S OF INFORMATION, ADVICE,
SUPPORT AND SELF-HELP National
Dugs Helpline. (See ALCOHOL and TOBACCO for detailed entries on those su
bjects.)
Depigmentation Also called hypo-pigmentation, this congenital or acquire
d disorder is one in which the
skin loses its pigmentation because of reduced
Depression
production. It can be classified into three groups: VITILIGO, ALBINISM a
nd postinflammatory
hypopigmentation.
MELANIN
Depilation The process of destroying hair substances and processes used
for this purpose being known
as depilatories. The purpose may be effected in three ways: by removing the hair
s at the level of the skin
surface; by pulling the hairs out (epilation); and by destroying the roots and s
o preventing the growth of
new hairs. Shaving is the most effective way of removing superfluous hairs. Rubb
ing morning and night with
a smooth pumice-stone is said to be helpful. Electrolysis and diathermy are also
used.
Depression Depression is a word that is regularly misused. Most people e
xperience days or weeks when
they feel low and fed up (feelings that may recur), but generally they get over
it without needing to seek
medical help. This is not clinical depression, best defined as a collection of p
sychological symptoms
including sadness; unhappy thoughts characterised by worry, poor self-image, sel
f-blame, guilt and low
selfconfidence; downbeat views on the future; and a feeling of hopelessness. Suf
ferers may consider
suicide, and in severe depression may soon develop HALLUCINATIONS and DELUSIONS.
Doctors make the diagnosis
of depression when they believe a patient to be ill with the latter condition, w
hich may affect physical
health and in some instances be lifethreatening. This form of depression is comm
on, with up to 15 per cent
of the population suffering from it at any one time, while about 20 per cent of
adults have medical
depression at some time during their lives such that it is one of the most commo
nly presenting disorders
in general practice. Women seem more liable to develop depression than men, with
one in six of the former
and one in nine of the latter seeking medical help. Manic depression is a seriou
s form of the disorder that
recurs throughout life and is manifested by bouts of abnormal elation the manic
stage. Both the manic and
depressive phases are commonly accompanied by psychotic symptoms such as delusio
ns, hallucinations and a
loss of sense of reality. This combination is sometimes termed a manic-depressiv
e psychosis or bipolar
affective disorder because of the illnesss division into two parts. Another psych
iatric description is the
catch-all term affective disorder.
191
Symptoms These vary with the illnesss severity. Anxiety and variable mood
s are the main symptoms in
mild depression. The sufferer may cry without any reason or be unresponsive to r
elatives and friends. In
its more severe form, depression presents with a loss of appetite, sleeping prob
192 Depressor
D
with physical symptoms. ANTIDEPRESSANT DRUGS are divided into three main
groups: TRICYCLIC
ANTIDEPRESSANT DRUGS (amitriptyline, imipramine and dothiepin are examples); MON
OAMINE OXIDASE INHIBITORS
(MAOIS) (phenelzine, isocarboxazid and tranylcypromine are examples); and SELECT
IVE SEROTONIN REUPTAKE
INHIBITORS (SSRIS) (fluoxetine well known as Prozac , fluvoxamine and paroxetine a
re examples). For manic
depression, lithium carbonate is the main preventive drug and it is also used fo
r persistent depression
that fails to respond to other treatments. Long-term lithium treatment reduces t
he likelihood of relapse in
about 80 per cent of manic depressives, but the margin between control and toxic
side-effects is narrow, so
the drug must be carefully supervised. Indeed, all drug treatment for depression
needs regular monitoring
as the substances have powerful chemical properties with consequential side-effe
cts in some people.
Furthermore, the nature of the illness means that some sufferers forget or do no
t want to take the
medication. ELECTROCONVULSIVE THERAPY (ECT) If drug treatments fail, severely de
pressed patients may be
considered for ECT. This treatment has been used for many years but is now only
rarely recommended. Given
under general anaesthetic, in appropriate circumstances, ECT is safe and effecti
ve and may even be
life-saving, though temporary impairment of memory may occur. Because the treatm
ent was often misused in
the past, it still carries a reputation that worries patients and relatives; hen
ce careful assessment and
counselling are essential before use is recommended. Some patients with depressi
on particularly those
with manic depression or who are a danger to themselves or to the public, or who
are suicidal may need
admission to hospital, or in severe cases to a secure unit, in order to initiate
treatment. But as far as
possible patients are treated in the community (see MENTAL ILLNESS).
Depressor (1) A muscle that lowers or flattens a part of the body. (2) T
he name given to a nerve by
whose stimulation motion, secretion, or some other function is restrained or pre
vented: for example, the
depressor nerve of the heart slows the beating of this organ.
Deprivation Score A measure of an individuals or groups lack of normal soc
ial amenities such as
proper housing,
diet and warmth. It was devised in the 1980s to help assess the medical
services needed by a socially
deprived population.
Dermabrasion Dermabrasion, or skin planing, is a method of removing the su
perficial layers of the
skin, useful in the treatment of tattoos and acne scars.
Dermatitis Synonymous with eczema in all respects. Although the lay term
eczema usually refers to
atopic (see ATOPY) or endogenous eczema, there are many other causes. Susceptibi
lity to dermatitis is
genetically determined in some cases; in others, environmental irritants and all
ergens are implicated.
Symptoms typically include itching, dryness or cracking and, occasionally, soren
ess of the skin. Physical
signs include redness (erythema), scaling, and vesiculation (tiny blisters just
beneath the surface of the
skin). (See also SKIN, DISEASES OF.)
Dermatofibroma Also known as histiocytoma. A firm, painless nodule in th
e skin, typically on a leg, due
to excessive formation of COLLAGEN. A common disorder, it is often a slow respon
se to an insect bite and
persists indefinitely.
Dermatoglyphics Dermatoglyphics is the study of the patterns made by the
ridges and crevices of the
hands and the soles of the feet.
Dermatologist A medically qualified specialist who diagnoses and treats
disorders of the skin (see
SKIN, DISEASES OF).
Dermatology In essence, this is the study of the skin. As well as being
an organ in its own right, the
skin is a stage on which other organs as well as the emotions most visibly play
out their roles. Changes in
its blood vessels and hence blood flow through the skin may indicate a major imm
unological response to
a range of potential factors (see SKIN, DISEASES OF).
Dermatome (1) Embryological tissue which has developed from the somites
to become the dermis and
subcutaneous tissue. The cutaneous area that is derived from each dermatome is s
upplied by a single dorsal
spinal nerve root.
Dextran
(2) A surgical instrument for removing very thin slices of skin for graf
ting.
Dermatomyositis A rare disease, possibly caused by an autoimmune reactio
n, in which muscle inflammation
and weakness is associated with a characteristic heliotrope ERYTHEMA of the face
and backs of the hands. In
adults it may be associated with underlying malignancy. Tissue changes are simil
ar to those in
POLYMYOSITIS.
Dermatophytes Fungi which can infect skin, hair and nails. About 30 spec
ies in three genera are
PATHOGENIC to humans (see RINGWORM).
Dermographism Dermographism, or factitious URTICARIA, refers to transien
t ERYTHEMA and wealing caused
by trauma to the skin.
Dermoid Cyst See CYSTS.
Desensitisation In psychiatry, a method for treating phobias used in BEH
AVIOUR THERAPY. The affected
individual is slowly acclimatised to the cause of his or her fear. (See also ALL
ERGY.)
Desferrioxamine An agent which binds to heavy metals, used in the treatm
ent of iron poisoning and
THALASSAEMIA.
Designer Drugs A group of chemical substances produced illegally whose p
roperties and effects are
similar to those of drugs of abuse. They may be derived from narcotic ANALGESICS
, AMPHETAMINES or
HALLUCINOGENS. Ecstasy is a widely used designer drug and has caused deaths amon
g teenagers. Designer drugs
are potentially dangerous, especially if taken with alcohol.
Desquamation The scaling-off of the superficial layer of the epidermis (
see SKIN).
Detached Retina Separation of the retina from the choroid in the EYE. It
may be due to trauma or be
secondary to tumour or inflammation of the choroid, and causes blindness in the
affected part of the
retina. It can be treated surgically using PHOTOCOAGULATION.
193
Detergents Substances which clean the skin surface. This means that, str
ictly speaking, any soap, or
soaplike substance used in washing, is a detergent. At the present day, however,
the term is largely used
for the synthetic detergents which are now used on such a large scale. These are
prepared by the cracking
and oxidation of high-petroleum waxes with sulphuric acid. The commoner ones in
commercial preparations are
aryl alkyl sulphate or sulphonate and secondary alkyl sulphate. In view of their
194 Dextrocardia
D
from PROTEIN, is in appropriate clinical circumstances used as a substit
ute for plasma for TRANSFUSION
purposes. Dextran is often used as an immediate transfusion measure to treat sev
ere bleeding or certain
types of shock until properly cross-matched blood is available. A blood sample f
or cross-matching must be
taken before intravenous dextran is given.
Dextrocardia A condition in which a persons heart is situated on the righ
t of the chest in a mirror
image of its usual position. This may be associated with similar inversion of th
e abdominal organs situs
inversus.
Dextromethophan An over-the-counter drug used to relieve dry, irritating
, persistent coughs, this
opioid acts as a cough suppressant. It is available either alone or in combinati
on with other drugs in
linctus, lozenges and syrups prepared to provide symptomatic relief for coughs a
nd colds.
Dextrose Another name for purified grape sugar or glucose. A common cons
tituent of intravenous fluids.
DiaDia- is a prefix meaning through or thoroughly.
Diabetes Insipidus Diabetes insipidus is a relatively rare condition and
must be differentiated from
DIABETES MELLITUS which is an entirely different disease. It is characterised by
excessive thirst and the
passing of large volumes of urine which have a low specific gravity and contain
no abnormal constituents.
It is either due to a lack of the antidiuretic hormone normally produced by the
HYPOTHALAMUS and stored in
the posterior PITUITARY GLAND, or to a defect in the renal tubules which prevent
s them from responding to
the antidiuretic hormone VASOPRESSIN. When the disorder is due to vasopressin in
sufficiency, a primary or
secondary tumour in the area of the pituitary stalk is responsible for onethird
of cases. In another
one-third of cases there is no apparent cause, and such IDIOPATHIC cases are som
etimes familial. A further
one-third of cases result from a variety of lesions including trauma, basal MENI
NGITIS and granulomatous
lesions in the pituitary-stalk area. When the renal tubules fail to respond to v
asopressin this is usually
because of a genetic defect transmitted as a sex-linked recessive characteristic
, and the disease is called
nephrogenic diabetes insipidus. Metabolic abnormalities such as HYPERCALCAEMIA and pota
ssium depletion render the
renal tubule less sensitive to vasopressin, and certain drugs such as lithium an
d tetracycline may have a
similar effect. If the disease is due to a deficiency of vasopressin, treatment
should be with the analogue
of vasopressin called desmopressin which is more potent than the natural hormone
and has less pressor
activity. It also has the advantage in that it is absorbed from the nasal mucosa
and so does not need to be
injected. Nephrogenic diabetes insipidus cannot be treated with desmopressin. Th
e urine volume can,
however, usually be reduced by half by a thiazide diuretic (see THIAZIDES).
Diabetes Mellitus Diabetes mellitus is a condition characterised by a ra
ised concentration of glucose
in the blood due to a deficiency in the production and/or action of INSULIN, a p
ancreatic hormone made in
special cells called the islet cells of Langerhans. Insulin-dependent and non-in
sulindependent diabetes
have a varied pathological pattern and are caused by the interaction of several
genetic and environmental
factors.
Insulin-dependent diabetes mellitus (IDDM) (juvenile-onset diabetes, typ
e 1 diabetes) describes
subjects with a severe deficiency or absence of insulin production. Insulin ther
apy is essential to prevent
KETOSIS a disturbance of the bodys acid/base balance and an accumulation of keton
es in the tissues. The
onset is most commonly during childhood, but can occur at any age. Symptoms are
acute and weight loss is
common.
Non-insulin-dependent diabetes mellitus (NIDDM) (maturity-onset diabetes
, type 2 diabetes) may be
further sub-divided into obese and non-obese groups. This type usually occurs af
ter the age of 40 years
with an insidious onset. Subjects are often overweight and weight loss is uncomm
on. Ketosis rarely
develops. Insulin production is reduced but not absent. A new hormone has been i
dentified linking obesity
to type 2 diabetes. Called resistin because of its resistance to insulin it was
first found in mice but
has since been identified in humans. Researchers in the United States believe th
at the hormone may, in
part, explain how obesity predisposes people to diabetes. Their hypothesis is th
at a protein in the bodys
fat cells triggers insulin resistance around the
Diabetes Mellitus
body. Other research suggests that type 2 diabetes may now be occurring
in obese children; this could
indicate that children should be eating a more-balanced diet and taking more exe
rcise.
Diabetes associated with other conditions (a) Due to pancreatic disease
for example, chronic
pancreatitis (see PANCREAS, DISORDERS OF); (b) secondary to drugs for example, G
LUCOCORTICOIDS (see
PANCREAS, DISORDERS OF); (c) excess hormone production for example, growth hormo
ne (ACROMEGALY); (d)
insulin receptor abnormalities; (e) genetic syndromes (see GENETIC DISORDERS).
Gestational diabetes Diabetes occurring in pregnancy and resolving after
wards.
Aetiology Insulin-dependent diabetes occurs as a result of autoimmune de
struction of beta cells within
the PANCREAS. Genetic influences are important and individuals with certain HLA
tissue types (HLA DR3 and
HLA DR4) are more at risk; however, the risks associated with the HLA genes are
small. If one parent has
IDDM, the risk of a child developing IDDM by the age of 25 years is 1525 per cent,
and the risk of a
sibling of an IDDM subject developing diabetes is about 3 per cent. Non-insulindependent diabetes has no
HLA association, but the genetic influences are much stronger. The risks of deve
loping diabetes vary with
different races. Obesity, decreased exercise and ageing increase the risks of di
sease development. The risk
of a sibling of a NIDDM subject developing NIDDM up to the age of 80 years is 304
0 per cent.
Diet Many NIDDM diabetics may be treated with diet alone. For those subj
ects who are overweight, weight
loss is important, although often unsuccessful. A diet high in complex carbohydr
ate, high in fibre, low in
fat and aiming towards ideal body weight is prescribed. Subjects taking insulin
need to eat at regular
intervals in relation to their insulin regime and missing meals may result in hy
poglycaemia, a lowering of
the amount of glucose in the blood, which if untreated can be fatal (see below).
Oral hypoglycaemics
are used in the treatment of non-insulin-dependent diabetes in addition
to diet, when diet alone fails
to control blood-sugar levels. (a) SULPHONYLUREAS act mainly by increasing the p
roduction of insulin; (b)
BIGUANIDES, of which only metformin is available, may be used alone or in additi
on to
195
sulphonylureas. Metformins main actions are to lower the production of gl
ucose by the liver and
improve its uptake in the peripheral tissues.
Complications The risks of complications increase with duration of disea
196 Diagnosis
D
Nephropathy Subjects with diabetes may
Insulin All insulin is injected mainly by syrdevelop kidney damage which can result in renal failure.
inge but sometimes by insulin pump because it is inactivated by gastroin
testinal enzymes. There are
three main types of insulin preparation: (a) short action (approximately six hou
rs), with rapid onset; (b)
intermediate action (approximately 12 hours); (c) long action, with slow onset a
nd lasting for up to 36
hours. Human, porcine and bovine preparations are available. Much of the insulin
now used is prepared by
genetic engineering techniques from micro-organisms. There are many regimens of
insulin treatment involving
different combinations of insulin; regimens vary depending on the requirements o
f the patients, most of
whom administer the insulin themselves. Carbohydrate intake, energy expenditure
and the presence of
infection are important determinants of insulin requirements on a day-to-day bas
is. A new treatment for
diabetes, pioneered in Canada and entering its preliminary clinical trials in th
e UK, is the
transplantation of islet cells of Langerhans from a healthy person into a patien
t with the disorder. If the
transplantation is successful, the transplanted cells start producing insulin, t
hus reducing or eliminating
the requirement for regular insulin injections. If successful the trials would b
e a significant advance in
the treatment of diabetes. Scientists in Israel have developed a drug, Dia Pep 2
77, which stops the bodys
immune system from destroying pancratic cells as happens in insulin-dependent di
aetes. The drug, given
y injection, offers the possiility of preventing type 1 diaetes in healthy pe
ople at genetic risk of
developing the disorder, and of checking its progression in affected individuals
whose cells are already
perishing. Trials of the drug are in progress.
Neuropathy (a) Symmetrical sensory polyneuropathy; damage to the sensory
nerves that commonly presents
with tingling, numness of pain in the feet or hands. () Asymmetrical motor dia
etic neuropathy,
presenting as progressive weakness and wasting of the proximal muscles of legs.
(c) Mononeuropathy;
individual motor or sensory nerves may e affected. (d) Autonomic neuropathy, wh
ich affects the autonomic
nervous system, has many presentations including IMPOTENCE, diarrhoea or constip
ation and postural
HYPOTENSION. Skin lesions There are several skin disorders associated with diae
tes, including: (a)
necroiosis lipoidica diaeticorum, characterised y one or more yellow atrophic
lesions on the legs; ()
ulcers, which most commonly occur on the feet due to peripheral vascular disease
, neuropathy and infection.
Diarrhoea 197
Dialysis A procedure used to filter off waste products from the lood an
d remove surplus fluid from the
ody in someone who has kidney failure (see KIDNEYS, DISEASES OF). The scientifi
c process involves
separating crystalloid and COLLOID sustances from a solution y interposing a s
emi-permeale memrane
etween the solution and pure water. The crystalloid sustances pass through the
memrane into the water
until a state of equilirium, so far as the crystalloid sustances are concerned
, is estalished etween
the two sides of the memrane. The colloid sustances do not pass through the me
mrane. Dialysis is
availale as either haemodialysis or peritoneal dialysis.
Haemodialysis Blood is removed from the circulation either through an ar
tificial arteriovenous fistula
(junction) or a temporary or permanent internal catheter in the jugular vein (se
e CATHETERS). It then
passes through an artificial kidney (dialyser) to remove toxins (e.g. potassium an
d urea) y diffusion
and excess salt and water y ultrafiltration from the lood into dialysis fluid
prepared in a
proportionator (often referred to as a kidney machine). Dialysers vary in design and
performance ut
all work on the principle of a semi-permeale memrane separating lood from dia
lysis fluid. Haemodialysis
is undertaken two to three times a week for 46 hours a session.
Peritoneal dialysis uses the peritoneal lining (see PERITONEUM) as a sem
i-permeale memrane.
Approximately 2 litres of sterile fluid is run into the peritoneum through the p
ermanent indwelling
catheter; the fluid is left for 34 hours; and the cycle is repeated 34 times per d
ay. Most patients
undertake continuous amulatory peritoneal dialysis (CAPD), although a few use a
machine overnight
(continuous cycling peritoneal dialysis, CCPD) which allows greater clearance of
toxins. Disadvantages of
haemodialysis include cardiovascular instaility, HYPERTENSION, one disease, AN
AEMIA and development of
periarticular AMYLOIDOSIS. Disadvantages of peritoneal dialysis include peritoni
tis, poor drainage of
fluid, and gradual loss of overall efficiency as endogenous renal function decli
nes. Haemodialysis is
usually done in outpatient dialysis clinics y skilled nurses, ut some patients
can carry out the
procedure at home. Both haemodialysis and peritoneal
dialysis carry a relatively high moridity and the ideal treatment for p
atients with end-stage renal
failure is successful renal TRANSPLANTATION.
Diamorphine Diamorphine is another name for HEROIN.
Diaphoresis Another name for sweating (see PERSPIRATION).
Diaphragm The diaphragm is the thin, dome-shaped muscular partition whic
h separates the cavity of the
198 Diastase
Diet
199
ing with increased excretion of waste products. The general lood pressu
re is also distinctly lowered.
The method is used in painful rheumatic conditions, oth of muscles and joints.
By concentrating the
current in a small electrode, the heating effects immediately elow this are ver
y much increased. The
diathermy knife utilises this technique to coagulate leeding vessels and cauter
ise anormal tissue during
surgery.
logical food chain with the result that animals at the end of the food c
hain such as irds or predators
may uild up lethal concentrations of the sustance in their tissues. In any cas
e, an increasing numer of
species of insects were ecoming resistant to DDT. Fortunately, newer insecticid
es have een introduced
which are toxic to DDT-resistant insects, ut there are douts whether this supp
ly of new insecticides can
e maintained as insects develop resistance to them.
Diathesis
Dicrotism
An archaic term meaning constitutional or inherited state giving an indi
vidual a predisposition towards
a disease, a group of diseases or a structural or metaolic anormality. An exam
ple is HAEMOPHILIA, a
leeding disorder. See TRANQUILLISERS; BENZODIAZEPINES.
A condition in which the PULSE occurs as a eat each time the heart cont
racts. A dicrotic wave is
naturally present in a tracing of any pulse as recorded y an instrument for the
purpose, ut in health it
is imperceptile to the finger. In fevers, a dicrotic pulse is a serious sign in
which the heart continues
to eat violently while the small lood vessels have lost their tone.
Dicephalus
Didanosine
Diazepam
The term applied to symmetrical TWINS with two separate heads.
CONJOINED
Dichlorodiphenyl Trichloroethane DDT is the generally used areviation
for the compound which has een
given the official name of dicophane. It was first synthesised in 1874, ut it w
as not until 1940 that, as
a result of research work in Switzerland, its remarkale toxic action on insects
was discovered. This work
was taken up and rapidly expanded in Great Britain and the USA, and one of its f
irst practical applications
200 Dietetics
D
which provided at least the minimum requirement of energy, protein, vita
mins and minerals needed y the
ody. However, since nutritional deficiencies are no longer a major prolem in d
eveloped countries, it
seems more appropriate to consider a healthy diet as eing one which provides all
essential nutrients in
sufficient quantities to prevent deficiencies ut which also avoids health prol
ems associated with
nutrient excesses. Major diet-related health prolems in prosperous communities
tend to e the result of
dietary excesses, whereas in underdeveloped, poor communities, prolems associat
ed with dietary
deficiencies predominate. Excessive intakes of dietary energy, saturated fats, s
ugar, salt and alcohol,
together with an inadequate intake of dietary fire, have een linked to the hig
h prevalence of OBESITY,
cardiovascular disease, dental caries, HYPERTENSION, gall-stones (see GALL-BLADD
ER, DISEASES OF),
non-insulindependent DIABETES MELLITUS and certain cancers (e.g. of the reast,
endometrium, intestine and
stomach) seen in developed nations. Health-promotion strategies in these countri
es generally advocate a
reduction in the intake of fat, particularly saturated fat, and salt, the avoida
nce of excessive intakes of
alcohol and simple sugars, an increased consumption of starch and fire and the
avoidance of oesity y
taking appropriate physical exercise. A maximum level of dietary cholesterol is
sometimes specified.
Undernutrition, including protein-energy malnutrition and specific vitamin and m
ineral deficiencies, is an
important cause of poor health in underdeveloped countries. Priorities here cent
re on ensuring that the
diet provides enough nutrients to maintain health. In healthy people, dietary re
quirements depend on age,
sex and level of physical activity. Pregnancy and lactation further alter requir
ements. The presence of
infections, fever, urns, fractures and surgery all increase dietary energy and
protein requirements and
can precipitate undernutrition in previously well-nourished people. In addition
to disease prevention, diet
has a role in the treatment of certain clinical disorders, for example, oesity,
diaetes mellitus,
HYPERLIPIDAEMIA, inorn errors of metaolism, food intolerances and hepatic and
renal diseases. Therapeutic
diets increase or restrict the amount and/or change the type of fat, carohydrat
e, protein, fire,
vitamins, minerals and/or water in the diet according to clinical indications. A
dditionally, the
consistency of the food eaten may need to e
altered. A commercially availale or homemade liquid diet can e used to p
rovide all or some of a
patients nutritional needs if necessary. Although the enteral (y mouth) route is
the preferred route for
feeding and can e used for most patients, parenteral or intravenous feeding is
occasionally required in a
Dioptre
treat FILARIASIS a group of diseases caused y parasitic worms called ne
matode filariae.
201
Dietitian
terminate a pregnancy or to clean out the uterus after a partial miscarr
iage. D and C is increasingly
eing replaced with a LASER technique using a hysteroscope a type of
See DIETETICS.
ENDOSCOPE.
Differential Diagnosis
Dilator
A list of the possile diagnoses that might explain a patients symptoms a
nd signs, and from which the
correct DIAGNOSIS will e extracted after further investigations.
(1) A muscle which has the action of increasing the diameter of an organ
or vessel. (2) A drug which
usually acts y relaxing smooth muscle to increase the diameter of lood vessels
, the ronchial tree, or
other organs. (3) An instrument used to increase the diameter of an orifice or o
rgan, either to treat a
stricture or to allow surgical access.
Differentiation The gradual diversification of the STEM CELLS of the ear
ly EMBRYO into the specialised
cells, tissues and organs that go to make up the fully developed organism.
Digestion The three processes y which the ody incorporates food are di
gestion, ABSORPTION, and
ASSIMILATION. In digestion, food is softened and converted into a form solule i
n the watery fluids of the
ody; or, in the case of fat, into minute gloules. The sustances formed are th
en asored from the owels
and carried throughout the ody y the lood. In assimilation, these sustances,
deposited from the lood,
are used y the various tissues for their growth and repair.
Digoxin One of a numer of drugs known as CARDIAC They increase the cont
ractility of heart muscle,
depress the conducting tissue while increasing myocardial excitaility, and incr
ease activity of the VAGUS
nerve. Digoxin is usually given orally for the treatment of atrial FIBRILLATION
and heart failure. The
adverse effects of overdosage (which occur more commonly in people with HYPOKALA
EMIA, the elderly, and
those with renal failure see KIDNEYS, DISEASES OF) are vomiting, DYSRHYTHMIA, mu
scle weakness, and visual
disturances. The ELECTROCARDIOGRAM (ECG) has a characteristic appearance. GLYCO
SIDES.
Dihydrocodeine
Diltiazem One of the CALCIUM-CHANNEL BLOCKERS, effective in most types o
f ANGINA; however, it should
not e given to patients with heart failure. A longer-acting version of the drug
can e used in
HYPERTENSION.
Diluents Diluents are watery fluids of a non-irritating nature, which ar
e given to increase the amount
of perspiration or of urine, and carry solids with them from the system. Example
s are water, milk,
arley-water, and solutions of alkaline salts.
Dimenhydrinate Dimenhydrinate, or dramamine, is an antihistamine drug, o
tainale without prescription,
to prevent and treat travel sickness.
Dimercaprol Also called British Anti-Lewisite (BAL), this is a chelating
agent used in the treatment of
metal poisoning (e.g. arsenic, lead, mercury). It has a high incidence of side-e
ffects and is now only
rarely used as it has een superseded y less toxic chelating agents.
Dioctyl Sodium Sulphosuccinate See DOCUSATE SODIUM.
An analgesic drug with similar efficacy to
Diodone
CODEINE.
A complex, radio-opaque, organic, iodinecontaining preparation, used for
contrast radiography of parts
of the ody in particular, the urinary tract (see PYELOGRAPHY).
Dilatation and Curettage Commonly referred to as D and C, a gynaecologic
al operation to scrape away the
lining of the UTERUS (ENDOMETRIUM). The procedure may e used to diagnose and tr
eat heavy leeding from the
wom (ENDOMETRIOSIS) as well as other uterine disorders. It can e used to
Dioptre A term used in the measurement of the refractive or focusing pow
er of lenses; one dioptre is
the power of a lens with a focal distance of one
D
202 Diphenhydramine
metre and is the unit of refractive power. As a stronger lens has a grea
ter refractive power, this
means that the focal distance will e shorter. The strength in dioptres therefor
e is the reciprocal of the
focal length expressed in metres.
D Diphenhydramine
A widely used antihistamine (see HISTAMINE DRUGS) with sedative effects.
ANTIDiphenoxylate Also known as cophentrope or Lomotil. When mixed with ATROP
INE sulphate, it is used as
tretament for adult patients with DIARRHOEA, particularly if chronic. It has no
antiacterial properties
ut is sometimes used to treat travellers diarrhoea.
Diphtheria Diphtheria is an acute infectious disease of the respiratory
tract. Rarely seen in the UK
since the introduction of inoculation in 1940, it is still an important cause of
disease in many parts of
the world. The infection is caused y the Coryneacterium diphtheriae and is spr
ead y water droplets. It
usually presents with a sore throat, and there is a slightly raised memrane on
the tonsils surrounded y
an inflammatory zone. There may e some swelling of the neck and lymph nodes, th
ough the patients
temperature is seldom much raised. Occasionally the disease occurs in the eye or
genital tract, or it may
complicate lesions of the skin. More serious consequences follow the asorption
of TOXINS which damage the
heart muscle and the nervous system.
Treatment Provided that the patient is not allergic to horse serum, an i
njection of the antitoxin is
given immediately. A one-week course of penicillin is started (or erythromycin i
f the patient is allergic
to penicillin). Diphtheria may cause temporary muscle weakness or paralysis, whi
ch should resolve without
special treatment; if the respiratory muscles are involved, however, artificial
respiration may e
necessary. All infants should e immunised against diphtheria; for details see t
ale under IMMUNISATION.
Diplegia Extensive PARALYSIS on oth sides of the ody ut affecting the
legs more than the arms.
DiploA prefix meaning twofold.
Diplococcus A group of spherical acterial organisms which usually occur
in pairs: for example,
pneumococci. (See BACTERIA.)
Diplo The layer of spongy one which intervenes etween the compact outer
and inner tales of the
skull.
Social services
are provided y localauthority social-services departments. They include
: practical help in the home
(usually
Dislocations 203
through home helps or aids to daily living); assistance in taking advant
age of availale educational
facilities; help with adaptations to the disaled persons house; provision of mea
ls (Meals on Wheels or
luncheon centres); and help in otaining a telephone. Many of these facilities w
ill involve the disaled
person in some expense, ut full details can e otained from the local social-s
ervices department which
will, if necessary, send a social worker to discuss the matter in the disaled p
ersons home. Owing to lack
of funds and staff, many localauthority social-services departments are unale t
o provide the full range of
services.
Aids to daily living There is now a wide range of aids for the disaled.
Full details and addresses of
local offices can e otained from: Disaled Living Foundation and British Red C
ross.
Aids to moility and transport Some car manufacturers make specially equ
ipped or adapted cars, and some
have official systems for discounts. Details can e otained from local dealers.
Help can also e otained
from Motaility, which provides advice.
Disarticulation The amputation of a one y cutting through the joint of
which the one forms a part.
Disc An anatomical term descriing a rounded flattened structure. Exampl
es are the cartilagenous disc
positioned etween two verterae (see SPINAL COLUMN) and the optic disc (see EYE
).
Discharge
tion, other than those arising directly from physical injury.
Disinfectants Sustances that destroy micro-organisms, thus preventing t
hem from causing infections.
The name is usually applied to powerful chemicals that are also capale of destr
oying tissue and so are
used only to sterilise inanimate surfaces. ANTISEPTICS are used to cleanse livin
g tissues.
Disinfection Processes y which vegetative organisms, excluding spores,
are killed in order to prevent
the items disinfected from passing on infection. Equipment, edlinen and hard su
rfaces may all e
disinfected the method chosen will depend on the material and size of the oject
. One of the most
important procedures in preventing the spread of infection is the careful washin
g of hands efore handling
equipment and etween treating different patients. STERILISATION is different fr
om disinfection in that the
methods used kill all living organisms and spores.
Methods
Dizygotic Twins
itself, but when taken in conjunction with alcohol it produces most unpl
easant effects: for example,
flushing of the face, palpitations, a sense of oppression and distress, and ulti
mately sickness and
vomiting. The rationale of treatment therefore is to give the alcoholic subject
a course of disulfiram and
then demonstrate, by letting him or her take some alcoholic liquor, how unpleasa
nt are the effects. If the
patient is co-operative, the treatment may be effective, but there is some risk
so it must be given under
skilled medical supervision.
Disuse Atrophy The wasting of muscles after prolonged immobility. This c
an be seen after lengthy
immobilisation in a plaster cast, and is particularly severe following paralysis
of a limb through nerve
injury. (See ATROPHY.)
Dithranol A drug used to treat PSORIASIS. It is usually very effective,
being applied normally for
short contact periods of up to 1 hour. Dithranol can cause severe skin irritatio
n so must be used with care
and at appropriate concentrations. Hands should be thoroughly washed after use.
Diuresis An increase in the production of urine. This may result from in
creased fluid intake, decreased
levels of antidiuretic hormone, renal disease, or the use of drugs (see DIURETIC
S).
Diuretics Substances which increase urine and solute production by the K
IDNEYS. They are used in the
treatment of heart failure, HYPERTENSION, and sometimes for ASCITES secondary to
liver failure. They may
work by extra-renal or renal mechanisms. The potential side-effects of diuretics
are HYPOKALAEMIA,
DEHYDRATION, and GOUT (in susceptible individuals).
Extra-renal mechanisms (a) Inhibiting release of antidiuretic hormone (e
.g. water, alcohol); (b)
increased renal blood flow (e.g. dopamine in renal doses). Renal mechanisms (a)
Osmotic diuretics act by
holding water in the renal tubules and preventing its reabsorption (e.g. mannitol)
; (b) loop diuretics
prevent sodium, and therefore water, reabsorption (e.g. FRUSEMIDE); (c) drugs ac
ting on the cortical
segment of the Loop of Henle prevent sodium reabsorption, but are weaker than loop
diuretics (e.g.
THIAZIDES);
205
(d) drugs acting on the distal tubule prevent sodium reabsorption by ret
aining potassium (e.g.
spironalactone).
Diverticular Disease The presence of numerous diverticula (sacs or pouch
es) in the lining of the COLON
accompanied by spasmodic lower abdominal pain and erratic bowel movements. The s
206 Dizziness
ocytes (see OCYTE). They may be of different sexes and are no more likely
to resemble each other than
any other sibling pairs.
Dizziness D
This means different things to different people, so it is important to e
stablish what the individual
means by dizziness. It may encompass a feeling of disequilibrium; it may be ligh
theadedness, faintness, a
sensation of swimming or floating, an inbalance or unsteadiness, or episodes of
mental confusion. It may be
true VERTIGO, which is an hallucination of movement. These symptoms may be due t
o diseases of the ear, eye,
central nervous system, cardiovascular system, or endocrine system, or they may
be a manifestation of
psychiatric disease. Dizziness is a common symptom in the elderly and by the age
of 80, two-thirds of women
and one-third of men have suffered from the condition.
DLE See LUPUS
Discoid lupus erythematosus
(DLE).
DMSA See LEAD POISONING
Treatment.
accurate copy of the genetic information of the parent cells (see GENETI
C CODE).
DNR An acronym for do not resuscitate advice sometimes written on a patien
ts hospital notes to
indicate that if he or she suffers, say, a lifethreatening complication (such as
a CARDIAC ARREST) to an
existing serious illness, the patient should not be given emergency lifesaving t
reatment. The use of DNR is
an emotive and controversial issue, even if the patient (or the relatives), when
a serious illness such as
spreading cancer is concerned, may have indicated a wish not to be resuscitated
in the event of organ
failures. (See ETHICS.)
Dobutamine A cardiac stimulant drug of the inotropic sympathomimetic gro
up (see SYMPATHOMIMETIC DRUGS),
dobutamine acts on sympathetic receptors in cardiac muscle, increasing the contr
actility and hence
improving the cardiac output but with little effect on the cardiac rate. It is p
articularly useful in
cardiogenic shock. It must be given by intravenous infusion. (See also HEART.)
DNA
Docetaxel
DNA is the abbreviation for deoxyribonucleic acid, one of the two types
Dopamine 207
the NHS. General practitioners must complete a three-year vocational tra
ining course before practising
as an independent GP. In Britain, surgical specialists are customarily addressed
as Mr. Other countries
have different regulations.
Docusate Sodium A faecal-softening agent used to treat constipation in o
ld people. It can be given
orally or as a rectal suppository.
Dog Bites See BITES AND STINGS; RABIES.
Dolichocephalic Dolichocephalic means long-headed, and is a term applied
to skulls the breadth of which
is less than four-fifths of the length.
Dominant Gene See GENETIC DISORDERS.
Donepezil A drug used for the symptomatic treatment of mild to moderate
DEMENTIA only in ALZHEIMERS
DISEASE. Around four in ten patients may benefit by a reduction in the rate of c
ognitive and non-cognitive
deterioration.
Donor Insemination Use of the SEMEN of an anonymous donor to produce fer
tilisation in cases of
INFERTILITY where the male partner has OLIGOSPERMIA or IMPOTENCE. The donor is c
hosen for ethnic and
physiognomic similarity to the male partner and is screened for transmissible di
seases (e.g. HIV, syphilis,
hepatitis, gonorrhoea, and genetic disorders). Insemination is performed at the
time of ovulation by
introducing the semen into the upper vagina. Semen may be fresh or have been sto
red frozen in liquid
nitrogen. (See ARTIFICIAL INSEMINATION.)
Donors People who donate parts of their bodies for use in other people.
Many organs and tissues can be
donated most commonly blood, but skin, corneas, kidneys, livers and hearts can a
ll be used. Combined
heart and lung transplants are being increasingly used for patients with severe
lung diseases, and, if the
recipients have a condition such as CYSTIC FIBROSIS in which the heart is normal
, it is sometimes possible
for them to receive a heart and lungs from one donor and to donate their own hea
rt to someone else. Recent
work has explored the possibility of using pancreatic transplants. Apart from bl
ood, it is unusual for
tissue to be taken from
living donors. Skin, small pieces of liver, and a kidney can, in theory,
be obtained from living
donors, but the ETHICS of this are hotly debated and the situations under which
it may be done are tightly
controlled. Because transplanted organs are seen by the receiving body as foreign
bodies, careful
matching before transplantation is necessary to avoid rejection, and immunosuppr
essive drugs may be
required for some time after the operation to prevent this from occurring. There
are strict regulations
about how death should be diagnosed before organs can be removed for transplanta
tion, and potential donors
must satisfy the BRAIN-STEM DEATH criteria, performed twice by two doctors who a
re independent of the
transplant team. There is a great shortage of suitable organs for donation partl
y because they must be in
excellent condition if the operation is to be a success. Some medical conditions
or modes of death make
people unsuitable as organ donors; this makes it all the more important that peo
ple should be encouraged to
donate their organs. People who wish to do so can carry a special card indicatin
g their willingness to
become donors in the event of their death. These cards can be obtained from vari
ous sources, including
hospitals, GPs surgeries and many public buildings such as libraries. In the UK,
informed positive
approval from the patient, or relatives, is required. Information about becoming
a blood donor can be
obtained by telephoning 08457 711 711. Those who wish to bequeath their bodies fo
r dissection purposes
should get in touch with HM Inspector of Anatomy. Other would-be organ donors ma
y contact the British Organ
Donor Society.
Dopa A precursor of DOPAMINE and NORADRENALINE. Levodopa is a drug used
in the treatment of
PARKINSONISM. It can cross the bloodbrain barrier and increase the concentration
of dopamine in the basal
ganglia. It also inhibits prolactin secretion and may be used to treat GALACTORR
HEA.
Dopamine Dopamine is one of the CATECHOLAMINES and a precursor of NORADR
ENALINE. Its highest
concentration is in that portion of the brain known as the basal nuclei (see BRA
IN) where its function is
to convey inhibitory influences to the extrapyramidal system. There is good evid
ence that dopamine
deficiency is one of the causative factors in PARKINSONISM. Dopamine is given by
intravenous infusion
D
f treatment is clearly
better than another. Otherwise, it would be unethical to continue. (See INTERVEN
TION STUDY.)
Double Vision See SQUINT.
Douche An application to the body of a jet of fluid via a pipe or tube.
It may be used to clean any
part of the body but is used most commonly with reference to the vagina (althoug
h used as a method of
contraception it is ineffective).
Downs (Down) Syndrome A genetic disorder in which the affected person usu
ally carries an extra
chromosome 47 instead of the usual 46. The extra chromosome occurs in the no. 21
group, hence the
disorder is described as trisomy 21. The condition was named after Dr J L H Down
, the London doctor who
first described it in 1866. The incidence is around one in 600 births. The disor
der is characterised by a
particular physical appearance and learning difficulties, with the affected indi
viduals having an
INTELLIGENCE QUOTIENT (IQ) ranging from 30 to 80 (normal is 100). Most people wi
th the syndrome have eyes
that slope up at the outer corners with skin folds that cover the inner ones. Th
e face and features are
smaller than normal, while the tongue is larger; the back of the head is flatten
ed and the hands are
usually short and broad. The facial features led to the syndrome being described
as mongolism, a term
that is no longer used. Children with Downs syndrome are usually friendly and fit
in well with the family.
Despite their learning disabilities, some learn to read and, if they have approp
riate educational and
environmental stimulation, can make the most of their abilities. A heart defect
is present in around 25 per
cent of the children at birth, and deafness and acute LEUKAEMIA occur more frequ
ently than in unaffected
youngsters. Those with the syndrome are particularly prone to developing ear inf
ections. ATHEROSCLEROSIS
often develops early in adults and ALZHEIMERS DISEASE tends to occur as early as
40 years of age. A
friendly home environment helps them to enjoy life, but a few individuals with t
he syndrome may eventually
require institutional care. Improved social
D
210 Doxorubicin
D
and medical care means that many now live until their 60s. Routine scree
ning tests early in pregnancy,
starting with blood analysis but going on if necessary to AMNIOCENTESIS and chor
ionic villus sampling (see
PRENATAL SCREENING OR DIAGNOSIS), can identify fetuses likely to develop the dis
order. If a sample of fetal
cells confirms the chromosome defect (triple marker test see PREGNANCY AND LABOU
R), the parents may
consider termination of the pregnancy. In the UK, screening is normally offered
to women over 35 because of
their increased risk. When younger parents have a child with Downs syndrome, the
chances of a subsequent
child with the disorder are relatively high as it is probable that both parents
carry a chromosome
abnormality insufficient to cause ill-health until combined. So they may wish to
discuss with their medical
advisers the question of further pregnancies. Parents who have a child with Downs
syndrome will
understandably feel a combination of strong emotions, including anger and guilt,
and constructive
counselling can be valuable. Among societies offering advice and support is the
Downs Syndrome
Association.
(guinea-worm). The major clinical problem is secondary infection of the
worm track, causing CELLULITIS,
SYNOVITIS, epididymo-ORCHITIS, periarticular FIBROSIS, and ARTHRITIS; TETANUS is
a potentially lethal
complication. CHEMOTHERAPY is unsatisfactory and the timehonoured method of extr
acting the female adult by
winding it around a matchstick remains in use. Surgical treatment may be necessa
ry. Ultimate prevention
consists of removing Cyclops spp. from drinking water.
Doxorubicin A successful and widely used antitumour drug. It is used in
the treatment of acute
LEUKAEMIA, LYMPHOMA, and various forms of sarcoma and CANCER, including cancer o
f the bladder. (See
CYTOTOXIC.)
Another term for sickle-cell anaemia (see ANAEMIA), which is characteris
ed by the presence in the blood
of red blood corpuscles that are sickle-like in shape. The anaemia is a severe o
ne and afflicts black
people and to a lesser extent people of Mediterranean background.
Doxycycline
Dressings
A wide-spectrum, long-acting antibiotic which is active against a range
of micro-organisms, including
the causative organisms of scrub typhus (see under TYPHUS FEVER), TRACHOMA, PSIT
TACOSIS, LYME DISEASE and
some influenzas.
See WOUNDS.
DPT Vaccine Often called the TRIPLE VACCINE, the injections produce immu
nity against DIPHTHERIA,
whooping cough (PERTUSSIS) and TETANUS. The vaccine is given as a course of thre
e injections to infants
around the ages of two, three and four months, together with haemophilus influen
za B and meningococcal C
vaccine as well as oral polio vaccine. A booster injection is given at school en
try (see schedule in
IMMUNISATION).
Dracontiasis Dracontiasis, or dracunculiasis, is a nematode infection ca
used by Dracunculus medinensis
Dracunculiasis See DRACONTIASIS.
Dramamine See DIMENHYDRINATE.
Draught A draught is a small mixture intended to be taken at one dose. I
t consists generally of two or
four tablespoonfuls of fluid.
Dreams See SLEEP.
Drepanocytosis
Drop Attack A brief episode affecting the nervous system that causes the
person to fall suddenly. There
is no loss of consciousness. The loss of tone in the muscles, responsible for th
e fall, may persist for
several hours; in such cases moving the patient or applying pressure to the sole
s of the feet may restore
muscle tone. In most cases, however, recovery is immediate. The cause is probabl
y a temporary interference
with the blood supply to the brain. In others there may be some disturbance of t
he vestibular apparatus
which controls the balance of the body. (See EAR, DISEASES OF; TRANSIENT ISCHAEM
IC ATTACKS OR EPISODES
(TIA, TIE).)
Drop Foot This is the inability to dorsiflex the foot at the ankle. The
foot hangs down and has to be
swung clear of the ground while walking. It is
Drugs
commonly caused by damage to the lateral popliteal nerve or the peroneal
muscles.
Drop Wrist This is the inability to extend the hand at the wrist. It is
usually due to damage to the
radial nerve which supplies the extensor muscles.
Drowning See APPENDIX 1: BASIC FIRST AID.
Drug Absorption Drugs are usually administered distant to their site of
action in the body; they must
then pass across cell membranes to reach their site of action. For example, drug
s given by mouth must pass
across the gut membrane to enter the bloodstream and then pass through the endot
helium of vessel walls to
reach the site of action in the tissues. This process is called absorption and m
ay depend on lipid
diffusion, aqueous diffusion, active transport, or pinocytosis a process in whic
h a cell takes in small
droplets of fluid by cytoplasmic engulfment.
Drug Addiction See DEPENDENCE.
Drug Assisted Rape Also known as date rape, this is an unwelcome phenomeno
n in which an intending
rapist undermines a potential victims resistance by giving her a hypnotic drug su
ch as benzodiazepine. The
British National Formulary warns that flunitrazepam (Rohypnol ) tablets may be par
ticularly subject to
abuse perhaps given to the unsuspecting victim in an alcoholic drink so the seda
tive effect is greatly
enhanced.
Drug Binding The process of attachment of a drug to a receptor or plasma
protein, fat,
mucopolysaccharide or other tissue component. This process may be reversible or
irreversible.
Drug Clearance The volume of blood from which a drug is completely remov
ed in one minute is known as
clearance. Renal clearance of a drug is the amount of blood completely cleared o
f the drug by the kidney in
one minute.
Drug Interactions Many patients are on several prescribed drugs, and num
erous medicines are available
over the counter, so the potential for drug interaction is large. A drug may int
eract with another by
211
inhibiting its action, potentiating its action, or by simple summation o
f effects. The interaction may
take place: (1) Prior to absorption or administration for example, antacids bind
tetracycline in the gut
and prevent absorption. (2) By interfering with protein binding one drug may dis
place another from
binding sites on plasma proteins. The action of the displaced drug will be incre
Duodenal Ulcer
factures a digestive juice which passes by a duct into the small intesti
ne. It also manufactures, by
means of special cells, a substance called INSULIN which passes straight into th
e blood.
213
common among the upper social classes, and those of blood group O.
The blood vessel in the fetus through which blood passes from the pulmon
ary artery to the aorta,
thereby bypassing the lungs, which do not function during intra-uterine life. (S
ee CIRCULATORY SYSTEM OF
THE BLOOD.) The ductus normally ceases to function soon after birth and within a
few weeks is converted
into a fibrous cord. Occasionally this obliteration does not occur: a condition
known as patent ductus
arteriosus. This is one of the more common congenital defects of the heart, and
one which responds
particularly well to surgical treatment. Closure of the duct can also be achieve
d in some cases by the
administration of indomethacin. (See HEART, DISEASES OF.)
Causes It is likely that there is some abrasion, or break, in the lining
membrane (or mucosa) of the
stomach and/or duodenum, and that it is gradually eroded and deepened by the aci
dic gastric juice. The
bacterium helicobacter pylori is present in the antrum of the stomach of people
with peptic ulcers; 15 per
cent of people infected with the bacterium develop an ulcer, and the ulcers heal
if H. pylori is
eradicated. Thus, this organism has an important role in creating ulcers. Mental
stress may possibly be a
provocative factor. Smoking seems to accentuate, if not cause, duodenal ulcer, a
nd the drinking of alcohol
is probably harmful. The apparent association with a given blood group, and the
fact that relatives of a
patient with a peptic ulcer are unduly likely to develop such an ulcer, suggest
that there is some
constitutional factor.
Ductus Deferens
Symptoms and signs Peptic ulcers may
Ductus deferens, or VAS DEFERENS, is the tube which carries spermatozoa
from the epidydimis to the
seminal vesicles. (See TESTICLE.)
present in different ways, but chronic, episodic pain lasting several mo
nths or years is most common.
Occasionally, however, there may be an acute episode of bleeding or perforation,
or obstruction of the
gastric outlet, with little previous history. Most commonly there is pain of var
ying intensity in the
middle or upper right part of the abdomen. It tends to occur 23 hours after a mea
l, most commonly at
night, and is relieved by some food such as a glass of milk; untreated it may la
st up to an hour. Vomiting
is unusual, but there is often tenderness and stiffness (guarding) of the abdomina
l muscles. Confirmation
of the diagnosis is made by radiological examination (barium meal), the ulcer appe
aring as a niche on the
film, or by looking at the ulcer directly with an endoscope (see FIBREOPTIC ENDO
SCOPY). Chief complications
are perforation of the ulcer, leading to the vomiting of blood, or HAEMATEMESIS;
or less severe bleeding
from the ulcer, the blood passing down the gut, resulting in dark, tarry stools
(see MELAENA).
Ductus Arteriosus
Dumbness See SPEECH DISORDERS.
Dumping Syndrome A sensation of weakness and sweating after a meal in pa
tients who have undergone
GASTRECTOMY. Rapid emptying of the stomach and the drawing of fluid from the blo
od into the intestine has
been blamed, but the exact cause is unclear.
Duodenal Ileus Dilatation of the DUODENUM due to its chronic obstruction
, caused by an abnormal
position of arteries in the region of the duodenum pressing on it.
Duodenal Ulcer This disorder is related to gastric ulcer (see STOMACH, D
ISEASES OF), both being a form
of chronic peptic ulcer. Although becoming less frequent in western communities,
peptic ulcers still affect
around 10 per cent of the UK population at some time. Duodenal ulcers are 1015 ti
mes more common than
gastric ulcers, and occur in people aged from 20 years onwards. The male to fema
le ratio for duodenal ulcer
varies between 4:1 and 2:1 in different communities. Social class and blood grou
ps are also influential,
with duodenal ulcer being more
Treatment of a perforation involves initial management of any complicati
ons, such as shock,
haemorrhage, perforation, or gastric outlet obstruction, usually involving surge
ry and blood replacement.
Medical treatment of a chronic ulcer should include regular meals, and the avoid
ance of fatty foods, strong
tea or coffee and alcohol. Patients should also stop smoking and try to reduce t
he stress in their lives.
ANTACIDS may provide symptomatic
D
214 Duodenum
D
relief. However, the mainstay of treatment involves four- to six-week co
urses with drugs such as
CIMETIDINE and RANITIDINE. These are H2 RECEPTOR ANTAGONISTS which heal peptic u
lcers by reducing
gastric-acid output. Of those relapsing after stopping this treatment, 6095 per c
ent have infection with
H. pylori. A combination of BISMUTH chelate, amoxycillin (see PENICILLIN; ANTIBI
OTICS) and METRONIDAZOLE
triple regime should eliminate the infection: most physicians advise the triple re
gime as first-choice
treatment because it is more likely to eradicate Helicobacter and this, in turn,
enhances healing of the
ulcer or prevents recurrence. Surgery may be necessary if medical measures fail,
but its use is much rarer
than before effective medical treatments were developed.
Duodenum The first part of the INTESTINE immediately beyond the stomach,
so-named because its length is
about 12 fingerbreadths.
Dupuytrens Contracture A condition of unknown aetiology in which there is
progressive thickening and
contracture of the FASCIA in the palm of the hand with adherence of the overlyin
g skin. A clawing deformity
of the fingers, particularly the little and ring fingers, develops. It is associ
ated with liver disease,
diabetes, epilepsy, and gout. Treatment is surgical to excise the affected fasci
a. Recurrence is not
uncommon.
Dura Mater The outermost and strongest of the three membranes or meninge
s which envelop the brain and
spinal cord. In it run vessels which nourish the inner surface of the skull. (Se
e BRAIN.)
DVT See DEEP VEIN THROMBOSIS (DVT).
Dwarfism Dwarfism, or short stature, refers to underdevelopment of the b
ody. The condition, which has
various causes, is not common. All children who by the age of five years are at
least what is technically
known as three standard deviations below the mean well below average size for chil
dren of that age
should be referred for specialist advice. Among the causes are: genetic: familia
l; abnormalities of
chromosomes, for example, TURNERS SYNDROME; abnormal skeletal development; and fa
ilure of primary growth.
Dyslexia
Dysdiadochokinesia Loss of the ability to perform rapid alternate moveme
nts, such as winding up a
watch. It is a sign of a lesion in the cerebellum. (See BRAIN.)
Dysentery A clinical state arising from invasive colo-rectal disease; it
is accompanied by abdominal
colic, diarrhoea, and passage of blood/mucus in the stool. Although the two majo
r forms are caused by
Shigella spp. (bacillary dysentery) and Entamoeba histolytica (amoebic dysentery
), other organisms
including entero-haemorrhagic Escherichia coli (serotypes 0157:H7 and 026:H11) a
nd Campylobacter spp. are
also relevant. Other causes of dysentery include Balantidium coli and that cause
d by schistosomiasis
(bilharzia) Schistosoma mansoni and S. japonicum infection.
Shigellosis This form is usually caused by Shigella dysenteriae-1 (Shigas
bacillus), Shigella
flexneri, Shigella boydii, and Shigella sonnei; the latter is the most benign an
d occurs in temperate
climates also. It is transmitted by food and water contamination, by direct cont
act, and by flies; the
organisms thrive in the presence of overcrowding and insanitary conditions. The
incubation is between one
and seven days, and the severity of the illness depends on the strain responsibl
e. Duration of illness
varies from a few days to two weeks and can be particularly severe in young, old
, and malnourished
individuals. Complications include perforation and haemorrhage from the colo-rec
tum, the haemolytic uraemic
syndrome (which includes renal failure), and REITERS SYNDROME. Diagnosis is depen
dent on demonstration of
Shigella in (a) faecal sample(s) before or usually after culture. If dehydration
is present, this should
be treated accordingly, usually with an oral rehydration technique. Shigella is
eradicated by antibiotics
such as trimethoprimsulphamethoxazole, trimethoprim, ampicillin, and amoxycillin
. Recently, a widespread
resistance to many antibiotics has developed, especially in Asia and southern Am
erica, where the agent of
choice is now a quinolone compound, for example, ciprofloxacin; nalidixic acid i
s also effective.
Prevention depends on improved hygiene and sanitation, careful protection of foo
d from flies, fly
destruction, and garbage disposal. A Shigella carrier must not be allowed to han
dle food.
215
entery may be accompanied by weight loss, anaemia, and occasionally DYSP
NOEA. E. histolytica
contaminates food (e.g. uncooked vegetables) or drinking water. After ingestion
of the cyst-stage, and
following the action of digestive enzymes, the motile trophozoite emerges in the
colon causing local
invasive disease (amoebic colitis). On entering the portal system, these organis
ms may gain access to the
liver, causing invasive hepatic disease (amoebic liver abscess). Other sites of abs
cess formation
include the lungs (usually right) and brain. In the colo-rectum an amoeboma may
be difficult to
differentiate from a carcinoma. Clinical symptoms usually occur within a week, b
ut can be delayed for
months, or even years; onset may be acute as for Shigella spp. infection. Perfor
ation, colo-rectal
haemorrhage, and appendicitis are unusual complications. Diagnosis is by demonst
ration of E. histolytica
trophozoites in a fresh faecal sample; other amoebae affecting humans do not inv
ade tissues. Research
techniques can be used to differentiate between pathogenic (E. dysenteriae) and
non-pathogenic strains (E.
dispar). Alternatively, several serological tests are of value in diagnosis, but
only in the presence of
invasive disease. Treatment consists of one of the 5nitroimidazole compounds met
ronidazole, tinidazole,
and ornidazole; alcohol avoidance is important during their administration. A fi
ve- to ten-day course
should be followed by diloxanide furoate for ten days. Other compounds emetine,
chloroquine, iodoquinol,
and paromomycin are now rarely used. Invasive disease involving the liver or oth
er organ(s) usually
responds favourably to a similar regimen; aspiration of a liver abscess is now rar
ely indicated, as
controlled trials have indicated a similar resolution rate whether this techniqu
e is used or not, provided
a 5-nitroimidazole compound is administered.
Dysidrosis Disturbance of sweat secretion.
Dyskinesia Abnormal movements of the muscles resulting from disorder of
the brain. Movements are
uncoordinated and involuntary and occur in facial as well as limb muscles. They
include athetosis (writhing
movements), CHOREA (jerking movements predominate), choreoathetosis (a combined
type), myoclonus (spasms),
tics and tremors.
Entamoeba histolytica infection Most
Dyslexia
cases occur in the tropics and subtropics. DysDyslexia is difficulty in reading or learning to
D
216 Dysmenorrhoea
D
read. It is always accompanied by difficulty in writing, and particularl
y by difficulties in spelling.
Reading difficulties might be due to various factors for example, a general lear
ning problem, bad
teaching or understimulation, or a perceptive problem such as poor eyesight. Spe
cific dyslexia (word
blindness), however, affects 48 per cent of otherwise normal children to some exte
nt. It is three times
more common in boys than in girls, and there is often a family history. The cond
ition is sometimes missed
and, when a child has difficulty with reading, dyslexia should be considered as
a possible cause. Support
and advice may be obtained from the British Dyslexia Association.
Dysmenorrhoea Painful MENSTRUATION.
Dyspareunia Dyspareunia means painful or difficult COITUS. In women the
cause may be physical for
example, due to local inflammation or infection in the vagina or psychological;
say, a fear of
intercourse. In men the cause is usually physical, such as prostatitis (see PROS
TATE, DISEASES OF) or a
tight foreskin (see PREPUCE).
Dyspepsia This is another name for indigestion. It describes a sensation
of pain or discomfort in the
upper abdomen or lower chest following eating. There may be additional symptoms
of heartburn, flatulence,
or nausea. There are many causes of dyspepsia including oesophagitis (see OESOPH
AGUS, DISEASES OF), PEPTIC
ULCER, gallstones (see under GALL-BLADDER, DISEASES OF), HIATUS HERNIA, malignan
cy of the stomach or
oesophagus, and hepatic or pancreatic disease. Occasionally it may be psychologi
cal in origin. Treatment
depends on the underlying cause but, if there is no specific pathology, avoidanc
e of precipitating foods
may be helpful. ANTACIDS may relieve discomfort and pain if taken when symptoms
occur or are expected.
ficulties in understanding language and in selfexpression, most frequent
ly after STROKE or other brain
damage. When there is a total loss in the ability to communicate through speech
or writing, it is known as
global aphasia. Many more individuals have a partial understanding of what is sa
id to them; they are also
able to put their own thoughts into words to some extent. The general term for t
his less severe condition
is dysphasia. Individuals vary widely, but in general there are two main types o
f dysphasia. Some people
may have a good understanding of spoken language but have difficulty in self-exp
ression; this is called
expressive or motor dysphasia. Others may have a very poor ability to understand
speech, but will have a
considerable spoken output consisting of jargon words; this is known as receptiv
e or sensory dysphasia.
Similar difficulties may occur with reading, and this is called DYSLEXIA (a term
Dysuria
Dysrhythmia
217
Disturbance in the rhythmical contractions of the heart. It is also call
ed ARRHYTHMIA.
with LEVODOPA. Particularly in paediatric practice this drug will often
be tried on a child with
dystonia.
Dystocia
Dystrophia Myotonica
Slow or painful birth of a child. This may occur because the baby is lar
ge and/or the mothers pelvis
is small or wrongly shaped for the baby to pass through easily. Abnormal present
ation of the baby is
another cause (see PREGNANCY AND LABOUR; BREECH PRESENTATION).
Dystonia Dystonia refers to a type of involuntary movement characterised
by a sustained muscle
contraction, frequently causing twisting and repetitive movements or abnormal po
stures, and caused by
inappropriate instructions from the brain. It is sometimes called torsion spasm,
and may be synonymous with
ATHETOSIS when the extremities are involved. Often the condition is of unknown c
ause (idiopathic), but an
inherited predisposition is increasingly recognised among some cases. Others may
be associated with known
pathology of the brain such as CEREBRAL PALSY or WILSONS DISEASE.
The presentation of dystonia may be focal (usually in adults) causing bl
epharospasm (forceful eye
closure), oromandibular dystonia (spasms of the tongue and jaw), cranial dystoni
a/Meige syndrome/Brueghels
syndrome (eyes and jaw both involved), spastic or spasmodic dysphonia/laryngeal
dystonia (strained or
whispering speech), spasmodic dysphagia (difficulty swallowing), spasmodic torti
/latero/ ante/retrocollis
(rotation, sideways, forward or backward tilting of the neck), dystonic writers c
ramp or axial dystonia
(spasms deviating the torso). Foot dystonia occurs almost exclusively in childre
n and adolescents. In
adults, the condition usually remains focal or involves at most an adjacent body
part. In children, it may
spread to become generalised. The condition has always been considered rare, but
commonly is either not
diagnosed or mistakenly thought to be of psychological origin. It may, in fact,
be half as common as
MULTIPLE SCLEROSIS (MS). Similar features can occur in some subjects treated wit
h major tranquillising
drugs, in whom a predisposition to develop dystonia may be present. One rare for
m, called dopa-responsive
dystonia, can be largely abolished by treatment
A type of muscular dystrophy (see MUSCLES, DISORDERS OF) in which the af
E Ear
The ear is concerned with two functions. The more evident is that of the
sense of hearing; the other is
the sense of equilibration and of motion. The organ is divided into three parts:
(1) the external ear,
consisting of the auricle on the surface of the head, and the tube which leads i
nwards to the drum; (2) the
middle ear, separated from the former by the tympanic membrane or drum, and from
the internal ear by two
other membranes, but communicating with the throat by the Eustachian tube; and (
3) the internal ear,
comprising the complicated labyrinth from which runs the vestibulocochlear nerve
into the brain.
External ear The auricle or pinna consists of a framework of elastic car
tilage covered by skin, the
lobule at the lower end being a small mass of fat. From the bottom of the concha
the external auditory (or
acoustic) meatus runs inwards for 25 mm (1 inch), to end blindly at the drum. Th
e outer half of the passage
is surrounded by cartilage, lined by skin, on which are placed fine hairs pointi
ng outwards, and glands
secreting a small amount of wax. In the inner half, the skin is smooth and lies
directly upon the temporal
bone, in the substance of which the whole hearing apparatus is enclosed.
Middle ear The tympanic membrane, forming the drum, is stretched complet
ely across the end of the
passage. It is about 8 mm (one-third of an inch) across, very thin, and white or
pale pink in colour, so
that it is partly transparent and some of the contents of the middle ear shine t
hrough it. The cavity of
the middle ear is about 8 mm (one-third of an inch) wide and 4 mm (one-sixth of
an inch) in depth from the
tympanic membrane to the inner wall of bone. Its important contents are three sm
all bones the malleus
(hammer), incus (anvil) and stapes (stirrup) collectively known as the auditory
ossicles, with two minute
muscles which regulate their movements, and the chorda tympani nerve which runs
across the cavity. These
three bones form a chain across the middle ear, connecting the drum with the int
ernal ear. Their function
is to convert the air-waves, which strike upon the drum, into mechanical movements which can affect the fluid in the inner ear. The middle ear has tw
o connections which are of
great importance as regards disease (see EAR, DISEASES OF). In front, it communi
cates by a passage 37 mm
(1.5 inches) long the Eustachian (or auditory) tube with the upper part of the t
hroat, behind the nose;
behind and above, it opens into a cavity known as the mastoid antrum. The Eustac
hian tube admits air from
the throat, and so keeps the pressure on both sides of the drum fairly equal.
Internal ear This consists of a complex system of hollows in the substan
ce of the temporal bone
enclosing a membranous duplicate. Between the membrane and the bone is a fluid k
nown as perilymph, while
the membrane is distended by another collection of fluid known as endolymph. Thi
s membranous labyrinth, as
it is called, consists of two parts. The hinder part, comprising a sac (the utri
cle) and three short
semicircular canals opening at each end into it, is the part concerned with the
balancing sense; the
forward part consists of another small bag (the saccule), and of a still more im
portant part, the cochlear
duct, and is the part concerned with hearing. In the cochlear duct is placed the
spiral organ of Corti, on
which sound-waves are finally received and by which the sounds are communicated
to the cochlear nerve, a
branch of the vestibulocochlear nerve, which ends in filaments to this organ of
Corti. The essential parts
in the organ of Corti are a double row of rods and several rows of cells furnish
ed with fine hairs of
varying length which respond to differing sound frequencies.
The act of hearing When sound-waves in the air reach the ear, the
s alternately pressed in and
pulled out, in consequence of which a to-and-fro movement is communicated
chain of ossicles. The
foot of the stapes communicates these movements to the perilymph. Finally
motions reach the delicate
filaments placed in the organ of Corti, and so affect the auditory nerve,
conveys impressions to the
centre in the brain.
drum i
to the
these
which
Ear, Diseases of Diseases may affect the EAR alone or as part of a more
generalised condition. The
disease may affect the outer, middle or inner ear or a combination of these.
Examination of the ear includes inspection of the external ear. An auris
cope is used to
Nose & Throat) surgeon and topical antibiotic or antifungal agents along with re
moval of any
precipitating cause are the usual treatments. TUMOURS of the ear can arise in th
e skin of the auricle,
often as a result of exposure to sunlight, and can be benign or malignant. Withi
n the ear canal itself, the
commonest tumours are benign outgrowths from the surrounding bone, said to occur
in swimmers as a result of
repeated exposure to cold water. Polyps may result from chronic infection of the
ear canal and drum,
particularly in the presence of a perforation. These polyps are soft and may be
large enough to fill the
ear canal, but may shrink considerably after treatment of the associated infecti
on. CHRONIC OTITIS EXTERNA
Diseases of the middle ear or infection of the middle ear, usually occur
s as a result of infection
spreading up the Eustachian tubes from the nose, throat or sinuses. It may follo
w a cold, tonsillitis or
sinusitis, and may also be caused by swimming and diving where water and infecte
d secretions are forced up
the Eustachian tube into the middle ear. Primarily it is a disease of children,
with as many as 1.5 million
cases occurring in Britain every year. Pain may be intense and throbbing or shar
p in character. The
condition is accompanied by deafness, fever and often TINNITUS. In infants, cryi
ng may be the only sign
that something is wrong though this is usually accompanied by some localising ma
nifestation such as
rubbing or pulling at the ear. Examination of the ear usually reveals redness, a
nd sometimes bulging, of
the ear drum. In the early stages there is no discharge, but in the later stages
there may be a discharge
from perforation of the ear drum as a result of the pressure created in the midd
le ear by the accumulated
pus. This is usually accompanied by an immediate reduction in pain. Treatment co
nsists of the immediate
administration of an antibiotic, usually one of the penicillins (e.g. amoxicilli
n). In the majority of
cases no further treatment is required, but if this does not quickly bring relie
f then it may be necessary
to perform a myringotomy, or incision of the ear drum, to drain pus from the mid
dle ear. When otitis media
is treated OTITIS MEDIA
otosclerosis affects about one person in 200; it customarily occurs early in adu
lt life. An overgrowth of
bone fixes the stapes (the innermost bone of the middle ear) and stops sound vib
rations from being
transmitted to the inner ear. The result is conductive deafness. The disorder us
ually affects both ears.
Those affected tend to talk quietly and deafness increases over a 1015 year perio
d. Tinnitus often occurs,
and occasionally vertigo. Abnormal hearing tests point to the diagnosis; the dea
fness may be partially
overcome with a hearing aid but surgery is eventually needed. This involves repl
acing the stapes bone with
a synthetic substitute (stapedectomy). (See also OTIC BAROTRAUMA.)
Eating Disorders The term eating disorders covers OBESITY, feeding problem
s in childhood, anorexia
nervosa, and bulimia nervosa. The latter two are described here.
Anorexia
nervosa Often called the slimmers disease, this is a syndrome characteris
ed by the loss of at least a
quarter of a persons normal body weight; by fear of normal weight; and, in women,
by AMENORRHOEA. An
individuals body image may be distorted so that the sufferer cannot judge real we
ight and wants to diet
even when already very thin. Anorexia nervosa usually begins in adolescence, aff
ecting about 12 per cent
of teenagers and college students at any time. It is 20 times more common among
women than men. Up to 10
per cent of sufferers sisters also have the syndrome. Anorexia may be linked with
episodes of bulimia (see
below). The symptoms result from secretive selfstarvation, usually with excessiv
e exercise, selfinduced
vomiting, and misuse of laxatives. An anorexic (or anorectic) person may wear la
yers of baggy clothes to
keep warm and to hide the figure. Starvation can cause serious problems such as
ANAEMIA, low blood
pressure, slow heart rate, swollen ankles, and osteoporosis. Sudden death from h
eart ARRHYTHMIA may occur,
particularly if the sufferer misuses DIURETICS to lose weight and also depletes
the bodys level of
potassium.
E
Ecstasy
Echinococcus The immature form of a small tapeworm, Taenia echinococcus,
found in dogs, wolves and
jackals and from which human beings become infected, so that they harbour the im
mature parasite in the form
known as hydatid cyst. (See TAENIASIS.)
Echocardiography The use of ultrasonics (see ULTRASOUND) for the purpose
of examining the HEART. By
thus recording the echo (hence the name) from the heart of ultrasound waves, it
is possible to study, for
example, the movements of the heart valves as well as the state of the interior
of the heart. Safe,
reliable and painless, the procedure cuts the need for the physically interventi
onist procedure of CARDIAC
CATHETERISATION.
Echolalia Echolalia is the meaningless repetition, by a person suffering
from mental deterioration, of
words and phrases addressed to him/her.
Echoviruses Echoviruses, of which there are more than 30 known types, oc
cur in all parts of the world.
Their full name is Enteric Cytopathogenic Human Orphan (ECHO hence the acronym).
They are more common in
children than in adults, and have been responsible for outbreaks of MENINGITIS,
common-cold-like illnesses,
gastrointestinal infections, and infections of the respiratory tract. They are p
articularly dangerous when
they infect premature infants, and there have been several outbreaks of such inf
ection in neonatal units,
in which premature infants and other seriously ill small babies are nursed. The
virus is introduced to such
units by mothers, staff and visitors who are unaware that they are carriers of t
he virus.
Eclampsia A rare disorder in which convulsions occur during late pregnan
cy (see also PREGNANCY AND
LABOUR Increased blood pressure). This condition occurs in around 50 out of ever
y 100,000 pregnant women,
especially in the later months and at the time of delivery, but in a few cases o
nly after delivery has
taken place. The cause is not known, although cerebral OEDEMA is thought to occu
r. In practically all cases
the KIDNEYS are profoundly affected. Effective antenatal care should identify mo
st women at risk of
developing eclampsia.
223
Symptoms Warning symptoms include dizziness, headache, oedema, vomiting,
and the secretion of albumin
(protein) in the urine. These are normally accompanied by a rise in blood pressu
re, which can be severe.
Preeclamptic symptoms may be present for some days or weeks before the seizure t
akes place, and, if a woman
is found to have these during antenatal care, preventive measures must be taken.
Untreated, CONVULSIONS and
unconsciousness are very likely, with serious migraine-like frontal headache and
224 ECT
E
endogenous CATECHOLAMINES and produces central and peripheral sympatheti
c stimulation of alpha and beta
ADRENERGIC RECEPTORS. It is taken into nerve terminals by the serotonin transpor
ter and causes release of
the NEUROTRANSMITTER substances serotonin and dopamine. Following this, SEROTONI
N depletion is prolonged.
As serotonin plays a major part in mood control, this leads to the characteristi
c midweek depression
experienced by MDMA users. Several fatalities in young people have been attribut
ed to adverse reactions
resulting from MDMA use/abuse and possibly accompanying alcohol consumption. The
principal effects are
increase in pulse, blood pressure, temperature and respiratory rate. Additional
complications such as
cardiac ARRHYTHMIA, heatstroke-type syndrome, HYPONATRAEMIA and brain haemorrhag
e may occur. There is also
concern over possible effects on the mental concentration and memory of those us
ing ecstasy. Management of
patients who get to hospital is largely symptomatic and supportive but may inclu
de gastric decontamination,
and use of DIAZEPAM as the first line of treatment as it reduces central stimula
tion which may also reduce
TACHYCARDIA, HYPERTENSION and PYREXIA.
ECT See ELECTROCONVULSIVE THERAPY (ECT).
Ectasia A term that means widening, usually referring to a disorder of a
duct bearing secretions from a
gland or organ (e.g. mammary duct ectasia).
Ecthyma In debilitated or immunodepressed subjects, staphylococcal IMPET
IGO or folliculitis
(inflammation of hair follicles [see SKIN]) may become ulcerated. This is called
ecthyma and is seen in
vagrants, drug addicts, and individuals with AIDS/HIV or uncontrolled DIABETES M
ELLITUS.
EctoEcto- is a prefix meaning on the outside.
Ectoderm The outer of the three germ layers of the EMBRYO during its ear
ly development. The ectoderm
develops into the nervous systems, organs of sensation, teeth and lining of mout
h, and the SKIN and its
associated structures such as hair and nails.
Ectopic Ectopic means out of the usual place. For example, the congenita
l displacement of the heart
outside the thoracic cavity is said to be ectopic. An ectopic gestation means a pr
egnancy outside of the
womb (see ECTOPIC PREGNANCY).
Ectopic Beat A heart muscle contraction that is outside the normal seque
nce of the cardiac cycle (see
HEART). The impulse is generated outside the usual focus of the SINOATRIAL NODE.
Also known as
extrasystoles, ectopic beats are called ventricular if they arise from a focus i
Electrical Injuries
225
Eczema
Egg
See DERMATITIS.
See OVUM.
Edentulous
Ego
Lacking teeth: this may be because teeth have not developed or because t
hey have been removed or fallen
out.
A psychoanalytical term to describe that part of the mind which develops
as a result of the
individuals interactions with the outside world. Freud (see FREUDIAN THEORY) desc
ribes the Ego as
reconciling the demands of the Id (a persons unconscious, instinctive mind), the
Superego (moral
conscience) and the reality of the outside world.
EDTA Ethylenediamine tetra-acetic acid is used to treat poisoning with m
etals such as lead and
strontium. One of the CHELATING AGENTS, EDTA is used in the form of sodium or ca
lcium salts. The stable
chelate compounds resulting from the treatment are excreted in the urine.
Eisenmenger Syndrome
A drug known as a non-nucleoside reverse transcriptase inhibitor, used i
n the treatment of HIV
infection in combination with other antiretroviral drugs (see VIRUSES; AIDS/HIV)
. It should not be used in
patients with severe kidney impairment or liver damage. Pregnant women and older
people should not take
efavirenz. The drug has a wide range of side-effects.
A condition in which the subject suffers from a defect in one of the div
iding walls (septum) of the
HEART and this is accompanied by PULMONARY HYPERTENSION. The defect allows blood
low in oxygen to flow from
the right to the left side of the heart and be pumped into the aorta, which norm
ally carries oxygenated
blood to the body. The patient has a dusky blue appearance, becomes breathless a
nd has a severely
restricted exercise tolerance. There is an increase in red blood cells as the bo
dy attempts to compensate
for the lowered oxygen delivery. The condition may be avoided by early surgical
repair of the septal
defect, but once it is evident, surgery may not be possible.
Efferent
Ejaculation
The term applied to vessels which convey away blood or a secretion from
a body part, or to nerves which
carry nerve impulses outwards from the nerve-centres. (Opposite: AFFERENT.)
The expulsion of SEMEN from the PENIS during ORGASM. The stimulation of
sexual intercourse (coitus) or
masturbation produces a spinal reflex action that causes ejaculation. As well as
containing spermatozoa
(male germ cells), the semen comprises several constituents arising from COWPERS
GLANDS, the PROSTATE
GLAND, the testicles and seminal vesicles (see TESTICLES) and these are discharg
ed in sequence. (See also
PREMATURE EJACULATION.)
EEG See ELECTROENCEPHALOGRAPHY (EEG).
Efavirenz
Effort Syndrome Also known as Da Costas syndrome, this is a condition in
which symptoms occur, such as
palpitations and shortness of breath, which are attributed by the patient to dis
order of the heart. There
is no evidence, however, of heart disease, and psychological factors are thought
to be of importance. (See
PSYCHOSOMATIC DISEASES.)
Effusion The passage of fluid through the walls of a blood vessel into a
tissue or body cavity. It
commonly occurs as a result of inflammation or damage to the blood vessel. A ple
ural effusion may occur in
heart failure (as a result of increased blood pressure in the veins forcing out
fluid) or as a result of
inflammation in the lung tissue (PNEUMONIA). Effusions may also develop in damag
ed joints.
Elastic Tissue CONNECTIVE TISSUE which contains a profusion of yellow el
astic fibres. Long, slender and
branching, these fibres (made up of elastin, an albumin-like PROTEIN) ensure tha
t the elastic tissue is
flexible and stretchable. The dermis layer of the skin, arterial walls and the a
lveolar walls in the LUNGS
all contain elastic tissue.
Electrical Injuries These are usually caused by the passage through the
body of an electric current of
high voltage owing to accidental contact with a live wire or to a discharge of l
ightning. The general
effects produced are included under the term electric
E
electric potential
current, but when
heart. This can be
an electro-
Electrolytes
Electrocardiography A method of recording the electrical activity of the
heart muscles. Electrodes from
a recording machine (electrocardiograph) are placed on the skin of the chest wal
l, arms and legs. The
record of the electrical changes is called an ECG (electrocardiogram). The numbe
r of electrodes used
depends on the complexity of the heart disorder being monitored. The procedure c
an be done in hospital,
doctors surgeries and the patients home, and should not cause any discomfort. In c
ertain circumstances
for example, where a person has had bouts of chest pain an exercise ECG may be p
erformed under medical
supervision. The patient walks on a treadmill while the ECG is recorded continuo
usly.
Electrocautery The use of an electrically heated needle or loop to destr
oy diseased or unwanted tissue.
Benign growths, warts and polyps can be removed with this technique.
Electrocoagulation A method of sealing blood vessels using heat generate
d by high-frequency electric
current through fine needles or a surgical knife. The procedure is used during s
urgery to close newly cut
vessels. It can also be used to stop nosebleeds and to remove vascular deformiti
es such as naevi (see
NAEVUS).
Electrocochleography Electrocochleography is a method of recording the a
ctivity of the cochlea, the
part of the inner ear concerned with hearing. (See EAR.)
Electroconvulsive Therapy (ECT) A controversial but sometimes rapidly ef
fective treatment for cases of
severe DEPRESSION, particularly where psychotic features are present (see PSYCHO
SIS), or in high-risk
patients such as suicidal or post-partum patients. ECT is only indicated after a
ntidepressants have been
tried and shown to be ineffective; the full procedure of treatment should be exp
lained to the patient,
whose consent must be obtained. Before treatment, the patient will have been fas
ted for at least eight
hours. After checking for any potential drug ALLERGY or interactions, the patien
t is given a general
anaesthetic and muscle relaxants. Depending on the side of the patients dominance
, either unilateral (on
the side of the non-dominant hemisphere of the BRAIN) or bilateral (if dominance
is uncertain, e.g. in
left-handed people) positioning of elec227
trodes is used. Unilateral ECT has the advantage of being associated wit
h less anterograde AMNESIA.
When the current passes, the muscles will contract for approximately 10 seconds,
with further tonic spasms
lasting up to a minute. The patient should then be put in the COMA or recovery p
osition and observed until
fully conscious. Up to 12 treatments may be given over a month, improvement usua
rence of CONGENITAL
deformities.
Embryo Research When a woman is treated for infertility it is necessary
to nurture human embryos for a
few days (until the first cell divisions of the fertilised egg have occurred) in
a specialised laboratory.
More eggs are fertilised than are usually needed because not all fertilisations
are successful. Surplus
embryos may be frozen for use in later attempts to implant an embryo in the womb
. Research has been done on
very early embryos but the practice is controversial and some countries have eit
her forbidden it or imposed
tight restrictions. In the UK such research is controlled by the government Huma
n Fertilisation &
Embryology Authority (see ASSISTED CONCEPTION).
Embryo Transfer Embryo transfer is the process whereby the initial stage
s of procreation are produced
outside the human body and completed in the uterus or womb. The procedure is als
o known as embryo
transplantation and in vitro fertilisation (IVF). It consists of extracting an ovum
(or egg) from the
prospective mothers body and placing this in a dish where it is mixed with the ma
le partners SEMEN and
special nutrient fluids. After the ovum is fertilised by the sperm it is transfe
rred to another dish
containing a special nutrient solution. Here it is left for several days while t
he normal early stages of
development (see FETUS) take place. The early EMBRYO, as it has then become, is
then implanted in the
mothers uterus, where it takes root and develops as a normal fetus. The first test-t
ube baby to use
the popular, and widely used, term for such a child was born by CAESAREAN SECTIO
N in England on 25 July
1978. Many other children conceived in this manner have since been born, and, th
ough only 10 per cent of
women conceive at the first attempt, the overall success rate is improving. Embr
yo transplantation and
research are controversial procedures and in many countries,
E
230 Emergency
including the UK, are controlled by legislation. Embryo transfer and res
earch using embryos are
regulated by the Human Fertilisation & Embryology Authority (see ASSISTED CONCEP
TION; APPENDIX 7: STATUTORY
ORGANISATIONS).
Emergency E
A condition that needs urgent medical care. Examples include life-threat
ening injuries involving blood
loss or damage to major organs, cardiac arrest or sudden loss of consciousness f
rom, say, a blow or an
epileptic fit. Emergency is a term also applied to any resuscitative procedure t
hat must be undertaken
immediately for instance, cardiopulmonary resuscitation (see APPENDIX 1: BASIC F
IRST AID
Cardiac/respiratory arrest) or TRACHEOSTOMY. Patients with an emergency conditio
n may initially be treated
on the spot by suitably qualified paramedical staff before being transported by
road or air ambulance to a
hospital Accident and Emergency department, also known as an A&E or Casualty dep
artment. These departments
are staffed by doctors and nurses experienced in dealing with emergencies; their
first job when an
emergency arrives is to conduct a TRIAGE assessment to decide the seriousness of
the emergency and what
priority the patient should be given in the context of other patients needing em
ergency care. As their
title shows, A&E departments (and the 999 and 112 telephone lines) are for patie
nts who are genuine
emergencies: namely, critical or life-threatening circumstances such as: unconsc
iousness. serious loss of
blood. suspected broken bones. deep wound(s) such as a knife wound. suspected he
art attack. difficulty in
breathing. suspected injury to brain, chest or abdominal organs. fits. To help p
eople decide which medical
service is most appropriate for them (or someone they are caring for or helping)
, the following questions
should be answered: Could the symptoms be treated with an overthe-counter (OTC)
medicine? If so, visit a
pharmacist. Does the situation seem urgent? If so, call NHS Direct or the GP for
telephone advice, and a
surgery appointment may be the best action. Is the injured or ill person an obvi
ous emergency (see above)?
If so, go to the local A&E department or call 999 for an ambu
lance, and be ready to give the name of the person involved, a brief des
cription of the emergency and
the place where it has occurred.
Emesis Emesis means VOMITING.
Emetics An emetic is a substance which induces VOMITING (emesis). Emetic
s were previously used for gut
decontamination in the treatment of poisoning but are now considered obsolete. T
his is because the efficacy
Empyema
power is accurately adjusted for parallel rays, so that vision is perfec
t for distant objects.
Emollients Emollients are substances which have a softening and soothing
effect upon the skin. They
include dusting powders such as French chalk, oils such as olive oil and almond
oil, and fats such as the
various pharmacopoeial preparations of paraffin, suet, and lard. Glycerin is als
o an excellent emollient.
Uses They are used in various inflammatory conditions such as eczema (se
e DERMATITIS), when the skin
becomes hard, cracked, and painful. They may be used in the form of a dusting po
wder, an oil or an
ointment.
Emotion Mental arousal that the individual may find enjoyable or unpleas
ant. The three components are
subjective, physiological and behavioural. The instinctive fear and flee respons
e in animals comprises
physiological reaction raised heart rate, pallor and sweating to an unpleasant e
vent or stimulus. The
loving relationship between mother and child is another wellrecognised emotional
event. If this emotional
bond is absent or inadequate, the child may suffer emotional deprivation, which
can be the trigger for
behavioural problems ranging from attention-craving to aggression. Emotional pro
blems are common in human
society, covering a wide spectrum of psychological disturbances. Upbringing, rel
ationships or psychiatric
illnesses such as anxiety and DEPRESSION may all contribute to the development o
f emotional problems (see
MENTAL ILLNESS).
Empathy The facility to understand and be sympathetic to the feelings an
d thoughts of another
individual. Empathy in the therapist is an essential component of successful psy
chotherapy and is a
valuable characteristic in anyone who is a member of a caring profession.
Emphysema The presence of air in the bodys tissues. Divided into two type
s, surgical and pulmonary
emphysema, the former occurs when air escapes from leaks in the LUNGS and OESOPH
AGUS perhaps as the
result of injury or infection and collects in the tissues of the chest and neck.
Air occasionally escapes
into other tissues as a result of surgery or injury, and bacterial infection can
also produce gas in soft
tissues (see gas gangrene under GANGRENE). Air or gas gives the affected
231
tissue an unmistakable crackling feel when touched. X-rays of an affecte
d area will usually show the
presence of air. Such air is generally absorbed by the body when the leak has be
en sealed. The second type
of emphysema affects the lung tissue and is called pulmonary emphysema. It is no
w grouped with other lung
disorders such as chronic BRONCHITIS and some types of ASTHMA under the umbrella
heading CHRONIC
OBSTRUCTIVE PULMONARY DISEASE (COPD). See under this entry for further
information.
Empirical Method of treatment founded simply on experience rather than o
n scientific evidence from, for
example, clinical trials. Because a given remedy has been successful in the trea
tment of a certain group of
symptoms, it is assumed, by those who uphold this principle, that it will be suc
cessful in the treatment of
other cases presenting similar groups of symptoms, without any inquiry as to the
cause of the symptoms or
reason underlying the action of the remedy. It is the contrary of rational or scien
tific treatment.
Sometimes empirical treatment is a reasonable course of action where there is no
known proven effective
treatment for a condition.
Empyema An accumulation of PUS within a cavity, the term being generally
reserved for collections of
pus within one of the pleural cavities (see LUNGS). Since the advent of antibiot
ics, the condition is
relatively uncommon in developed countries. The condition is virtually an ABSCES
S, and therefore gives rise
to the general symptoms accompanying that condition. However, on account of the
thick, unyielding wall of
the chest, it is unlikely to burst through the surface, and therefore it is of p
articular importance that
the condition should be recognised early and treated adequately. The condition m
ost commonly follows an
attack of PNEUMONIA; it may also occur in the advanced stage of pulmonary TUBERC
ULOSIS. Empyema also occurs
at times through infection from some serious disease in neighbouring organs, suc
h as cancer of the GULLET,
or follows upon wounds penetrating the chest wall. Treatment may be by surgery o
r by drainage through a
tube inserted into the pleural cavity, combined with instillation of agents whic
h break down the
secretions.
E
232 Emulsions
Emulsions Emulsions are oil-in-water or water-in-oil dispersions. Therap
eutic emulsions (creams)
require an added stabilising substance.
Enamel See TEETH.
Encephalin E
A naturally occurring brain PEPTIDE, the effects of which resemble those
of MORPHINE or other opiates
(see ENDORPHINS; ENKEPHALINS).
Encephalitis Encephalitis means inflammation or infection of the brain,
usually caused by a virus; it
may also be the result of bacterial infection. It occurs throughout the world an
d affects all racial groups
and ages. Rarely it occurs as a complication of common viral disease such as mea
sles, mumps, glandular
fever, or chickenpox. It may occur with no evidence of infection elsewhere, such
as in HERPES SIMPLEX
encephalitis, the most common form seen in Europe and America. RABIES is another
form of viral
encephalitis, and the HIV virus which causes AIDS invades the brain to cause ano
ther form of encephalitis
(see AIDS/HIV). In some countries North and South America, Japan and east Asia a
nd Russia there may be
epidemics spread by the bite of mosquitoes or ticks. The clinical features begin
with influenzalike
symptoms aches, temperature and wretchedness; then the patient develops a headac
he with drowsiness,
confusion and neck stiffness. Severely ill patients develop changes in behaviour
, abnormalities of speech,
and deterioration, sometimes with epileptic seizures. Some develop paralysis and
memory loss. CT (see
COMPUTED TOMOGRAPHY) and MRI brain scans show brain swelling, and damage to the
temporal lobes if the
herpes virus is involved. ELECTROENCEPHALOGRAPHY (EEG), which records the brainw
aves, is abnormal.
Diagnosis is possible by an examination of the blood or other body fluids for an
tibody reaction to the
virus, and modern laboratory techniques are very specific. In general, drugs are
not effective against
viruses antibiotics are of no use. Herpes encephalitis does respond to treatment
with the antiviral
agent, aciclovir. Treatment is supportive: patients should be given painkillers,
and fluid replacement
drugs to reduce brain swelling and counter epilepsy if it occurs. Fortunately, m
ost sufferers from
encephalitis make a complete recovery, but some are left severely disabled with
physical defects,
personality and memory
disturbance, and epileptic fits. Rabies is always fatal and the changes
found in patients with AIDS are
almost always progressive. Except in very specific circumstances, it is not poss
ible to be immunised
against encephalitis. Encephalitis lethargica is one, now rare, variety that rea
ched epidemic levels after
Endoscopy
235
parathyroid hormone (see above), regulates the bodys calcium balance. Def
iciencies in thyroid function
produce HYPOTHYROIDISM and, in children, retarded development. Excess thyroid ac
tivity causes
thyrotoxicosis. (See THYROID GLAND, DISEASES OF.)
End Organ
Endocrinology
Peptides (see PEPTIDE) produced in the brain which have a pain-relieving
action; hence their
alternative name of opiate peptides. Their name is derived from endogenous MORPH
INE. They have been defined
as endogenous opiates or any naturally occurring substances in the brain with ph
armacological actions
resembling opiate alkaloids such as morphine. There is some evidence that the pa
in-relieving action of
ACUPUNCTURE may be due to the release of these opiate peptides. It has also been
suggested that they may
have an antipsychotic action and therefore be of value in the treatment of major
psychotic illnesses such
as SCHIZOPHRENIA.
The study of the endocrine system, the substances (hormones) it secretes
and its disorders (see
ENDOCRINE GLANDS.)
Endoderm The inner layer of the three germ layers of the EMBRYO during i
ts early development. The
endoderm develops into the lining of the gastrointestinal tract and associated g
lands (LIVER; gall-bladder
see LIVER; PANCREAS), the lining of the bronchi and alveoli of the LUNGS and muc
h of the URINARY TRACT.
Endogenous Coming from within the body. Endogenous depression, for insta
nce, occurs as a result of
causes inside a person.
Endolymph The fluid that fills the membranous labyrinth of the inner ear
(see EAR).
Endometriosis The condition in which the endometrium (the cells lining t
he interior of the UTERUS) is
found in other parts of the body. The most common site of such misplaced endomet
rium is the muscle of the
uterus. The next most common site is the ovary (see OVARIES), followed by the PE
RITONEUM lining the PELVIS,
but it also occurs anywhere in the bowel. The cause is not known. Endometriosis
never occurs before puberty
and seldom after the menopause. The main symptoms it produces are MENORRHAGIA, D
YSPAREUNIA, painful
MENSTRUATION and pelvic pain. Treatment is usually by removal of the affected ar
ea, but in some cases
satisfactory results are obtained from the administration of a PROGESTOGEN such
as NORETHISTERONE,
236 Endothelium
an out-patient basis, often without the necessity for a general anaesthe
tic.
Endothelium
E
The membrane lining various
e pleura (lining the lung), the
pericardium (lining the heart), the
organs), the lymphatic
vessels, blood vessels, and joints.
thin flat cells, which
render the surface perfectly smooth
Clinical course The incubation period of enteric fever is 721 days. Early
symptoms include headache,
malaise, dry cough, constipation and a slowly rising fever. Despite the fever, t
he patients pulse rate is
often slow and he or she may have an enlarged SPLEEN. In the second week of illn
ess, organisms invade the
bloodstream again and symptoms progress. In general, symptoms of typhoid fever a
re more severe than those
of paratyphoid fever: increasing mental slowness and confusion are common, and a
more sustained high fever
is present. In some individuals, discrete red spots appear on the upper trunk (r
ose spots). By the third
week of illness the patient may become severely toxic, with marked confusion and
delirium, abdominal
distension, MYOCARDITIS, and occasionally intestinal haemorrage and/or perforati
on. Such complications may
be fatal, although they are unusual if prompt treatment is given. Symptoms impro
ve slowly into the fourth
and fifth weeks, although relapse may occur. Diagnosis Enteric fever should be c
onsidered in any traveller
or resident in an ENDEMIC area presenting with a febrile illness. The most commo
n differential diagnosis is
MALARIA. Diagnosis is usually made by isolation of the organism from cultures of
blood in the first two
weeks of illness. Later the organisms are found in the stools and urine. Serolog
ical tests for ANTIBODIES
against Salmonella typhi antigens (see ANTIGEN) (the Widal test) are less useful
due to cross-reactions
with antigens on other bacteria, and difficulties with interpretation in individ
uals immunised with typhoid
vaccines.
Treatment Where facilities are available, hospital admission is required
. Antibiotic therapy with
chloramphenicol or amoxyacillin is effective. However, the potential toxicity of
the former and the
widespread resistance that has developed to both these antibiotics has led to th
e use of QUINOLONES such as
CIPROFLOXACIN as the initial therapy for enteric fever in the UK and in areas wh
ere resistant organisms are
common. A few individuals become chronic carriers of the organisms after they ha
ve recovered from the
symptoms. These people are a potential source of spread to others and should be
excluded from occupations
that involve handling food or drinking-water.
Enuresis
239
Prolonged courses of antibiotic therapy may be required to eradicate car
riage.
part of the intestine or brought to the exterior via the abdominal wall.
Prevention Worldwide, the most important
Enterotoxin
preventive measure is improvement of sanitation and maintenance of clean
water supplies. Vaccination is
available for travellers to endemic areas.
A type of toxin (see TOXINS) that causes inflammation of the intestinal
lining and results in vomiting
and diarrhoea (see FOOD POISONING).
Enteritis
A family of VIRUSES which include the POLIOMYELITIS, COXSACKIE and ECHO
(see ECHOVIRUSES) groups of
viruses. Their importance lies in their tendency to invade the central nervous s
ystem. They receive their
name from the fact that their mode of entry into the body is through the gut.
Enteritis means inflammation of the intestines. (See DIARRHOEA; INTESTIN
E, DISEASES OF.)
Enterobiasis Infection with Enterobius vermicularis, the threadworm (or
pinworm as it is known in the
USA). It is the most common of all the intestinal parasites in Britain, and the
least harmful. The male is
about 6 mm ( inch) in length and the female about 12 mm ( inch) in length. Each re
sembles a little piece
of thread. These worms live in considerable numbers in the lower bowel, affectin
g children particularly.
They usually cause no symptoms but can result in great irritation round the anus
or within the female
genitalia, especially at night when the female worm emerges from the anus to lay
its eggs and then die. The
most effective form of treatment is either viprynium embonate or piperazine citr
ate, which needs to be
taken by the whole family. Bedclothes must then be laundered.
Enterocele A HERNIA of the bowel.
Enterogastrone A hormone derived from the mucosal lining of the small in
testine which inhibits the
movements and secretion of the stomach.
Enterokinase The ENZYME secreted in the DUODENUM and jejunum (see INTEST
INE) which converts the enzyme,
trypsinogen, secreted by the PANCREAS, into TRYPSIN. (See also DIGESTION.)
Enteroptosis A condition in which, owing to a lax condition of the mesen
teries (see MESENTERY) and
ligaments which support the intestines, the latter descend into the lower part o
f the abdominal cavity.
Enterostomy An operation by which an artificial opening is formed into t
he intestine and joined to
another
Enteroviruses
Entonox A proprietary analgesic drug taken by inhalation and comprising
half nitrous oxide and half
oxygen. It is valuable in providing relief to casualties who are in pain, as it
provides analgesia without
making them unconscious. Entonox is also used in obstetric practice to ease the
pains of childbirth.
Entropion See EYE, DISORDERS OF.
Enuresis Bed-wetting, or the involuntary passage of urine at night. It c
an occur at all ages but is a
particular problem with children and the elderly. In general, paediatricians pre
fer not to treat enuresis
much before the age of six, as it may be a normal phenomenon and usually stops a
s the child grows older.
However, when the condition persists, the child (and parents) need advice. Treat
ment is by positive
reinforcement of bladder control, alarm systems such as the pad and bell, or ocasi
onally by drugs such as
Desmopressin, which reduces night-time urinary output. Some children have an irri
table bladder and can be
helped by drugs which relieve this. Enuresis is often a result of psychological
disturbance, particularly
where family relationships are disrupted. In this circumstance medication is unl
ikely to be effective.
Constipation is a common cause of urinary incontinence and hence bed-wetting in
the elderly and should
be treated. Enuresis in the elderly may also be due to organic disease or to men
tal deterioration and
confusion. Appropriate investigation, treatment and nursing should be arranged.
(See NOCTURNAL ENURESIS.)
Advice is available from the Enuresis Resource and Information Centre (ERIC)
E
242 Epicondyle
normal in oriental races but uncommon in others, although babies may hav
e a temporary fold that
disappears. Folds are present in people with DOWNS (DOWN) SYNDROME.
Epicondyle
E
contributes to the control not only of infectious diseases but also of c
onditions such as heart disease
and cancer. Their distributions in populations can provide important pointers to
possible causes. The
relation between the environment and disease is an essential part of epidemiolog
y. (See ENVIRONMENT AND
HEALTH; PUBLIC HEALTH.)
The protuberance above a CONDYLE at the end of a bone with an articulati
ng joint for example, at the
bottom of the humerus, the bone of the upper arm.
Epidermis
Epidemic
The outer layer of the SKIN, which forms the protective covering of the
body.
Epidemic is a term applied to a disease which affects a large number of
people in a particular locality
at one time. The term is, in a sense, opposed to ENDEMIC, which means a disease
always found in the
locality in question. A disease may, however, be endemic as a rule for example,
MALARIA in swampy
districts and may become at times epidemic, when an unusually large number of pe
ople are affected. The
rapid expansion of air travel has extended the scope for the spread of epidemic
and endemic disease. An
epidemic disease is usually infectious from person to person, but not necessaril
y so since many persons in
a locality may simply be exposed to the same cause at one time; for example, out
breaks of lead-poisoning
are epidemic in this sense. The conditions which govern the outbreak of epidemic
s are poorly understood,
but include infected food supplies, such as drinking water contaminated by waste
from people with CHOLERA
or typhoid fever (see ENTERIC FEVER); milk infected with TUBERCLE bacillus; or fa
st food products
contaminated with salmonella. The migrations of certain animals, such as rats, a
re in some cases
responsible for the spread of PLAGUE, from which these animals die in great numb
ers. Certain epidemics
occur at certain seasons: for example, whooping-cough occurs in spring, whereas
measles produces two
epidemics as a rule, one in winter and one in March. Influenza, the common cold,
and other infections of
the upper respiratory tract, such as sore throat, occur predominantly in the win
ter. There is another
variation, both as regards the number of persons affected and the number who die
in successive epidemics:
the severity of successive epidemics rises and falls over periods of five or ten
years.
Epidemiology The study of disease as it affects groups of people. Origin
ating in the study of epidemics
of diseases like CHOLERA, PLAGUE and SMALLPOX, epidemiology is an important disc
ipline which
Epidermophyton A fungus infection of the skin causing WORM or tinea.
RINGEpididymis An oblong body attached to the upper part of each TESTICLE, c
omposed of convoluted vessels
and ducts, that connects the VASA EFFERENTIA to the VAS DEFERENS. Sperm cells pr
oduced in the testis pass
along the epididymis, maturing as they go, to be stored in the seminal vesicles
until EJACULATION occurs.
The epididymis may be damaged by trauma or infection resulting sometimes in ster
ility. Cysts may also
occur.
Epidural Anaesthesia See ANAESTHESIA.
Epigastrium The region lying in the middle of the ABDOMEN over the stoma
ch.
Epigenetics The science of how the activity of DNA (deoxyribonucleic aci
d, which is the fundamental
genetic material of cells) can be altered semipermanently by chemical processes
rather than by natural
MUTATION. Genes contain instructions for making proteins. The natural process of
implementing these
instructions gene expression can be altered by chemical groups attaching themsel
ves to the chemical
bases that make up a strand of DNA. This, in turn, affects the generation of pro
teins from the genes so
tagged. Some chemical groups can even stop a gene from being expressed. Recently
, research in Australia
showed that such a chemically induced alteration could be inherited, at least in
mice. This points to the
possibility that inherited epigenetic characteristics could cause inherited disea
ses in the same way that
natural genetic mutations do. These developments suggest that epigenetics will b
e an important part of
genetic studies and research. Not all geneticists, however, believe that this de
veloping
Epilepsy
243
aspect of genetics is so important and this debate will continue.
people who have a single seizure, a significant minority (20 per cent) h
ave no further attacks.
Epiglottis
Major (generalised) seizures have a
A leaf-like piece of elastic CARTILAGE covered with mucous membrane, whi
ch stands upright between the
back of the tongue and the glottis, or entrance to the LARYNX. In the act of swa
llowing, it prevents fluids
and solids from passing off the back of the tongue into the larynx.
sudden, often unprovoked onset; the patient emits a cry, then falls to t
he ground, rigid, blue, and
then twitching or jerking both sides of the body: the tonic-clonic convulsion. D
rowsiness and confusion may
last for some hours after recovering consciousness. Some experience a momentary
warning (AURA): a smell, or
sensation in the head or abdomen, vision, or dj vu.
Epiglottitis Acute epiglottitis is a septicaemic illness which includes
an acute inflammatory OEDEMA of
the EPIGLOTTIS, due to Haemophilus influenzae. It progresses very rapidly and a
child can be dangerously
ill or even die within hours of onset. Once recognised, however, it is easily an
d successfully treated by
immediate transfer to hospital for emergency intubation and ventilation and use
of antibiotics and
steroids. Fortunately it is now very rare as a result of the introduction of hae
mophilus vaccine into the
primary vaccination course of infants. (See LARYNGOTRACHEO-BRONCHITIS.)
Epignathus Maldevelopment of the FETUS in which the deformed remains of
one twin are united to the
upper jaw of the other.
Epilation Removal of hair by the roots. (See DEPILATION.)
Epilepsy (See also FIT; SEIZURE.) Epilepsy is the name given to any cond
ition in which a person suffers
repeated fits or seizures. It is present in one in 200 (05 per cent) of the popul
ation and up to 5 per
cent of all children will have had a fit by the age of 12, although most of thes
e are harmless
accompaniments of an acute feverish illness. It is a recurrent and paroxysmal di
sorder starting suddenly
and ceasing spontaneously due to occasional sudden excessive rapid and local dis
charge of the nerve cells
in the grey matter (cortex) of the BRAIN. Epilepsy always arises in this way fro
m the brain, but its origin
is often of microscopic size. It is diagnosed by the clinical symptoms based on
the observations of
witnesses. Its cause can sometimes be established by laboratory tests, and brain
244 Epiloia
can swim under supervision. Adults must avoid working at heights, with e
xposed dangerous machinery, and
driving vehicles on public roads. Current legislation allows driving after two y
ears of complete freedom
from attacks during waking hours; those who for more than three years have had a
history of attacks only
while asleep may also drive.
E
Treatment identifies, and avoids where possible, any factors (such as sh
ortage of sleep or excessive
fluids) which aggravate or trigger attacks. If fits are very infrequent, treatme
nt may not be recommended.
However, frequent fits may be embarassing, may cause injury or may cause long-te
rm brain damage so
treatment is advisable. Anti-epileptic drugs are usually necessary for several y
ears under medical
supervision. Carbamazepine and sodium valproate are the most frequently prescrib
ed. The dose is governed by
the degree of control of fits and sometimes drug levels can be monitored by bloo
d tests to check on dosage.
Strict adherence to the drug schedule gives a reasonable chance of total suppres
sion of fits, especially in
younger patients whose fits have started recently. The table summarises anticonv
ulsant drugs in use.
Interactions can occur between anti-epileptics and, if drug treatment is changed
, the patient needs careful
monitoring. In particular, abrupt withdrawal of a drug should be avoided as this
may precipitate severe
rebound seizures. Indications First-choice drugs: Ethosuximide Phenobarbitone Ph
enytoin Carbamazepine
Valproate Second-line drugs: Primidone Clobazam Vigabatrin Lamotrigine Gabapenti
n Topirimate
PM, JME M, P M, P, CP M, P, CP M, PM, JME M, P, CP M, CP M, P, CP M, P,
CP M, P, CP P
M = major generalised tonic-clonic; P = partial or focal; CP = complex p
artial (temporal lobe); PM =
petit mal; JME = juvenile myoclonic epilepsy. Anticonvulsant drugs
As all anticonvulsant drugs have an effect on the brain, it is not surpr
ising that there may be
side-effects, especially inolving alertness or behaviour. In each case careful a
ssessment is necessary for
doctor and patient to agree on the best compromise between stopping fits and avo
iding ill-effects of
medication.
Patients who have an epileptic seizure should not be restrained or have
a gag or anything else placed
in their mouths; nor should they be moved unless in danger of further injury. An
y tight clothing around the
neck should be loosened and, when the seizure has passed, the person should be p
laced in the recovery
position to facilitate a return to consciousness (see APPENDIX 1: BASIC FIRST AI
D). Patients with epilepsy
and their relatives can obtain further advice and information from the British E
pilepsy Association or
Epilepsy Action Scotland.
Epiloia See TUBEROUS SCLEROSIS.
Epiphora Inadequate drainage of tears in the eyes with the result that t
hey overflow down the cheeks.
The condition is caused by an abnormality of the tear ducts which drain away the
normal secretions that
keep the eyeball moist (see EYE).
Epiphysis See BONE
Growth of bones.
Epiphysitis Inflammation of an epiphysis (see Growth of bones).
BONE
Ergocalciferol
surface instead of at the end of the organ. Surgical correction carried
out in infancy has a high
success rate.
Epistasis (1) Stopping a flow or discharge of, for example, blood from a
wound. (2) In genetics the
term describes a type of gene action (see GENES) where a gene is able to block t
he action of another one.
Epistaxis Bleeding from the nose. (See HAEMORRHAGE.)
Epithelioma Epithelioma is a tumour of malignant nature arising in the E
PITHELIUM covering the surface
of the body. (See CANCER.)
Epithelium Epithelium is the cellular layer which forms the epidermis on
the skin, covers the inner
surface 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 another, and is one of the simpl
est tissues of the body. It
is of several forms: for example, the epidermis is formed of scaly epithelium, t
he cells being in several
layers and more or less flattened. (See SKIN.) The bowels are lined by a single
layer of columnar
epithelium, the cells being long and narrow in shape. The air passages are lined
by ciliated epithelium:
that is to say, each cell is provided with flagellae (lashes) which drive the fl
uid upon the surface of the
passages gradually upwards.
Epizotic Any disease in animals which diffuses itself widely. The term co
rresponds to the word
EPIDEMIC as applied to human beings. In plague, for example, an epizotic in rats
usually precedes the
epidemic in human beings.
245
infectious MONONUCLEOSIS. It is similar to the viruses that cause herpes
and is associated with
BURKITTS LYMPHOMA. It has been suggested as precipitating some attacks of MYALGIC
ENCEPHALOMYELITIS (ME),
also known as CHRONIC FATIGUE SYNDROME (CFS).
Eptifibitide An antiplatelet drug, best given under the supervision of a
specialist. It inhibits the
aggregation of PLATELETS in the blood that occurs in THROMBUS formation, and is
used with HEPARIN and
ASPIRIN to prevent early myocardial infarction (heart attack see HEART, DISEASES
OF) in patients with
unstable ANGINA PECTORIS.
Epulis Epulis is a term applied to any tumour connected with the jaws. (
See MOUTH, DISEASES OF.)
Equine Oestrogens See OESTROGENS.
Erbs Paralysis Erbs paralysis is a form of paralysis of the arm due to str
etching or tearing of the
fibres of the brachial nerve plexus. Such damage to the brachial plexus may occu
r during birth, especially
when the baby is unusually large, and it is found that the arm lies by the side
of the body with elbow
extended, forearm pronated, and the fingers flexed. The infant is unable to rais
e the arm.
ERCP See ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP).
Erection
A species, structure or disorder named after a particular individual, cu
stomarily the one who first
described or discovered it. The use of eponyms has been widespread in medicine,
but more descriptive and
so more practical terms are replacing them.
The rigid state of the PENIS when it responds to sexual stimulus. An ere
ction is necessary for
effective penetration of the VAGINA. As a result of sexual arousal, the three cy
linders of erectile tissue
in the penis become engorged with blood, lengthening, raising and hardening the
penis. Muscles surrounding
the blood vessels contract and retain the blood in the penis. Erections also occ
ur during sleep and in
young boys. Inability to have or maintain an erection is one cause of IMPOTENCE
(see also SILDENAFIL
CITRATE).
Epsom Salts
ErgEponym
The popular name for magnesium sulphate, which was used as a saline purg
ative.
Epstein Barr Virus The virus that causes glandular fever or
A prefix indicating activity or work.
Ergocalciferol A combination of CALCIFEROL and vitamin D2 (see APPENDIX
5: VITAMINS) given to prevent
or
E
246 Ergometrine
cure RICKETS, a deficiency disorder caused by the lack of calcium and vi
tamin D in the diet.
Ergometrine An active constituent of ergot, it has a powerful action in
controlling the excessive
bleeding from the UTERUS which may occur after childbirth. The official British
Pharmacopoeia preparation
is ergometrine maleate.
E
Ergonomics A broad science involving the application of psychological an
d physiological principles to
the study of human beings in relation to their work and working surroundings. It
includes the design of
buildings, machinery, vehicles, and anything else with which people have contact
in the course of their
work.
Ergosterol A sterol found in yeasts and fungi and in plant and animal fa
t. Under the action of sunlight
or ultraviolet rays it produces vitamin D2. The substance produced in this way i
s known as calciferol, and
is used for the prevention and cure of RICKETS and OSTEOMALACIA. A similar chang
e in the ergosterol of the
skin is produced when the body is freely exposed to sunlight. Calciferol is prob
ably not so active as, and
differs chemically from, the vitamin D occurring in fish-liver oils. (See APPEND
IX 5: VITAMINS.)
Ergot Poisoning Ergot poisoning, or ergotism, occasionally results from
eating bread made from rye
infected with the fungus, Claviceps purpurea. Several terrible epidemics (St Ant
honys Fire), characterised
by intense pain and hallucinations, occurred in France and Germany during the Mi
ddle Ages (see ERYSIPELAS).
Its symptoms are the occurrence of spasmodic muscular contractions, and the grad
ual production of gangrene
in parts like the fingers, toes and tips of the ears because of constriction of
blood vessels and therefore
the blood supply.
Ergotamine One of the alkaloids in ergot. In the form of ergotamine tart
rate it is usually given orally
to treat MIGRAINE, but treatment carries a risk and should be medically supervis
ed.
Ergotism See ERGOT POISONING.
Erogenous A term to describe those parts of the body for
example, the mouth, breasts and genitals which, when stimulated, result
in the individuals sexual
arousal.
Erosion Erosion means a process of gradual wearing down of structures in
the body. The term is applied
to the effect of tumours, when they cause destruction of tissue in their neighbo
Erythroderma
the course of a few hours. (See EASES OF.)
also SKIN, DISErysipelas A streptococcal infection (see STREPTOCOCCUS) of the skin cha
racterised by an acute onset
with fever, malaise and a striking, usually unilateral, rash (see ERUPTION) almo
st always on a lower leg or
the face. Shivering, local pain and tenderness are associated with a sharply def
ined, spreading, bright red
swollen zone of skin inflammation. On the leg, blistering and PURPURA may follow
. The bacteria enter the
skin through a fissure in a toe cleft (often associated with tinea pedis [RINGWO
RM]) or via a crack in the
skin behind an ear or in a nostril.
Treatment PENICILLIN in full dosage should be given orally for ten days.
In those allergic to
penicillin, ERYTHROMYCIN can be substituted. Recurrent attacks are common and ma
y cause progressive
lymphatic damage leading to chronic OEDEMA. Such recurrences can be prevented by
long-term prophylactic
oral penicillin. Erythema Redness of the skin due to dilatation of dermal blood
vessels. It may be
transient or chronic, localised or widespread, and it can be blanched by pressur
e. Erythema may be caused
by excessive exposure to heat or ultraviolet light, or by inflammation of the sk
in due to infection,
DERMATITIS, and various allergic reactions for example, to drugs. It may be emot
ional (e.g. as in
flushing), mediated by the autonomic nervous system.
Erythema ab igne is a fixed redness of the skin caused by chronic exposu
re to heat from a domestic fire
or radiator. Erythema pernio (See CHILBLAIN.) Redness induced by spasm of the sk
in arterioles due to cold.
It affects the hands, feet or calves in winter. The red swollen areas are cooler
than normal. Erythema
nodosum A singular pattern of red, tender nodules occurring on the shins, often
lasting several weeks. It
may be caused by a streptococcal throat infection, primary tuberculosis, SARCOID
OSIS, or may be
drug-induced.
Erythema multiforme is an acute allergic eruption of the extremities cha
racterised by circular areas of
erythema, purpura and blistering, which resolve over two or three weeks, caused
by infections or drugs. In
severe forms the
247
mucous membranes of the eyes, mouth and genitalia may be involved.
Erythema infectiosum is an acute contagious disease of children caused b
y a parvovirus (see
PARVOVIRUSES). In young children a bright erythema of the face gives a slapped ch
eek appearance.
248 Erythromelalgia
and scaly. It is also called generalised exfoliative dermatitis (see SKI
N, DISEASES OF). It may
complicate chronic eczema (see DERMATITIS) or PSORIASIS, particularly in men, in
the second half of life.
It may also result from HYPERSENSITIVITY to a drug, such as gold injections used
in RHEUMATOID ARTHRITIS.
Rarely, it may be a manifestation of T-cell LYMPHOMA.
E
Erythropoeisis The process by which ERYTHROCYTES or red blood cells are
produced. The initiating cell
is the haemopoietic stem cell from which an identifiable proerythroblast develop
s. This goes through
several stages as a normoblast before losing its nucleus to become an erythrocyt
e. This process takes place
in the blood-forming bone-marrow tissue.
Universal inflammation of the skin may cause heart failure, particularly
in elderly people with
pre-existing heart disease. It may lead to HYPOTHERMIA due to excessive heat los
s from the skin and protein
deficiency caused by the shedding of large quantities of skin scales containing
keratin. Rarely, these
complications can be fatal.
The protein, produced mainly in the kidney, that is the major stimulus f
or the production of
ERYTHROCYTES, or red blood corpuscles. It is used when treating ANAEMIA dure to
end-stage kidney failure
and in premature newborns with anaemia. (See also BLOOD.)
Treatment depends on the cause, but in
Eschar
eczematous erythroderma, oral CORTICOSTEROIDS (PREDNISOLONE) in full dos
age may be needed.
Hard adherent crust caused by tissue killed by heat, chemicals or diseas
e.
Erythromelalgia A condition in which the fingers or toes, or even larger
portions of the limbs, become
purple and bloated in appearance, and very painful. In people suffering from the
condition which is not a
common one the attacks come and go, being worse in summer (unlike chilblains), a
nd worse on exertion or
when the affected parts are warmed or allowed to hang down. The condition may ap
pear without apparent
cause, but is often associated with vascular diseases, such as HYPERTENSION and
POLYCYTHAEMIA VERA. It aso
occurs in association with certain diseases of the central nervous system, and i
n cases of metallic
poisoning (e.g. arsenic, mercury and thallium). Treatment is unsatisfactory but
aspirin provides sympomatic
relief.
Ethics
Essential Amino Acids See INDISPENSABLE AMINO ACIDS.
Essential (Benign) Hypertension See HYPERTENSION.
Essential Fatty Acids Three acids arachidonic, linolenic and tinoleic wh
ich are essential for life,
but which the body cannot produce. They are found in natural vegetable and fish
oils and their functions
are varied. EFAs have a vital function in fat metabolism and transfer and they a
re also precursors of
PROSTAGLANDINS.
Ester An organic compound formed from an alcohol and an acid by the remo
val of water.
Ethacrynic Acid A potent diuretic, with a rapid onset, and a short durat
ion (46 hours), of action.
(See THIAZIDES; DIURETICS.)
Ethambutol Ethambutol is a synthetic drug, often included in the treatme
nt regimen of TUBERCULOSIS when
the infection is thought to be resistant to other drugs. The main side-effects a
re visual disturbances,
chiefly loss of acuity and colour blindness. Such toxic effects are more common
when excessive dosages are
used, or the patient has some renal impairment, in which case the drug should be
avoided as it should be
in young children.
Ethanol Ethanol is another name for ethyl alcohol. (See ALCOHOL.)
Ether A colourless, volatile, highly inflammable liquid, formed by the a
ction of sulphuric acid on
alcohol. Ether boils below body temperature and therefore rapidly evaporates whe
n sprayed over the skin.
Dissolving many substances such as fats, oils and resins better than alcohol or
water, it is used in the
preparation of many drugs. Formerly used as an anaesthetic, it has been replaced
by safer and more
efficient drugs.
Etherified Starch Along with DEXTRAN and GELATIN, this is a substance wi
th a large molecular structure
used to treat shocked patients with burns (see BURNS AND SCALDS) or SEPTICAEMIA
in order to expand and
maintain their blood volume. Like other plasma substitutes, this form of starch
can be
249
used as an emergency, short-term treatment for severe bleeding until blo
od for transfusion is
available. Plasma substitutes must be used with caution in patients who have hea
rt disease or impairment of
their kidney function. Patients should be monitored for hypersensitivity reactio
ns and for changes in their
BLOOD PRESSURE (see SHOCK).
Ethics Within most cultures, care of the sick is seen as entailing speci
al duties, codified as a set of
moral standards governing professional practice. Although these duties have been
stated and interpreted in
differing ways, a common factor is the awareness of an imbalance of power betwee
n doctor and patient and an
acknowledgement of the vulnerability of the sick person. A function of medical e
thics is to counteract this
inevitable power imbalance by encouraging doctors to act in the best interests o
f their patients, refrain
from taking advantage of those in their care, and use their skills in a manner w
hich preserves the honour
of their profession. It has always been accepted, however, that doctors cannot u
se their knowledge
indiscriminately to fulfil patients wishes. The deliberate ending of life, for ex
ample, even at a
patients request, has usually been seen as alien to the shared values inherent in
medical ethics. It is,
however, symptomatic of changing concepts of ethics and of the growing power of
patient choice that legal
challenges have been mounted in several countries to the prohibition of EUTHANAS
IA. Thus ethics can be seen
as regulating individual doctor-patient relationships, integrating doctors withi
n a moral community of
their professional peers and reflecting societal demands for change. Medical eth
ics are embedded in
cultural values which evolve. Acceptance of abortion within well-defined legal p
arameters in some
jurisdictions is an example of how society influences the way in which perceptio
ns about ethical
obligations change. Because they are often linked to the moral views predominati
ng in society, medical
ethics cannot be seen as embodying uniform standards independent of cultural con
text. Some countries which
permit capital punishment or female genital mutilation (FGM see CIRCUMCISION), f
or example, expect
doctors to carry out such procedures. Some doctors would argue that their ethica
l obligation to minimise
pain and suffering obliges them to comply, whereas others would deem their ethic
al obligations to be the
complete opposite. The medical community attempts to address such variations by
establishE
250 Ethics
E
ing globally applicable ethical principles through debate within bodies
such as the World Medical
Association (WMA) or World Psychiatric Association (WPA). Norm-setting bodies in
creasingly reflect accepted
concepts of human rights and patient rights within professional ethical codes. P
ractical changes within
society may affect the perceived balance of power within the doctor-patient rela
tionship, and therefore
have an impact on ethics. In developed societies, for example, patients are incr
easingly well informed
about treatment options: media such as the Internet provide them with access to
specialised knowledge.
Social measures such as a well-established complaints system, procedures for leg
al redress, and guarantees
of rights such as those set out in the NHSs Patients Charter appear to reduce the
perceived imbalance in
the relationship. Law as well as ethics emphasises the importance of informed pa
tient consent and the often
legally binding nature of informed patient refusal of treatment. Ethics reflect
the changing relationship
by emphasising skills such as effective communication and generation of mutual t
rust within a doctorpatient
partnership. A widely known modern code is the WMAs International Code of Medical
Ethics which seeks to
provide a modern restatement of the Hippocratic principles. Traditionally, ethic
al codes have sought to
establish absolutist positions. The WMA code, for example, imposes an apparently
absolute duty of
confidentiality which extends beyond the patients death. Increasingly, however, e
thics are perceived as a
tool for making morally appropriate decisions in a sphere where there is rarely
one right answer. Many
factors such as current emphasis on autonomy and the individual values of patien
ts; awareness of social
and cultural diversity; and the phenomenal advance of new technology which has b
lurred some moral
distinctions about what constitutes a person have contributed to the perception th
at ethical dilemmas
have to be resolved on a case-by-case basis. An approach adopted by American eth
icists has been moral
analysis of cases using four fundamental principles: autonomy, beneficence, nonmaleficence and justice.
The four principles provide a useful framework within which ethical dilemmas can b
e teased out, but they
are criticised for their apparent simplicity in the face of complex problems and
for the fact that the
moral imperatives implicit in each principle often conflict with some or all of
the other three. As with
any other approach to problemsolving, the four principles require interpretation. Enduring ethical prec
epts such as the obligation
to benefit patients and avoid harm (beneficence and non-maleficence) may be diff
erently interpreted in
cases where prolongation of life is contrary to a patients wishes or where sentie
nce has been irrevocably
lost. In such cases, treatment may be seen as constituting a harm rather than a ben
efit. The importance
accorded to ethics in daily practice has undergone considerable development in t
he latter half of the 20th
century. From being seen mainly as a set of values passed on from experienced pr
actitioners to their
students at the bedside, medical ethics have increasingly become the domain of l
awyers, academic
philosophers and professional ethicists, although the role of experienced practi
tioners is still considered
central. In the UK, law and medical ethics increasingly interact. Judges resolve
cases on the basis of
established medical ethical guidance, and new ethical guidance draws in turn on
common-law judgements in
individual cases. The rapid increase in specialised journals, conferences and po
stgraduate courses focused
on ethics is testimony to the ever-increasing emphasis accorded to this area of
study. Multidisciplinary
practice has stimulated the growth of the new discipline of health-care ethics whi
ch seeks to provide
uniformity across long-established professional boundaries. The trend is to set
common standards for a
range of health professionals and others who may have a duty of care, such as ho
spital chaplains and
ancillary workers. Since a primary function of ethics is to find reasonable answ
ers in situations where
different interests or priorities conflict, managers and health-care purchasers
are increasingly seen as
potential partners in the effort to establish a common approach. Widely accepted
ethical values are
increasingly applied to the previously unacknowledged dilemmas of rationing scar
ce resources. In modern
debate about ethics, two important trends can be identified. As a result of the
increasingly high profile
accorded to applied ethics, there is a trend for professions not previously subj
ect to widely agreed
standards of behaviour to adopt codes of ethical practice. Business ethics or th
e ethics of management are
comparatively new. At the same time, there is some debate about whether professi
onals, such as doctors,
traditionally subject to special ethical duties, should be seen as simply doing
a job for payment like any
other worker. As some doctors perceive their power and prestige eroded by health
-care managers deciding on
Ethylene
how and when to ration care and pressure for patients to exercise autono
my about treatment decisions,
it is sometimes argued that realistic limits must be set on medical obligations.
A logical implication of
patient choice and rejection of medical paternalism would appear to be a concomi
tant reduction in the
freedom of doctors to carry out their own ethical obligations. The concept of co
nscientious objection,
incorporated to some extent in law (e.g. in relation to abortion) ensures that d
octors are not obliged to
act contrary to their own personal or professional values.
Ethics Committees (In the USA, Institutional Review Boards.) Various typ
es of ethics committee operate
in the UK, fulfilling four main functions: the monitoring of research; debate of
difficult patient cases;
establishing norms of practice; and publishing ethical guidance. The most common
Local Research Ethics
Committees (LRECs) have provided a monitoring system of research on humans since
the late 1960s.
Established by NHS health authorities, LRECs were primarily perceived as exercis
ing authority over research
carried out on NHS patients or on NHS premises or using NHS records. Their power
and significance, however,
developed considerably in the 1980s and 90s when national and international guid
ance made approval by an
appropriately constituted ethics committee obligatory for any research project inv
olving humans or human
tissue. The work of LRECs is supplemented by so-called independent ethics committe
es usually set up by
pharmaceutical companies, and since 1997 by multicentre research ethics committe
es (MRECs). An MREC is
responsible for considering all health-related research which will be conducted
within five or more
locations. LRECs have become indispensable to the conduct of research, and are d
oubtless partly responsible
for the lack of demand in the UK for legislation governing research. A plethora
of guidelines is available,
and LRECs which fail to comply with recognised standards could incur legal liabi
lity. They are increasingly
governed by international standards of practice. In 1997, guidelines produced by
the International
Committee on Harmonisation of Good Clinical Practice (ICH-GCP) were introduced i
nto the UK. These provide a
unified standard for research conducted in the European Union, Japan and United
States to ensure the mutual
acceptance of clinical data by the regulatory authorities in these countries. Ot
her categories of ethics
committee include
251
Ethics Advisory Committees, which debate difficult patient cases. Most a
re attached to specialised
health facilities such as fertility clinics or childrens care facilities. The 199
0s have seen a greatly
increased interest in professional ethics and the establishment of many new ethi
cs committees, including
some like that of the National Council for Hospice and Specialist Palliative Car
e Services which cross
professional boundaries. Guidance on professional and ethical standards is produ
ced by these new bodies and
by the well-established ethics committees of regulatory or representative bodies
, such as the medical and
nursing Royal Colleges, the General Medical Council, United Kingdom Central Coun
cil for Nursing, Midwifery
and Health Visiting, British Medical Association (see APPENDIX 8: PROFESSIONAL O
RGANISATIONS) and bodies
representing paramedics and professions supplementary to medicine. Their guidanc
e ranges from general codes
of practice to detailed analysis of single topics such as EUTHANASIA or surrogac
y. LRECs are now supervised
by a central body COREC (www.corec.gov.org.uk).
Ethinylestradiol A highly active oestrogen about 20 times more active th
an STILBOESTROL; it is active
when given by mouth. (See OESTROGENS.)
Ethmoid A bone in
e nose from the membranes
the brain. It is a spongy
the ethmoidal sinuses is
sometimes responsible for
252 Ethyloestrenol
Ethyloestrenol See ANABOLIC STEROIDS.
Etidronate
E
Also known as disodium etidronate, this is one of a group of substances
called biphosphates used mainly
to treat PAGETS DISEASE OF BONE. The drug is given orally and, when combined with
calcium carbonate
(Didrone ), it is used to treat osteoporosis (see under BONE, DISORDERS OF) and to
prevent bone loss in
postmenopausal women, especially if hormone replacement therapy (HRT see under M
ENOPAUSE) is not
appropriate.
sterile. A male castrated before puberty will have a feminine appearance
and underdeveloped secondary
sexual characteristics. The term was historically used to describe boys, castrat
ed to make them suitable
for working in harems, or boy singers, castrated to retain their higher-register
voices (castrati singers).
Euphoria
Etiology, or AETIOLOGY, means the group of conditions which form the cau
se of any disease.
A feeling of well-being. This may occur normally; for instance, when som
eone has passed an examination.
In some neurological or psychiatric conditions, however, patients may have an ex
aggerated and quite
unjustified feeling of euphoria. This is then a symptom of the underlying condit
ion. Euphoria may also be
druginduced by drugs of addiction or by therapeutic drugs such as CORTICOSTEROID
S.
Etomidate
Euphoriants
An intravenous agent for inducing general ANAESTHESIA prior to surgery o
r other procedures that require
patients to be unconscious. When the drug is injected intravenously, pain someti
mes occurs, but this can be
minimised by premedication with an opioid analgesic (see ANALGESICS).
Drugs which induce a state of well-being.
Etiology
EuA prefix meaning satisfactory or beneficial.
Eucalyptus Eucalyptus (Eucalyptus globulus) is a tree, originally a nati
ve of Australia and now grown
all over the world. Its important constituent, oil of eucalyptus, is an oil of p
leasant smell and spicy
taste, which is obtained by distillation from the leaves of the tree. The oil ma
y be used as a disinfectant
and deodorant.
Eugenics The study and cultivation of conditions that may improve the hu
man race, in particular the
detection and elimination of genetic disease.
Eukaryote A cell that has a NUCLEUS bounded by a membrane and with chrom
osomes containing DNA, RNA and
proteins. The cell divides by MITOSIS and also contains MITOCHONDRIA. Animals, p
lants and cellular
organisms made up of this type of cell are included in the biological superkingd
om of Eukaryote.
Eunuch A man whose testes (see TESTICLE) have been removed or seriously
damaged so that he is unable to
produce male hormones and thus is
EUPHORIA
or
Eustachian Tubes The passages, one on each side, leading from the throat
to the middle ear. Each is
about 38 mm (1 inches) long and is large at either end, though at its narrowest p
art it only admits a fine
probe. The tubes open widely in the act of swallowing or yawning. The opening in
to the throat is situated
just behind the lower part of the nose, so that a catheter can be passed through
the corresponding nostril
into the tube for inflation of the middle ear. (See also EAR; NOSE.)
Evolution
proposal to change the law prohibiting euthanasia in the UK. Such pragma
tic rather than ethical or
legal arguments were a key feature of the conclusions of the House of Lords Sele
ct Committee on Medical
Ethics in 1994. There has also been much debate about whether euthanasia should
attract a lesser penalty
than other forms of murder which carry a mandatory life sentence. Nevertheless,
in the UK, killing a person
intentionally is still classified as murder, even if that person consents to the
killing. Most of the
detailed information available about the practice of euthanasia comes from the N
etherlands, where court
rulings in the 1970s and 1980s began to permit voluntary euthanasia under certai
n circumstances (although
both euthanasia and assisted suicide remain technically illegal). The difficulty
of maintaining limits was
highlighted in 19945 when it became clear that a small percentage of Dutch patien
ts undergoing euthanasia
had previously expressed an interest but not specifically requested it (involunt
ary euthanasia) or had no
known desire for it and may have been opposed to it (non-voluntary euthanasia).
The relevance of terminal
illness and physical suffering was tested in Holland in 1994 when a patient rece
ived euthanasia who was not
physically ill and subject to mental rather than physical suffering. Nevertheles
s, Dutch doctors risk
prosecution if they fail to follow rules of careful conduct when carrying out eu
thanasia or assisted
suicide. (See also ETHICS; SUICIDE.)
Euthyroid The descriptive term for a person with a normally functioning
THYROID GLAND, or someone who
has had successful treatment for an underactive (hypothyroid) or overactive (hyp
erthyroid) gland.
Evacuant Evacuant is a name for a purgative medicine (see LAXATIVES).
Evacuator A device for extracting fluid from a cavity. In its basic form
it comprises a hollow flexible
bulb attached (using a valve system) to a tube inserted into the cavity. Another
valve leads to the
discharge tube. One use of an evacuator is to empty the urinary bladder of extra
neous material during
surgery for removal of CALCULI or for PROSTATECTOMY.
Evaluation See PUBLIC HEALTH.
253
Evidence See EVIDENCE-BASED MEDICINE.
Evidence-Based Medicine The process of systematically identifying, appra
ising and using the best
available research findings, integrated with clinical expertise, as the basis fo
r clinical decisions about
individual patients. The aim is to encourage clinicians, health-service managers
and consumers of health
care to make decisions, taking account of the best available evidence, on the li
kely consequences of
alternative decisions and actions. Evidence-based medicine has been developing i
nternationally for the past
25 years, but since around 1990 its development has accelerated. The Internation
al COCHRANE COLLABORATION
finds and reviews relevant research. Several other centres have been set up to l
ook at the clinical
application of research results, including the Centre for Evidence-Based Medicin
e in Oxford.
Evisceration Extrusion of the abdominal VISCERA or internal organs, usua
lly as the result of serious
injury. (Usually described as disembowelment when deliberately carried out by on
e person on another.) In
surgery the term refers to partremoval of the viscera, and in OPHTHALMOLOGY it i
s an operation to remove
the contents of the eyeball (see also EYE).
Evolution An uninterrupted process of change from one condition, form or
state to another. In
biological evolution, all varieties of living things are seen as having develope
d by inheritable,
incremental changes from unicellular structures to complex organisms such as hum
ankind. Although the
likelihood of some form of evolution had been postulated by scientists in the la
te 18th and early 19th
centuries, the prime contribution to the development of biological evolutionary
doctrine came from the
British scientist, Charles Darwin, who argued in his book The Origin of Species
by Means of Natural
Selection (1859) that natural selection resulted in the survival of the fittest
organisms. The precise
biological mechanism of evolution was not unravelled until the 20th century, wit
h the discovery of
CHROMOSOMES and GENES and the development of the science of genetics. Charles Da
rwins theory was based on
his studies of the varied and unique animal life in the Galapagos Islands in the
19th century. He believed
that the diversity of life on the planet could be ascribed to the combined effec
ts of random
E
Expectoration
Exhalation Also called expiration, this is the act of breathing air from
the lungs out through the
bronchi, trachea, mouth and nose. (See also RESPIRATION.)
Exhibitionism Public flaunting of a persons characteristics. Also a term
describing the public
exposure of genitals to another person, regarded as a form of sexual deviation,
colloquially called
flashing.
Exocrine Gland A gland that secretes its products through a duct to the
surface of the body or of an
organ. The sweat glands in the skin and the salivary glands in the mouth are exa
mples. The secretion is set
off by a hormone (see HORMONES) or a NEUROTRANSMITTER.
Exogenous Arising outside the body. For example, exogenous DEPRESSION is
an illness caused by an
outside factor such as the death of a close relative; an exogenous illness may o
ccur because of something
eaten in the diet.
Exomphalos The term applied to a congenital HERNIA formed by the project
ion of abdominal organs through
the UMBILICUS.
Exophthalmometer Also known as a proptometer. An instrument used to meas
ure the extent of protrusion of
the eyeball a development that occurs in certain disorders such as GOITRE, TUMOU
R, OEDEMA, injuries,
orbital inflammation or cavernous venous thrombosis (a blood clot in the caverno
us sinus in the base of the
skull behind each eye). (See EXOPHTHALMOS.)
Exophthalmos Exophthalmos, or PROPTOSIS, refers to forward displacement
of the eyeball and must be
distinguished from retraction of the eyelids, which causes an illusion of exopht
halmos. Lid retraction
usually results from activation of the autonomic nervous sytem. Exophthalmos is
a more serious disorder
caused by inflammatory and infiltrative changes in the retro-orbital tissues and
is essentially a feature
of Graves disease, though it has been described in chronic thyroiditis (see THYRO
ID GLAND, DISEASES OF).
Exophthalmos commonly starts shortly after the development of thyrotoxicosis but
may occur months or even
years after hyperthyroidism has been successfully treated. The degree of exophth
almos is not correlated
with the severity
255
of hyperthyroidism even when their onset is simultaneous. Some of the wo
rst examples of endocrine
exophthalmos occur in the euthyroid state and may appear in patients who have ne
ver had thyrotoxicosis;
this disorder is named ophthalmic Graves disease. The exophthalmos of Graves disea
se is due to
256 Expiration
up from the chest by the AIR act by which it is brought up.
PASSAGES,
or the
Expiration (1) Breathing out air from the lungs. (2) The act of dying.
Exploration E
A surgical operation to investigate the cause of a patients illness.
Exposure
Extinction (1) In behavioural psychology, the lessening of a conditioned
reflex that occurs when it is
not regularly reinforced. An example is in the treatment of unsatisfactory behav
iour such as violence, when
by preventing the individual from enjoying the rewards of violent acts namely, t
he attention he or she
attracts the conditioned reflex that is part of the cycle of violence is reduced
in strength. (2)
Elimination of life or of a biological species.
Extirpation
(1) A term used in BEHAVIOUR THERAPY to describe a method of treating fe
ars and phobias (see PHOBIA).
The subject is confronted by the circumstances that he or she fears, either grad
ually or suddenly, with the
aim of defusing the fear or phobia. (2) The term is also a colloquialism for pub
lic exposure by a man of
his genitals to achieve sexual gratification.
Extra- is the Latin prefix meaning outside of, or in addition such as ex
tracapsular, meaning outside
the capsule of a joint, and extrasystole, meaning an additional contraction of t
he heart.
Exsanguinate
Extracellular
The removal of blood from the body. This may occur as the result of a se
rious accident in which the
victim bleeds extensively. Rarely, it may happen that bleeding becomes uncontrol
lable during an operation.
An adjective that describes an object or event outside a cell. An exampl
e is extracellular fluid, the
medium surrounding a cell.
Extension Extension is the process of straightening or stretching a limb
. When used in the natural
sense, it involves the contraction of the muscles opposing those used in FLEXION
. In cases of fractured
limbs (see BONE, DISORDERS OF Bone fractures), extension is employed during the
application of splints,
in order to reduce the displacement caused by the fracture, and prevent movement
of the broken ends of
bone. It is effected by gently and steadily pulling upon the part of the limb be
yond the fracture.
Extension of a more permanent type is used in the aftertreatment of some fractur
es, as well as in diseases
of the spine, by placing the patient upon an inclined bed and affixing weights t
o his or her lower limbs,
or to his or her head by means of adhesive plaster or of straps.
Exteriorisation In surgery, the procedure to transfer an organ from its
normal place in the body to the
skin surface. It may be temporary or permanent. A common example is when the int
estine is brought to the
abdominal surface as a COLOSTOMY: this may be permanent because of serious disea
se in the lower part of the
COLON, or temporary to allow a disorder in the colon to be treated.
The total removal of a growth, organ or tissue by surgery.
ExtraExtracts Extracts are preparations, usually of a semi-solid consistency,
containing the active parts of
various plants extracted in one of several ways. In the case of some extracts, t
he juice of the fresh plant
is simply pressed out and purified; in the case of others the active principles
are dissolved out in water,
which is then to a great extent driven off by evaporation. Other extracts are si
milarly made by the help of
alcohol, and in some cases ether is the solvent.
Extradural Outside the DURA MATER, the outermost of the three membranes
that cover the BRAIN and SPINAL
CORD. The extradural or epidural space is the space between the vertebral canal
and the dura mater of the
spinal cord. (See ANAESTHESIA Local anaesthetics: epidural.)
Extrapyramidal System This is a complex part of the nervous system, exte
nding from the cortex to the
medulla in the BRAIN, from which emerge descending spinal pathways which influen
ce voluntary motor activity
throughout the body. Although the normal functions of the system are poorly unde
rstood, there are
characteristic signs of an extrapyramidal LESION. These include disturbance of v
oluntary movements, notably
slowness and poverty of movement; disturbance of
Eye 257
muscular tone, which may be increased or decreased; and involuntary move
ments, such as a tremor,
irregular jerking movements, or slow writhing movements.
Diseases There are several diseases that result from lesions to the extr
apyramidal system, of which the
most common is PARKINSONISM. Others include WILSONS DISEASE, KERNICTERUS, CHOREA
and ATHETOSIS.
Extrasensory Perception (ESP) An alleged way of perceiving current event
s (clairvoyance), future events
(precognition) or the thoughts of other people (telepathy). ESP has never been s
cientifically proven and
does not involve the use of any known senses.
Extrasystole Extrasystole is a term applied to premature contraction of
one or more of the chambers of
the heart. A beat of the heart occurs sooner than it should do in the ordinary r
hythm and is followed by a
longer rest than usual before the next beat. In an extrasystole, the stimulus to
contraction arises in a
part of the heart other than the usual. Extrasystoles often give rise to an unpl
easant sensation as of the
heart stumbling over a beat, but their occurrence is not usually serious.
Extrauterine Pregnancy See ECTOPIC PREGNANCY.
Extravasation An escape of fluid from the vessels or passages which ough
t to contain it. Extravasation
of blood due to tearing of vessel walls is found in STROKE, and in the commoner
condition known as a
bruise. Extravasation of urine takes place when the bladder or the URETHRA is ru
ptured by a blow on the
abdomen or on the crutch (PERINEUM), or torn in a fracture of the pelvis. Intrav
enous infusions frequently
extravasate.
Extrinsic (1) Originating outside the body. (2) An extrinsic muscle is o
ne whose origin is some way
from the part of the body it acts upon for example, the muscles controlling the
movement of the eyeball
which are attached to the bony orbit in which the eye sits.
Extrovert A person who is outgoing, enjoys mixing with others and looks
for fresh activities to take
part
in. Tends to act emotionally rather than intellectually.
Exudation The process in which some of the constituents of the blood pas
s slowly through the walls of
the small vessels in the course of inflammation, and also means the accumulation
resulting from this
process. For example, in PLEURISY the solid, rough material deposited on the sur
face of the lung is an
exudation.
Eye The eye is the sensory organ of sight. It is an elaborate photorecep
258 Eye
sieve-like structure through which aqueous humour leaves the eye.
The middle coat (uveal tract) consists
E
of the choroid, ciliary body and iris. CHOROID A highly vascular sheet o
f tissue lining the posterior
two-thirds of the sclera. The network of vessels provides the blood supply for t
he outer half of the
retina. The blood supply of the choroid is derived from numerous ciliary vessels
which pierce the sclera in
front and behind. CILIARY BODY A ring of tissue extending 6 mm back from the ant
erior limitation of the
sclera. The various muscles of the ciliary body by their contractions and relaxa
tions are responsible for
changing the shape of the lens during ACCOMMODATION. The ciliary body is lined b
y cells that secrete
aqueous humour. Posteriorly, the ciliary body is continuous with the choroid; an
teriorly it is continuous
with the iris. IRIS A flattened muscular diaphragm that is attached at its perip
hery to the ciliary body,
and has a round central opening the pupil. By contraction and relaxation of the
muscles of the iris, the
pupil can be dilated or constricted (dilated in the dark or when aroused; constr
icted in bright light and
for close work). The iris forms a partial division between the anterior chamber
and the posterior chamber
of the eye. It lies in front of the lens and forms the back wall of the anterior
chamber. The iris is
visible from in front, through the transparent cornea, as the coloured part of th
e eye. The amount and
distribution of iris pigment determine the colour of the iris. The pupil is mere
ly a hole in the centre of
the iris and appears black.
The inner layer The retina is a multilayered tissue (ten layers in all)
which extends from the edges of
the optic nerve to line the inner surface of the choroid up to the junction of c
iliary body and choroid.
Here the true retina ends at the ora serrata. The retina contains light-sensitiv
e cells of two types: (i)
cones cells that operate at high and medium levels of illumination; they subserv
e fine discrimination of
vision and colour vision; (ii) rods cells that function best at low light intens
ity and subserve
black-and-white vision. The retina contains about 6 million cones and about 100
million rods. Information
from them is conveyed by the nerve fibres which are in the inner part of the ret
ina, and leave the eye in
the optic nerve. There are no photoreceptors at the optic disc (the point where
the optic nerve leaves the
eye) and therefore there is no light perception from this small area. The optic
disc thus produces a physiological blind spot in the visual field. The r
etina can be subdivided into
several areas: PERIPHERAL RETINA contains mainly rods and a few scattered cones.
Visual acuity from this
Eye 259
zonular fibres can be adjusted by the muscles of the ciliary body, thus
changing the shape of the lens
and altering its power of accommodation. VITREOUS HUMOUR A transparent jelly-lik
e structure made up of a
network of collagen fibres suspended in a viscid fluid. Its shape conforms to th
at of the vitreous cavity
within which it is contained: that is, it is spherical except for a shallow conc
ave depression on its
anterior surface. The lens lies in this depression.
Eyelids These are multilayered curtains of tissue whose functions includ
e spreading of the tear film
over the front of the eye to prevent desiccation; protection from injury or exte
rnal irritation; and to
some extent the control of light entering the eye. Each eye has an upper and low
er lid which form an
elliptical opening (the palpebral fissure) when the eyes are open. The lids meet
at the medial canthus and
lateral canthus respectively. The inner medial canthus is fixed; the lateral can
thus more mobile. An
epicanthus is a fold of skin which covers the medial canthus in oriental races.
Each lid consists of
several layers. From front to back they are: very thin skin; a sheet of muscle (
orbicularis oculi, whose
fibres are concentric around the palpebral fissure and which produce closure of
the eyelids); the orbital
septum (modified near the lid margin to form the tarsal plates); and finally, li
ning the back surface of
the lid, the conjunctiva (known here as tarsal conjunctiva). At the free margin
of each lid are the
eyelashes, the openings of tear glands which lie within the lid, and the lacrima
l punctum. Toward the
medial edge of each lid is an elevation known as the papilla: the lacrimal punct
um opens into this papilla.
The punctum forms the open end of the cannaliculus, part of the tear-drainage me
chanism.
Orbit The bony cavity within which the eye is held. The orbits lie one o
n either side of the nose, on
the front of the skull. They afford considerable protection for the eye. Each is
roughly pyramidal in
shape, with the apex pointing backwards and the base forming the open anterior p
art of the orbit. The bone
of the anterior orbital margin is thickened to protect the eye from injury. Ther
e are various openings into
the posterior part of the orbit namely the optic canal, which allows the optic n
erve to leave the orbit
en route for the brain, and the superior orbital and inferior orbital fissures,
which allow passage of
nerves and blood vessels to and from the orbit. The most important structures ho
lding the eye within the
orbit are the extra-ocular muscles, a suspensory ligament
of connective tissue that forms a hammock on which the eye rests and whi
ch is slung between the medial
and lateral walls of the orbit. Finally, the orbital septum, a sheet of connecti
ve tissue extending from
the anterior margin of the orbit into the lids, helps keep the eye in place. A p
260 Eyeball
E
ning within the lid, parallel to the lid margin. The canaliculi from upp
er and lower lid join to form a
common canaliculus which opens into the lacrimal sac. LACRIMAL SAC A small sac o
n the side of the nose
which opens into the nasolacrimal duct. During blinking, the sac sucks tears int
o itself from the
canaliculus. Tears then drain by gravity down the nasolacrimal duct. NASOLACRIMA
L DUCT A tubular structure
which runs down through the wall of the nose and opens into the nasal cavity.
Visual pathway Light stimulates the rods and cones of the retina. Electr
ochemical messages are then
passed to nerve fibres in the retina and then via the optic nerve to the optic c
hiasm. Here information
from the temporal (outer) half of each retina continues to the same side of the
brain. Information from the
nasal (inner) half of each retina crosses to the other side within the optic chi
asm. The rearranged nerve
fibres then pass through the optic tract to the lateral geniculate body, then th
e optic radiation to reach
the visual cortex in the occipital lobe of the brain.
Eyeball See EYE.
Eye, Disorders of Arcus senilis The white ring or crescent which tends t
o form at the edge of the
cornea with age. It is uncommon in the young, when it may be associated with hig
h levels of blood lipids
(see LIPID).
Astigmatism (See ASTIGMATISM.) Blepharitis A chronic inflammation of the
lid margins. SEBORRHOEA and
staphylococcal infection are likely contributors. The eyes are typically intermi
ttently red, sore and
gritty over months or years. Treatment is difficult and may fail. Measures to re
duce debris on the lid
margins, intermittent courses of topical antibiotics, steroids or systemic antib
iotics may help the
sufferer. Blepharospasm Involuntary closure of the eye. This may accompany irrit
ation but may also occur
without an apparent cause. It may be severe enough to interfere with vision. Tre
atment involves removing
the source of irritation, if present. Severe and persistent cases may respond to
injection of Botulinum
toxin into the orbicularis muscle.
Cataract A term used to describe any opacity in the lens of the eye, fro
m the smallest spot to total
opaqueness. The prevalence of cataracts is age-related: 65 per cent of individua
ls in their sixth decade
have some degree of lens opacity, while all those over 80 are affected. Cataract
s are the most important
cause of blindness worldwide. Symptoms will depend on whether one or both eyes a
re affected, as well as the
position and density of the cataract(s). If only one eye is developing a catarac
t, it may be some time
before the person notices it, though reading may be affected. Some people with c
ataracts become
shortsighted, which in older people may paradoxically improve their ability to rea
d. Bright light may
worsen vision in those with cataracts. The extent of visual impairment depends o
n the nature of the
cataracts, and the first symptoms noticed by patients include difficulty in reco
gnising faces and in
reading, while problems watching television or driving, especially at night, are
pointers to the condition.
Cataracts are common but are not the only cause of deteriorating vision. Patient
s with cataracts should be
able to point to the position of a light and their pupillary reactions should be
normal. If a bright light
is shone on the eye, the lens may appear brown or, in advanced cataracts, white
(see diagram). While
increasing age is the commonest cause of cataract in the UK, patients with DIABE
TES MELLITUS, UVEITIS and a
history of injury to the eye can also develop the disorder. Prolonged STEROID tr
eatment can result in
cataracts. Children may develop cataracts, and in them the condition is much mor
e serious as vision may be
irreversibly impaired because development of the brains ability to interpret visu
al signals is hindered.
This may happen even if the cataracts are removed, so early referral for treatme
nt is essential. One of the
physical signs which doctors look for when they suspect cataract in adults as we
ll as in children is the
red reflex. This is observable when an ophthalmoscopic examination of the eye is m
ade (see
OPHTHALMOSCOPE). Identification of this red reflex (a reflection of light from t
he red surface of the
retina see EYE) is a key diagnostic sign in children, especially young ones. Ther
e is no effective medical
treatment for established cataracts. Surgery is necessary and the decision when
to operate depends mainly
on how the cataract(s) affect(s) the patients vision. Nowadays, surgery can be do
ne at any time with
limited risk. Most patients with a vision of 6/18 6/10 is the minimum standard f
or driving or worse in
both eyes should
Eye, Disorders of
261
E
Cataract: the opaque lens of any eye with cataract (left) is replaced wi
th an implanted artificial lens
(right).
benefit from surgery, though elderly people may tolerate visual acuity o
f 6/18 or worse, so surgery
must be tailored to the individuals needs. Younger people with a cataract will ha
ve more demanding visual
requirements and so may opt for an earlier operation. Most cataract surgery in Bri
tain is now done under
local anaesthetic and uses the phaco-emulsification method. A small hole is made i
n the anterior capsule
of the lens after which the hard lens nucleus is liquified ultrasonically. A rep
lacement lens is inserted
into the empty lens bag (see diagram). Patients usually return to their normal a
ctivities within a few days
of the operation. A recent development under test in the USA for children requir
ing cataract operations is
an intra-ocular flexible implant whose magnifying power can be altered as a chil
d develops, thus precluding
the need for a series of corrective operations as happens now.
Chalazion A firm lump in the eyelid relating to a blocked meibomian glan
d, felt deep within the lid.
Treatment is not always necessary; a proportion spontaneously resolve. There can
be associated infection
when the lid becomes red and painful requiring antibiotic treatment. If troubles
ome, the chalazion can be
incised under local anaesthetic. Conjunctivitis Inflammation of the conjunctiva
(see EYE) which may affect
one or both eyes. Typically the eye is red, itchy, sticky and gritty but is not
usually painful. Redness is
not always present. Conjunctivitis can occasionally be painful, particularly if
there is an associated
keratitis (see below) for example, adenovirus infection, herpetic infect
ion. The cause can be
infective (bacteria, viruses or CHLAMYDIA), chemical (e.g. acids, alkalis) or al
lergic (e.g. in hay fever).
Conjunctivitis may also be caused by contact lenses, and preservatives or even t
he drugs in eye drops may
cause conjunctival inflammation. Conjunctivitis may addtionally occur in associa
tion with other illnesses
for example, upper-respiratory-tract infection, Stevens-Johnson syndrome (see ER
YTHEMA erythema
multiforme) or REITERS SYNDROME. The treatment depends on the cause. In many pati
ents acute conjunctivitis
is self-limiting.
Dacryocystitis Inflammation of the lacrimal sac. This may present acutel
y as a red, painful swelling
between the nose and the lower lid. An abscess may form which points through the
skin and which may need to
be drained by incision. Systemic antibiotics may be necessary. Chronic dacryocys
Eye, Disorders of
Retina, disorders of The retina can be damaged by disease that affects t
he retina alone, or by diseases
affecting the whole body. Retinopathy is a term used to denote an abnormality of
the retina without
specifying a cause. Some retinal disorders are discussed below. DIABETIC RETINOP
ATHY Retinal disease
occurring in patients with DIABETES MELLITUS. It is the commonest cause of blind
registration in Great
Britain of people between the ages of 20 and 65. Diabetic retinopathy can be div
ided into several types.
The two main causes of blindness are those that follow: first, development of ne
w blood vessels from the
retina, with resultant complications and, second, those following water logging (o
edema) of the macula.
Treatment is by maintaining rigid control of blood-sugar levels combined with la
ser treatment for certain
forms of the disease in particular to get rid of new blood vessels. HYPERTENSIVE
RETINOPATHY Retinal
disease secondary to the development of high blood pressure. Treatment involves
control of the blood
pressure (see HYPERTENSION). SICKLE CELL RETINOPATHY People with sickle cell dis
ease (see under ANAEYIA)
can develop a number of retinal problems including new blood vessels from the re
tina. RETINOPATHY OF
PREMATURITY (ROP) Previously called retrolental fibroplasia (RLF), this is a dis
order affecting
low-birth-weight premature babies exposed to oxygen. Essentially, new blood vess
els develop which cause
extensive traction on the retina with resultant retinal detachment and poor visi
on. RETINAL ARTERY
OCCLUSION; RETINAL VEIN OCCLUSION These result in damage to those
areas of retina supplied by the affected blood vessel: the blood vessels
become blocked. If the
peripheral retina is damaged the patient may be completely symptom-free, althoug
h areas of blindness may be
detected on examination of field of vision. If the macula is involved, visual lo
ss may be sudden, profound
and permanent. There is no effective treatment once visual loss has occurred. SE
NILE MACULAR DEGENERATION
(Senile indicates age of onset and has no bearing on mental state.) This is the le
ading cause of
blindness in the elderly in the western world. The average age of onset is 65 ye
ars. Patients initially
notice a disturbance of their vision which gradually progresses over months or y
ears. They lose the ability
to recognise fine detail; for example, they cannot read fine print, sew, or reco
gnise peoples faces. They
always retain the ability to recognise large objects such
263
as doors and chairs, and are therefore able to get around and about reas
onably well. There is no
effective treatment in the majority of cases. RETINITIS PIGMENTOSAA group of rar
e, inherited diseases
characterised by the development of night blindness and tunnel vision. Symptoms
start in childhood and are
progressive. Many patients retain good visual acuity, although their peripheral
vision is limited. One of
the characteristic findings on examination is collections of pigment in the reti
na which have a
characteristic shape and are therefore known as bone spicules. There is no effecti
ve treatment. RETINAL
DETACHMENTusually occurs due to the development of a hole in the retina. Holes c
an occur as a result of
degeneration of the retina, traction on the retina by the vitreous, or injury. F
luid from the vitreous
passes through the hole causing a split within the retina; the inner part of the
retina becomes detached
from the outer part, the latter remaining in contact with the choroid. Detached
retina loses its ability to
detect light, with consequent impairment of vision. Retinal detachments are more
common in the
short-sighted, in the elderly or following cataract extraction. Symptoms include
spots before the eyes
(floaters), flashing lights and a shadow over the eye with progressive loss of v
ision. Treatment by laser
is very effective if caught early, at the stage when a hole has developed in the
retina but before the
retina has become detached. The edges of the hole can be spot welded to the underl
ying choroid. Once a
detachment has occurred, laser therapy cannot be used; the retina has to be repo
sitioned. This is usually
done by indenting the wall of the eye from the outside to meet the retina, then
making the retina stick to
the wall of the eye by inducing inflammation in the wall (by freezing it). The o
utcome of surgery depends
largely on the extent of the detachment and its duration. Complicated forms of d
etachment can occur due to
diabetic eye disease, injury or tumour. Each requires a specialised form of trea
tment.
Scleritis Inflammation of the sclera (see EYE). This can be localised or
diffuse, can affect the
anterior or the posterior sclera, and can affect one or both eyes. The affected
eye is usually red and
painful. Scleritis can lead to thinning and even perforation of the sclera, some
times with little sign of
inflammation. Posterior scleritis in particular may cause impaired vision and re
quire emergency treatment.
There is often no apparent cause, but there are some associated conditions for e
xample, RHEUMATOID
ARTHRITIS, GOUT, and an autoimmune disease
E
Fat Necrosis
ones health and/or appearance or from a MENTAL ILLNESS such as DEPRESSION
, or from one of the EATING
DISORDERS. Certain religious customs and practices may demand periods of fasting
. Forced fasting, often
extended, has been used for many years as an effective means of torture. Without
food and drink the body
rapidly becomes thinner and lighter as it draws upon its stored energy reserves,
initially mainly fat. Body
temperature gradually falls, and muscle is progressively broken down as the body
struggles to maintain its
vital functions. Dehydration, leading to cardiovascular collapse, inevitably fol
lows unless a basic amount
of water is taken particularly if the bodys fluid output is high, such as may occ
ur with excessive
sweating. After prolonged fasting the return to food should be gradual, with car
eful monitoring of
blood-pressure levels and concentrations of serum ELECTROLYTES. Feeding should c
onsist mainly of liquids
and light foods at first, with no heavy meals being taken for several days.
Fat A food that has more energy-producing power, weight for weight, than
any other. Animal fat is a
mixture in varying proportions of stearic, palmitic, and oleic acids combined wi
th glycerin. Butter
contains about 80 per cent of fat; ordinary cream, 20 per cent; and rich cream 4
0 per cent whilst olive
oil is practically a pure form of fat. When taken to a large extent in the diet,
fat requires to be
combined with a certain proportion of either CARBOHYDRATE or PROTEIN in order th
at it may be completely
consumed, otherwise harmful products, known as ketones, may form in the blood. E
ach gram of fat has an
energy-producing equivalent of 93 Calories (see CALORIE). Fats are divided into s
aturated fats that is,
animal fats and dairy produce; and unsaturated fats, which include vegetable oil
s from soya bean, maize and
sunflower, and marine oils from fish (e.g. cod-liver oil). (See also ADIPOSE TIS
SUE; LIPID; OBESITY.)
Body fat Most of the bodys fat is stored in which
the skin and around various
internal organs. Some, however, is stored in liver, muscle
ructures such as bone
marrow (see BONE). Various methods can be used to estimate
but all are indirect and
not very accurate, depending as they do on hard-to-measure
ition between fat and lean
tissues. The average body fat of healthy young men and
ADIPOSE TISSUE
267
women is below 20 per cent and 25 per cent respectively of their body we
ight. In economically developed
countries, middle-aged men and women usually undergo a steady increase in body f
at. This is probably not a
feature of ageing, however, since in developing nations, which have different di
Femur The thigh bone, which is the longest and strongest bone in the bod
As the upper end is set at
angle of about 120 degrees to the rest of the bone, and since the weight of t
body is entirely borne
the two femora, fracture of
Fetus
one of these bones close to its upper end is a common accident in old pe
ople, whose bones are often
weakened by osteoporosis (see under BONE, DISORDERS OF). The femur fits, at its
upper end, into the
acetabulum of the pelvis, forming the hip-joint, and, at its lower end, meets th
e tibia and patella in the
knee-joint.
Fenestration A largely obsolete surgical operation to form a new opening
in the bony LABYRINTH of the
inner ear in the treatment of deafness caused by otosclerosis (see under EAR, DI
SEASES OF). Nowadays the
disorder is usually surgically treated by STAPEDECTOMY.
Fertilisation The process by which male and female gametes (spermatozoa
and ocytes respectively) fuse
to form a zygote which develops, by a complex process of cell division and diffe
rentiation, into a new
individual of the species. In humans, fertilisation occurs in the FALLOPIAN TUBE
S. Sperm deposited in the
upper vagina traverse the cervix and uterus to enter the Fallopian tube. Many sp
erm attempt to penetrate
the zona pellucida surrounding the ocyte, but only one is able to penetrate the oc
yte proper and this
prevents any other sperm from entering. Once the sperm has entered the ocyte, the
two nuclei fuse before
the zygote begins to divide.
269
have hand and facial deformities and are sometimes mentally retarded.
Fetal Blood Sampling A procedure performed during a mothers labour in whi
ch a blood sample is taken
from a vein in the scalp of the FETUS. This enables tests to be performed that i
ndicate whether the fetus
is, for example, suffering from a shortage of oxygen (HYPOXIA). If so, the obste
trician will usually
accelerate the babys birth.
Fetal Transplant A procedure in which cells for example, from the pancre
as are taken from an
aborted FETUS and then transplanted into the malfunctioning organ (pancreas) of
an individual with a
disorder of that organ (in this case, diabetes). The cells from the fetus are in
tended to take over the
function of the hosts diseased or damaged cells. Fetal brain cells have also been
transplanted into brains
of people suffering from PARKINSONISM. These treatments are at an experimental s
tage.
Fetishism This is a form of sexual deviation in which the person becomes
sexually stimulated by parts
of the body, such as the feet, which are not usually regarded as erotogenic. Som
e people are sexually
aroused by items of clothing or shoes.
Fertility Rate
Fetoscopy
The number of live births that occur in a year for every 1,000 women of
childbearing age (this is
usually taken as 1544 years of age). The fertility rate in the UK (all ages) was
54.9 in 2002 (UK Health
Statistics, 2001 edition, The Stationery Office).
Inspection of a FETUS by passing a fibreoptic instrument called a fetosc
ope through the abdominal wall
of a pregnant woman into her UTERUS. The procedure is usually conducted in the 1
8th to 20th week of
pregnancy to assess the fetus for abnormalities and to take blood samples to pre
clude diseases such as
HAEMOPHILIA, DUCHENNE MUSCULAR DYSTROPHY and sickle-cell ANAEMIA. The procedure
should be used only if
there is a serious possibility of abnormality, the presence of which will usuall
y have been indicated by
other screening tests such as ULTRASOUND and tests of blood obtained by (intraut
erine) cordocentesis
(withdrawal of blood by syringe inserted into the umbilical cord).
Fester A popular, not a medical, term used to mean any collection or for
mation of pus. It is applied to
both abscesses and ulcers. (See ABSCESS; ULCER; WHITLOW.)
Festination The involuntary quickening of gait seen in some nervous dise
ases, especially in
PARKINSONISM.
Fetal Alcohol Syndrome A disorder of newborn infants that is caused by t
he toxic effects on the growing
FETUS of excessive amounts of alcohol taken by the mother. Low birth-weight and
retarded growth are the
main consequences, but affected babies may
Fetus The name given to the unborn child after the eighth week of develo
pment. Humans, like all
animals, begin as a single cell, the OVUM, in the ovary (see OVARIES). After FER
TILISATION with a
SPERMATOZOON, the ovum becomes embedded in the mucous membrane of the UTERUS, it
s
F
270 Fever
F
covering being known as the decidua. Increase in size is rapid, and deve
lopment of complexity is still
more marked. The original cell divides repeatedly to form new cells, and these b
ecome arranged in three
layers known as the ectoderm, mesoderm and endoderm. The first produces the skin
, brain and spinal cord,
and the nerves; the second the bones, muscles, blood vessels and connective tiss
ues; while the third
develops into the lining of the digestive system and the various glands attached
to it. The embryo develops
upon one side of the ovum, its first appearance consisting of a groove, the edge
s of which grow up and join
to form a tube, which in turn develops into the brain and spinal cord. At the sa
me time, a part of the ovum
beneath this is becoming pinched off to form the body, and within this the endod
erm forms a second tube,
which in time is changed in shape and lengthened to form the digestive canal. Fr
om the gut there grows out
very early a process called the allantois, which attaches itself to the wall of
the uterus, developing into
the PLACENTA (afterbirth), a structure well supplied with blood vessels which dr
aws nourishment from the
mothers circulation via the wall of the womb. The remainder of the ovum which wit
hin two weeks of
conception has increased to about 2 mm (1/12 inch) in size splits into an outer
and inner shell, from the
outer of which are developed two covering membranes, the chorion and amnion; whi
le the inner constitutes
the yolk sac, attached by a pedicle to the developing gut of the embryo. From tw
o weeks after conception
onwards, the various organs and limbs appear and grow. The human embryo at this
stage is almost
indistinguishable in appearance from the embryo of other animals. After around t
he middle of the second
month, it begins to show a distinctly human form and then is called the fetus. T
he property of life is
present from the very beginning, although the movements of the fetus are not usu
ally felt by the mother
until the fifth month. During the first few days after conception the eye begins
to be formed, beginning as
a cupshaped outgrowth from the mid-brain, its lens being formed as a thickening
in the skin. It is very
soon followed by the beginnings of the nose and ear, both of which arise as pits
on the surface, which
increase in complexity and are joined by nerves that grow outward from the brain
. These three organs of
sense have practically their final appearance as early as the beginning of the s
econd month. The body
closes in from behind forwards,
the sides growing forwards from the spinal region. In the neck, the grow
th takes the form of five
arches, similar to those which bear gills in fishes. From the first of these the
lower jaw is formed; from
the second the hyoid bone, all the arches uniting, and the gaps between them clo
sing up by the end of the
second month. At this time the head and neck have assumed quite a human appearan
ce. The digestive canal
begins as a simple tube running from end to end of the embryo, but it grows in l
ength and becomes twisted
in various directions to form the stomach and bowels. The lungs and the liver ar
ise from this tube as two
little buds, which quickly increase in size and complexity. The kidneys also app
ear very early, but go
through several changes before their final form is reached. The genital organs a
ppear late. The swellings,
which form the ovary in the female and the testicle (or testis) in the male, are
produced in the region of
the loins, and gradually descend to their final positions. The external genitals
are similar in the two
sexes till the end of the third month, and the sex is not clearly distinguishabl
e till late in the fourth
month. The blood vessels appear in the ovum even before the embryo. The heart, o
riginally double, forms as
a dilatation upon the arteries which later produce the aorta. These two hearts l
ater fuse into one. The
limbs appear at about the end of the third week, as buds which increase quickly
in length and split at
their ends into five parts, for fingers or toes. The bones at first are formed o
f cartilage, in which true
bone begins to appear during the third month. The average period of human gestat
ion is 266 days or 280
days from the first day of the last menstrual period. The average birth weight o
f an infant born of a
healthy mother (in the UK) is 3,200 g (see table). The following table gives the
average size and weight of
the fetus at different periods: Age Length Weight 4 weeks 5 mm 13 grams 3 months
8 to 9 cm 30 to 60 grams
5 months 15 to 25 cm 170 to 340 grams 7 months 32 to 35 cm 1,360 to 1,820 grams
Birth 45 to 60 cm 3,200
grams (See also PREGNANCY AND LABOUR.)
Fever Fever, or PYREXIA, is the abnormal rise in body TEMPERATURE that f
requently accompanies disease
in general.
Fibreoptic Endoscopy
y the occurrence of a
CRISIS that is, a sudden termination of the symptoms or by a more gradual subsid
ence of the
temperature, technically termed a lysis. If death ensues, this is due to failure
of the vital centres in
the brain or of the heart, as a result of either the infection or hyperpyrexia.
Treatment Fever is a symptom, and the correct treatment is therefore tha
t of the underlying condition.
Occasionally, however, it is also necessary to reduce the temperature by more di
rect methods: physical
cooling by, for example, tepid sponging, and the use of antipyretic drugs such a
s aspirin or paracetamol.
Fibre, Dietary See ROUGHAGE.
Fibreoptic Endoscopy A visualising technique enabling the operator to ex
amine the internal organs with
the minimum of disturbance or damage to the tissues. The procedure has transform
ed the management of, for
example, gastrointestinal disease. In chest disease, fibreoptic bronchoscopy has
now replaced the rigid
wide-bore metal tube which was previously used for examination of the tracheo-br
onchial tree. The principle
of fibreoptics in medicine is that a light from a cold light source passes down
a bundle of quartz fibres
in the endoscope to illuminate the lumen of the gastrointestinal tract or the br
onchi. The reflected light
is returned to the observers eye via the image bundle which may contain up to 20,
000 fibres. The tip of
the instrument can be angulated in both directions, and fingertip controls are p
rovided for suction, air
insufflation and for water injection to clear the lens or the mucosa. The oesoph
agus, stomach and duodenum
can be visualised; furthermore, visualisation of the pancreatic duct and direct
endoscopic cannulation is
now possible, as is visualisation of the bile duct. Fibreoptic colonoscopy can v
isualise the entire length
of the colon and it is now possible to biopsy polyps or suspected carcinomas and
to perform polypectomy.
The flexible smaller fibreoptic bronchoscope
F
272 Fibrillation
F
has many advantages over the rigid tube, extending the range of view to
all segmental bronchi and
enabling biopsy of pulmonary parenchyma. Biopsy forceps can be directed well bey
ond the tip of the
bronchoscope itself, and the more flexible fibreoptic instrument causes less dis
comfort to the patient.
Fibreoptic laparoscopy is a valuable technique that allows the direct vizualisat
ion of the abdominal
contents: for example, the female pelvic organs, in order to detect the presence
of suspected lesions (and,
in certain cases, effect their subsequent removal); check on the development and
position of the fetus; and
test the patency of the Fallopian tubes. (See also ENDOSCOPE; BRONCHOSCOPE; LARY
NGOSCOPE; LAPAROSCOPE;
COLONOSCOPE.)
Fibrillation A term applied to rapid contraction or TREMOR of muscles, a
nd especially to a form of
abnormal action of the heart muscle in which individual bundles of fibres take u
p independent action. It is
believed to be due to a state of excessive excitability in the muscle associated
with the stretching which
occurs in dilatation of the heart. The main causes are ATHEROSCLEROSIS, chronic
rheumatic heart disease and
hypertensive heart disease (see HEART, DISEASES OF). Fibrillation is distinguish
ed as atrial or
ventricular, depending on whether the muscle of the atria or of the ventricles i
s affected. In atrial
fibrillation, the heartbeats and the pulse become extremely irregular, both as r
egards time and force; when
the atrium is fibrillating there is no significant contraction of the atrial mus
cle but the cardiac output
is maintained by ventricular contraction. In ventricular fibrillation there is n
o significant contractile
force, so that there is no cardiac output. The commonest cause is myocardial inf
arction. Administration of
DIGOXIN, timolol or verapamil may restore normal rhythm, and in some patients, C
ARDIOVERSION a controlled
direct-current electric shock given via a modified defibrillator placed on the c
hest wall is effective.
Fibrin A substance formed in the BLOOD as it clots: indeed, its formatio
n causes clotting. The
substance is produced in threads; after the threads have formed a close meshwork
through the blood, they
contract, and produce a dense, felted mass. The substance is formed not only fro
m shed blood but also from
LYMPH which exudes from the lymph vessels. Thus fibrin is found in all inflammat
ory conditions within
serous cavities like the PLEURA, PERITONEUM, and PERICARDIUM, and forms
a thick coat upon the surface
of the inflamed membranes. It is also found in inflamed joints, and in the lung
as a result of pneumonia.
(See COAGULATION.)
Fibula
273
bleeding and usually occur in women over 30 years of age. In some women
the fibroid may be small enough
to remove surgically but, if it is large, a HYSTERECTOMY is often necessary. Sma
ll, symptomless fibroids
are no danger and can be left untreated.
Cause There is no investigational evidence of inflammatory, metabolic or
structural abnormality, and
the problem seems functional rather than pathological. SEROTONIN deficiency has
a significant role in
fibromyalgia syndrome.
Fibroma
firmed the usefulness of low-dose AMITRIPTYLor DOTHIEPIN together with a
graded exercise programme to
increase aerobic fitness. How this works is still unclear; its efficacy may be d
ue to its normalising
effects on the sleep centre or pain gating (reduction of pain sensation) at the sp
inal-cord level.
Prognosis is often poor. Nevertheless, suitable advice and training can help mos
t patients to learn to cope
better with their condition and avoid unnecessary investigations and drug treatm
ents.
A benign tumour comprising mainly CONNECTIVE TISSUE the substance that s
urrounds body structures,
binding them together. Examples are neurofibroma, affecting connective tissue ar
ound nerves, and ovarian
fibroma which develops around the follicles from which eggs (ova) develop in the
OVARIES. Unless the
fibroma is causing symptoms (as a result of pressure on surrounding tissues) it
does not require treatment.
If symptoms occur, the tumour is removed surgically.
Fibromyalgia Syndrome Symptoms These vary, with pain and fatigue general
ly prominent, sometimes causing
considerable disability. Patients can usually dress and wash independently but c
annot cope with a job or
household activities. Pain is mainly axial, but may affect any region. ANALGESIC
S, NONSTEROIDAL
ANTI-INFLAMMATORY DRUGS (NSAIDS) and local physical treatments are
generally ineffective. Patients often have a poor sleep pattern, waking
exhausted. Unexplained
headache, urinary frequency and abdominal symptoms are common, but no cause has
been found. Patients
generally score highly on measures of anxiety and DEPRESSION. Fibromyalgia is no
t an ideal description;
idiopathic diffuse-pain syndrome and non-restorative sleep disorder are increasi
ngly preferred terms.
Clinical findings are generally unremarkable; most important is the presence of
multiple hyperalgesic
tender sites (e.g. low cervical spine, low lumbar spine, suboccipital muscle, mi
d upper trapezius,
tennis-elbow sites, upper outer quadrants of buttocks, medial fat pad of knees).
In fibromyalgia,
hyperalgesia (excessive discomfort) is widespread and symmetrical, but absent at
sites normally non-tender.
Claims by patients to be tender all over are more likely to be due to fabricatio
n or psychiatric
disturbance. OSTEOARTHRITIS and periarticular syndrome are much more common and
should be excluded,
together with other conditions, such as hypothyroidism (see THYROID GLAND, DISEA
SES OF), SYSTEMIC LUPUS
ERYTHEMATOSUS (SLE) and inflammatory myopathy (see MUSCLES, DISORDERS OF), which
may present with similar
symptoms.
Management Controlled trials have conINE
Fibrosarcoma A cancer of the CONNECTIVE TISSUE arising in the fibroblast
s, stem cells that produce
connective tissue cells. The tumours can develop in bone or in soft tissue and o
ccur most commonly in the
limbs. Treatment is by surgery or RADIOTHERAPY.
Fibrosing Alveolitis See ALVEOLITIS.
Fibrosis The formation of fibrous or scar tissue, which is usually due t
o infection, injury or surgical
operation.
Fibrositis Pain, muscular stiffness and inflammation affecting the soft
tissues of the arm, legs and
trunk. The cause is unknown but may include immunological factors, muscular stra
in and psychological
stress. Treatment is usually palliative.
Fibrous Dysplasia A rare disease in which areas of bone are replaced by
fibrous tissue (see CONNECTIVE
TISSUE). This renders the bone fragile and liable to fracture. It may involve on
ly one bone usually the
thigh bone or FEMUR or several bones. This latter form of the disease may be acc
ompanied by pigmentation
of the skin and the early onset of PUBERTY.
Fibrous Tissue See CONNECTIVE TISSUE.
Fibula The slender outer bone of the leg. The head of
F
274 Filariasis
this bone articualtes with the TIBIA just below the knee, and at the ANK
LE it articulates with the
TALUS bone.
Filariasis
F
The term used to describe several clinical entities caused by one or oth
er of the nematode filariae;
these include Wuchereria bancrofti/Brugia malayi, Onchocerca volvulus, Loa loa,
Dracunculus medinensis
(DRACONTIASIS or guineaworm disease), Mansonella perstans, etc. These organisms
have widely differing
geographical distributions. Whereas lymphatic filariasis is present throughout m
uch of the tropics and
subtropics, ONCHOCERCIASIS (river-blindness) is largely confined to west and cen
tral Africa and southern
America. Loaiasis is an infection of west and central Africa, and dracontiasis i
nvolves west and central
Africa and western India only. Clinically, the lymphatic filariases characterist
ically cause ELEPHANTIASIS
(lymphoedema); onchocerciasis gives rise to ophthalmic complications (river-blin
dness), rashes and
subcutaneous nodules; loaiasis causes subcutaneous Calabar swellings and subconjun
ctival involvement; and
dracontiasis predisposes to secondary bacterial infections (usually involving th
e lower limbs). Diagnosis
is by finding the relevant filarial nematode, either in blood (day and night fil
ms should be examined), or
in one or other of the body fluids. An EOSINOPHILIA is often present in peripher
al blood. Serological
diagnosis is also of value. In onchocerciasis, skin-snips and the Mazotti reacti
on are valuable adjuncts to
diagnosis. The mainstay of chemotherapy consists of diethylcarbamazine (aimed pr
edominantly at the larval
stage of the parasite). However, ivermectin (not available in the UK) is effecti
ve in onchocerciasis, and
metronidazole or one of the benzimidazole compounds have limited value in dracon
tiasis. Suramin has been
used to kill adult filarial worms. Prevention consists of eradication of the rel
evant insect vector.
Filaricide A generic term for drugs used to treat filarial infections (s
ee FILARIASIS).
Filling The insertion, in denistry, of a specially prepared material int
o a cavity drilled into a
tooth, usually for the treatment of dental caries (see TEETH, DISORDERS OF).
Finasteride Finasteride is a drug which inhibits the ENZYME
that metabolises TESTOSTERONE into the more potent ANDROGEN, dihydrotest
osterone. This action results
in a reduction of prostate tissue. The drug is used to treat an enlarged PROSTAT
E GLAND, thus improving
urinary flow. Its sideeffects include reduced LIBIDO, and IMPOTENCE. Finasteride
offers an alternative to
PROSTATECTOMY for some men but a significant minority do not improve. Women of c
hildbearing age should not
handle broken or crushed tablets.
Fingerprint The unique pattern of fine ridges in the outer horny layer o
f the skin at the front of the
tip of each finger and thumb. The ridges are of three types: loops (70 per cent)
, whorls (25 per cent) and
arches (5 per cent). Fingerprint patterns are used as a routine forensic test by
police forces to identify
individuals. Some patterns can indicate that the subject has an inherited disord
er.
First Aid Emergency procedures to help an ill or injured person before h
e or she receives expert
medical attention or is admitted to hospital. Courses of instruction in first ai
d comprise 612 sessions,
each of about 2 hours duration. Syllabuses of instruction are published by variou
s organisations, the
principal ones being the British Red Cross, the St John Ambulance Association, a
nd the St Andrews
Ambulance Association. (See APPENDIX 1: BASIC FIRST AID; APPENDIX 2: ADDRESSES:
SOURCES OF INFORMATION,
ADVICE, SUPPORT AND SELF-HELP.)
Fissure A term applied both to clefts of normal anatomical structure and
also to small narrow ulcers
occurring in skin and mucous membrane. The latter type of fissure occurs especia
lly at the corners of the
mouth and at the anus. (See LIPS; RECTUM, DISEASES OF.)
Fistula An unnatural, narrow channel leading from some natural cavity su
ch as the duct of a gland, or
the interior of the bowels to the surface. Alternatively a fistula may be a comm
unication between two
such cavities where none should exist as, for example, a direct communication be
tween the bladder and
bowel.
Cause Fistulas may be congenital or develop as a result of injury or inf
ection. A SALIVARY fistula may
develop between the salivary gland
Flatulence
and the outside of the cheek because of a blockage in the duct from the
gland to the mouth. A urinary
fistula may be one consequence of a fracture of the PELVIS which has damaged the
URETHRA. Fistulas of the
anus are one of the most common forms, usually the result of infection and ABSCE
SS formation.
Treatment As a rule, a fistula is extremely difficult to close, especial
ly after it has persisted for
some time. The treatment consists in an operation to restore the natural channel
, be it salivary duct, or
urethra, or bowel. This is effected by appropriate means in each locality, and w
hen it is attained the
fistula heals quickly under simple dressings. Fit A popular name for a sudden co
nvulsive SEIZalthough the
term is also extended to include sudden seizures of every sort. During the occur
rence of a fit of any sort,
the chief object should be to prevent the patient from doing any harm to him or
herself as a result of the
convulsive movements. The person should therefore be laid flat, and the head sup
ported on a pillow or other
soft material. (See CONVULSIONS; ECLAMPSIA; EPILEPSY; FAINTING; HYSTERIA; STROKE
; URAEMIA; APPENDIX 1:
BASIC FIRST AID.) URE,
Fitness An ability to perform daily activities without becoming overtire
d. Fitness is dependent on
strength, flexibility and endurance, and the level of an individuals fitness will
often depend on their
type of employment and the extent to which they indulge in physical exercise, wh
ether training in the local
health club or at home or regularly participating in sports. Regular fitness imp
roves ones health and
well-being. Fitness exercises should be matched to a persons age and abilities an
d there is a health
danger if someone regularly exercises beyond their capabilities.
5-Hydroxytryptamine See SEROTONIN.
Flaccid Relaxed or lacking in stiffness. Used to describe muscles that a
re not contracting (or
following DENERVATION), and organs for example, the penis that are lying loose,
empty, or with
wrinkles. (Opposite: firm or erect.)
Flap A section of tissue (usually skin) separated from
275
underlying structures but still attached at its distal end by a PEDICLE
through which it receives its
blood supply. The free end may then be sutured into a new position to cover a de
fect caused by trauma or
excision of diseased tissue. A free flap involves detachment of a section of tis
sue, often including bone
and muscle, to a distant site where the artery and vein supplying it are anastom
osed to adjacent vessels
and the tissue is sutured into place. (See RECONSTRUCTIVE (PLASTIC) SURGERY.)
276 Flatus
Flatus Gas from the intestines (see INTESTINE) that is passed out via th
e ANUS and formed in the large
intestine as a result of bacteria breaking down carbohydrate and amino acids in
digested food.
Flavine See ANTISEPTICS.
F
STRUATION; MENORRHAGIA.) In the majority of cases, flooding is the sign
of a miscarriage (see
ABORTION).
Flucloxacillin A PENICILLINASE-resistant PENICILLIN used to treat penici
llin-resistant staphylococci
infection (see also STAPHYLOCOCCUS; ANTIBIOTICS).
Flexible Training
Fluconazole
A term applied to the system of postgraduate medical training that allow
s young doctors to integrate
their domestic commitments with the training requirements necessary to become a
fully qualified specialist,
usually by working part-time.
Fluctuation
Flexion The bending of a joint in the SAGITTAL plane. Usually an anterio
r movement, it is occasionally
posterior, as in the case of the knee-joint. Lateral flexion refers to the bendi
ng of the spine in the
coronal plane that is, from side to side.
Flexor A MUSCLE that causes bending of a limb or other body part.
Flexure A bend in an organ or body part. The term is used, for example,
to describe the skin on the
inner aspect of the elbow or knee, as in the hepatic flexure of the COLON.
An oral triazole antifungal drug used to treat local and systemic infect
ions.
A sign obtained from collections of fluid by laying the fingers of one h
and upon one side of the
swelling, and, with those of the other, tapping or pressing suddenly on a distan
t point of the swelling.
The thrill communicated from one hand to the other through the fluid is one of the
most important signs
of the presence of an ABSCESS, or of effusion of fluid into joints or into the p
eritoneal cavity (see
PERITONEUM).
Flucytosine A synthetic drug used as an intravenous adjunct to amphoteri
cin to treat severe systemic
fungal infections such as candidiasis (see CANDIDA) and cryptococcosis.
Fluid Balance
Particles that appear to be floating in a persons field of vision. They m
ove quickly as the eye moves,
but when the eye is still they seem to drift. Vision is not usually affected. Mo
st floaters are shadows on
the retina from minute particles in the vitreous humour (see EYE) which lies in
the main part of the
eyeball behind the lens. As a person ages, the jelly-like vitreous humour usuall
y shrinks a little and
becomes detached from the retina; this produces floaters which vanish over time.
If a person notices a
sudden cloud of floaters, sometimes accompanied by flashes of light, it is likel
y that a tear in or
detachment of the retina has occurred. This requires prompt medical attention (s
ee EYE, DISORDERS OF
Retinal detachment).
The appropriate balance of fluid input and output (along with dissolved
salts essential for life) over
24 hours. During this period, about 2,500 millilitres (ml) of fluid should be ta
ken in by a 70-kg man and
the same amount excreted; of this, 1,500 ml will be drunk, 800 ml will be in the
food eaten, and 200 ml
produced by food metabolism. Excreted water is made up of 1,500 ml of urine, 800
ml insensible loss and 200
ml in the faeces. A 70-kg mans total body fluid is 42 litres 60 per cent of body
weight. Intracellular
fluid comprises 28 litres, extracellular, 14 litres and blood, 5 litres. Water i
s controlled mainly by the
sodium concentration in the body fluids via the release of antidiuretic hormone
(ADH see VASOPRESSIN)
from the posterior part of the PITUITARY GLAND. In seriously ill people, close m
onitoring of fluid intake
and output, along with measurements of PLASMA sodium and calcium concentrations,
is an essential factor in
treatment.
Flooding
Flukes
A popular name for an excessive blood-stained discharge from the womb (U
TERUS). (See MENFlukes are a variety of parasitic worms. (See FASCIOLIASIS.)
Floaters
Flutter 277
Flunitrazepam
Fluorouracil
A drug with the trade name Rohypnol , flunitrazepam is one of the BENZODIA
ZEPINES with a prolonged
action prescribed as a hypnotic (see HYPNOTICS). The British National Formulary
warns that the drug may be
particularly subject to abuse (see DRUG-ASSISTED RAPE).
An drug of the antimetabolite group a group that disrupts normal cell di
vision. Fluorouracil is used
intravenously to treat recurrent and inoperable carcinoma of the colon and rectu
m, as well as secondaries
from cancer of the breast. It can be used topically for some malignant and prema
lignant skin lesions. (See
CYTOTOXIC.)
Fluocinolone Fluocinolone is one of the CORTICOSTEROIDS and is applied t
o the skin as a cream, lotion
or ointment. It is more potent than hydrocortisone. It must not be given by mout
h.
Fluorescein A dye which has the special property of absorbing blue-light
energy and emitting this
energy as green light. This property is made use of in examining the cornea for
scratches or ulceration; it
is also used to detect abnormally permeable (or leaking) blood vessels in the re
tina and iris especially
in diabetic retinopathy and diseases of the macula (see EYE; EYE, DISORDERS OF).
Fluoridation See FLUORINE.
Fluorine One of the halogen series of elements. In the form of fluoride
it is one of the constituents
of bone and teeth. Supplementing the daily intake of fluorine diminishes the inc
idence of dental caries
(see TEETH, DISORDERS OF). In America and in Britain, evidence indicates that pe
ople who, throughout their
lives, have drunk water with a natural fluorine content of 1 part per million ha
ve less dental caries than
those whose drinking water is fluorine-free. All the available evidence indicate
s that this is the most
satisfactory way of giving fluorine, and that if the concentration of fluorine i
n drinking water does not
exceed 1 part per million, there are no toxic effects. Several water companies i
n the UK have added
fluoride to the public water supply, but opponents of this policy, who claim tha
t fluoride has serious
sideeffects, have prevented fluoridation being introduced nationwide.
Fluoroscope An apparatus for rendering X-rays visible after they have pa
ssed through the body, by
projecting them on a screen of calcium tungstate. The technique is known as fluo
roscopy. It provides a
method of being able to watch, for instance, the beating of the heart, or the mo
vements of the intestine
after the administration of a barium meal. (See also X-RAYS.)
Fluoxetine Better known by its trade name Prozac , this drug one of the SE
LECTIVE SEROTONINREUPTAKE
INHIBITORS (SSRIS) has been widely used, especially in North America, for the tr
eatment of depression and
anxiety (see MENTAL ILLNESS). Though causing fewer side-effects than TRICYCLIC A
NTIDEPRESSANT DRUGS (the
first such drugs widely used), SSRI drugs should be prescribed with care and sho
uld not be stopped
abruptly. Unlike benzodiazepine tranquillisers such as Valium , fluoxetine is not
addictive, but there have
been rare reports of it allegedly provoking people to acts of violence. The drug
acts by modifying the
activities of neurotransmitters, notably DOPAMINE and SEROTONIN in the brain, th
us prolonging the effects
of these chemical messengers.
Flupenthixol A tranquilliser used in the treatment of schizophrenia (see
MENTAL ILLNESS).
Fluphenazine One of the phenothiazine derivatives, of value as an antips
ychotic drug. (See also
NEUROLEPTICS.)
Flurazepam See BENZODIAZEPINES.
Flutamide An antiandrogen (see ANDROGEN) drug used in the treatment of c
ancer of the PROSTATE GLAND,
sometimes in conjunction with GONADORELIN.
Fluticasone An aerosol corticosteroid drug used in the prevention and tr
eatment of attacks of ASTHMA.
Inhaled corticosteroids have few or no systemic side-effects unless given in exc
essive dosage.
Flutter The term applied to a form of abnormal cardiac rhythm, in which
the atria contract at a rate of
200400 beats a minute, and the ventricles more slowly. The abnormal rhythm is the
result
F
278 Fluvastatin
of a diseased heart. (See FIBRILLATION.)
HEART, DISEASES OF;
Fluvastatin One of the STATINS group of drugs used to reduce the levels
of LDL-CHOLESTEROL in the blood
and thus help to prevent coronary heart disease, which is more prevalent in peop
le with raised blood
cholesterol levels (see HEART, DISEASES OF).
F
Foetus See FETUS.
Folic Acid One of the constituents of the vitamin B complex, folic acid
derives its name from the fact
that it is found in many green leaves, including spinach and grass. It has also
been obtained from liver,
kidney and yeasts. It has proved to be of value in the treatment of macrocytic a
naemias (see ANAEMIA),
particularly those associated with SPRUE and nutritional deficiencies. In order
to prevent NEURAL TUBE
defects and cleft lip or palate (see CLEFT PALATE), all women planning to become
pregnant should be advised
to have a diet rich in folic acid in the months before conception until 13 weeks
gestation, or to take
folic acid tablets. Recent research has suggested that adequate levels of folic
acid can prevent the
build-up of homocysteine, a compound in the blood closely associated with heart
attacks and strokes. It has
been suggested that the official recommendation of 200 micrograms a day in the d
iet should be doubled. (See
APPENDIX 5: VITAMINS.)
Follicular Hormone See OESTRADIOL.
Fomentation (See also POULTICES.) Any warm application to the surface of
the body in the form of a
cloth. Usually, the fomentation cloth is heated by being wrung out of hot water.
Fomites A traditional term used to include all articles which have been
brought into sufficiently close
contact with a person sick of some infectious disease to retain the infective ma
terial and spread the
disease. For example, clothes, bedding, carpets, toys and books may all be fomit
es until they are
disinfected.
Fontanelle Areas on the head on which bone has not yet formed. The chief
of these is the anterior
fontanelle, situated on the top of the head between the frontal and two parietal
bones. In shape it is
four-sided, about 25 mm (1 inch) square at the time of birth, gradually diminish
ing until it is completely
covered by bone, which should happen by the age of 18 months. The pulsations of
the brain can be readily
felt through it. Delay in its closure is particularly found in cases of RICKETS,
as well as in other states
although the animals may show no symptoms. Duck eggs may harbour Salmonella (usu
ally S. typhimurium),
arising from surface contamination with the birds faeces, and foods containing un
cooked or lightly cooked
hens eggs, such as mayonnaise, have been associated with enteritis. The incidence
of human S. enteritidis
infection has been increasing, by more than 15-fold in England and Wales annuall
y, from around 1,100 a year
in the early 1980s to more than 32,000 at the end of the 1990s, but has since fa
llen to about 10,000. A
serious source of infection seems to be poultry meat and hens eggs. Although Salm
onella are mostly killed
by heating at 60 C for 15 minutes, contaminated food requires considerably longer
cooking and, if frozen,
must be completely thawed beforehand, to allow even cooking at a sufficient temp
erature. Enteritis caused
by Campylobacter jejuni is usually self-limiting, lasting 13 days. Since reportin
g of the disease began in
1977, in England and Wales its incidence has increased from around 1,400 cases i
nitially to nearly 13,000
in 1982 and to over 42,000 in 2004. Outbreaks have been associated with unpasteu
rised milk: the main source
seems to be infected poultry. ESCHERICHIA COLI O157 was first identified as a
cause of food poisoning in the early 1980s, but its incidence has increa
sed sharply since, with more
than 1,000 cases annually in the United Kingdom in the late 1990s. The illness c
an be severe, with bloody
diarrhoea and lifethreatening renal complications. The reservoir for this pathog
en is thought to be cattle,
and transmission results from consumption of raw or undercooked meat products an
d raw dairy products.
Cross-infection of cooked meat by raw meat is a common cause of outbreaks of Esc
herichia coli O157 food
poisoning. Water and other foods can be contaminated by manure from cattle, and
person-to-person spread can
occur, especially in children. Food poisoning associated with fried or boiled ri
ce is caused by Bacillus
cereus, whose heat-resistant spores survive cooking. An
F
forceps are designed to fit around the infants head and allow traction to be
Forensic Medicine That branch of medicine concerned with matters of law
and the solving of crimes, for
example, by determining the cause of a death in suspicious circumstances or iden
tifying a criminal by
examining tissue found at the scene of a crime. The use of DNA identification to
establish who was present
at the scene of the crime is now a widely used procedure in forensic medicine.
Formaldehyde The British Pharmacopoeia preparation, formaldehyde solutio
n, contains 3438 per cent
formaldehyde in water. It is a powerful antiseptic, and also has the power to ha
rden the tissues. The
vapour is very irritating to the eyes and nose.
Uses For disinfection it is largely used in the form of a spray; it can
also be vaporised by heat. One
of its advantages is that it does not damage metals or fabrics. In 3 per cent so
lution in water it is used
for the treatment of warts on the palms of the hands and the soles of the feet.
Formestane One of the steroidal AROMATASE INHIBITORS recently introduced
for the treatment of patients
with advanced postmenopausal breast cancer. It is better tolerated than non-ster
oidal aromatase inhibitors
and acts by blocking the conversion of androgens (see ANDROGEN) to OESTROGEN in
peripheral tissue.
Formulary A list of formulae used as drugs and other medical preparation
s. The British National
Formulary is an authoritative six-monthly publication containing information and
advice on medicines and
drugs. Published jointly by the British Medical Association and the Royal Pharma
ceutical Society of Great
Britain, with input from the Department of Health, it is distributed to all NHS
doctors by the government.
In 2005 a BNF for children was published and many hospitals and general practice
s produce formularies for
use by doctors working in those facilities.
Frenum Also known as the fraenum or frenulum, this comprises the folds o
f mucous membrane that anchor
the bottom of the tongue to the floor of the mouth.
Frequency (1) The number of regular recurrences of an event during a giv
en period of time. Examples in
medicine are the heartbeat, and sound vibrations in the EAR or vocal cords. (2)
The word is also used to
describe frequent passage of urine, a symptom that is usually caused by disorder
s in the urinary tract
for example, an infection; or any systemic disease which increases the daily out
put of urine for example,
DIABETES MELLITUS and DIABETES INSIPIDUS or disorders of the kidney.
Freudian Theory A theory that emotional and allied diseases are due to a
psychic injury or trauma,
generally of a sexual nature, which did not produce an adequate reaction when it
was received and therefore
remains as a subconscious or affect memory to trouble the patients mind. As an exte
nsion of this theory,
Freudian treatment consists of encouraging the patient to tell everything that h
appens to be associated
with trains of thought which lead up to this memory, thus securing a purging of th
e mind from the
original affect memory which is the cause of the symptoms. This form of treatment
is also called
psychocatharsis or abreaction. The general term, psychoanalysis, is applied, in
the first place, to the
method of helping the patient to recover buried memories by free association of
thoughts. In the second
place, the term is applied to the body of psychological knowledge and theory acc
umulated and devised by
Sigmund Freud (18561939) and his followers. The term psychoanalyst has traditionall
y been applied to
those who have undergone
F
282 Friction
Freudian training, but Freuds ideas are being increasingly questioned by
some modern psychiatrists.
the head, and sometimes infection develops known as SINUSITIS (see NOSE,
DISORDERS OF).
Friction
The anterior part of the cerebral hemisphere as far back as the central
sulcus. It contains the motor
cortex and the parts of the brain concerned with personality, behaviour and lear
ning. (See BRAIN.)
The name given either to the FREMITUS felt, or to the grating noise hear
d, when two rough surfaces of
the body move over one another. It is characteristically obtained over the chest
in cases of dry PLEURISY.
F
Friedreichs Ataxia A hereditary disease resembling LOCOMOTOR ATAXIA, and
due to degenerative changes
in nerve tracts and nerve cells of the spinal cord and the brain. It occurs usua
lly in children, or at any
rate before the 20th year of life, and affects often several brothers and sister
s. Its chief symptoms are
unsteadiness of gait, with loss of the knee jerks, followed later by difficultie
s of speech, tremors of the
hands, head and eyes, deformity of the feet, and curvature of the spine. There i
s often associated heart
disease. The sufferer gets gradually worse, but may live, with increasing disabi
lity, for 2030 years.
Frigidity A term used to describe a lack of interest in sexual intercour
se (COITUS) or the inability to
achieve intercourse or ORGASM. Though applicable to both sexes, frigidity is usu
ally applied to women with
these sexual problems.
Fringe Medicine See COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM).
Frhlichs Syndrome A condition in children characterised by obesity, physic
al sluggishness, and
retarded sexual development. It is the result of disturbed PITUITARY GLAND funct
ion.
Frontal Describing the anterior part of a body or organ.
Frontal Bone The bone which forms the forehead and protects the frontal
lobes of the brain. Before
birth, the frontal bone consists of two halves, and this division may persist th
roughout life a deep
groove remaining down the centre of the forehead. Above each eye is a heavy ridg
e in the bone, most marked
in men; behind this, in the substance of the bone, is a cavity on each side (the
frontal sinus) which
communicates with the nose. CATARRH in these cavities produces the frontal heada
che characteristic of a
cold in
Frontal Lobe
Frontal Sinus One of the airspaces that form the paranasal sinuses (see
SINUS) within some of the
frontal bones of the skull. These sinuses are lined with mucous membrane and ope
n into the nasal cavity.
Frostbite This results from the action of extreme cold (below 0 C) on the
skin. VASOCONSTRICTION
results in a reduced blood and hence, oxygen supply, leading to NECROSIS of the
skin and, in severe
cases, of the underlying tissues. Chiefly affecting exposed parts of the body, s
uch as the face and the
limbs, frostbite occurs especially in people exercising at high altitudes, or in
those at risk of
peripheral vascular disease, such as diabetics (see DIABETES MELLITUS), who shou
ld take particular care of
their fingers and toes when in cold environments. In mild cases the condition so
metimes known as frostnip
the skin on exposed parts of the body, such as the cheeks or nose, becomes white
and numb with a sudden
and complete cessation of cold and discomfort. In more severe cases, blisters de
velop on the frozen part,
and the skin then gradually hardens and turns black until the frozen part, such
as a finger, is covered
with a black shell of dead tissue. Swelling of the underlying tissue occurs and
this is accompanied by
throbbing and aching. If, as is often the case, only the skin and the tissues im
mediately under it are
frozen, then in a matter of months the dead tissue peels off. In the most severe
cases of all, muscles,
bone and tendon are also frozen, and the affected part becomes cold, swollen, mo
ttled and blue or grey.
There may be no blistering in these severe cases. At first there is no pain, but
in time shooting and
throbbing pains usually develop.
Prevention This consists of wearing the right clothing and never venturi
ng on even quite short
expeditions in cold weather, particularly on mountains, without taking expert ad
vice as to what should be
worn.
Treatment Frostnip is the only form of frost-
psilocybin, a hallucinogenic substance. Children who take such mushrooms may dev
elop a high fever and need
medical care. In adults the symptoms usually disappear within six hours.
Treatment If possible, early gastric lavage should be carried out in all
cases of suspected poisoning.
Identification of the mushroom species is a valuable guide to treatment. For mus
carine poisoning, ATROPINE
is a specific antidote. As stated above, hospital referral is advisable for peop
le who have ingested
poisonous fungi.
Funiculitis Inflammation of the SPERMATIC CORD, usually arising in men w
ith epididymitis (inflammation
of the EPIDIDYMIS in the TESTICLE). The condition can be painful. ANTIBIOTICS an
d ANALGESICS are effective
treatment.
Funnel Chest See CHEST DEFORMITIES.
Funnybone Colloquial name for the small area at the back of the elbow wh
ere the ULNAR NERVE goes over a
prominence at the lower end of the HUMERUS bone. If the nerve is hit, acute pain
results, accompanied by
tingling in the forearm and hand.
Furuncle Another term for a boil.
Fusidic Acid A valuable antistaphylococcal antibiotic used both orally a
nd topically. It is
particularly useful in osteomyelitis (see BONE, DISORDERS OF).
Fusobacterium A species of gram-negative, rod-shaped BACTERIA. It occurs
among the normal flora of the
human mouth, COLON and reproductive tract. Occasionally, fusobacterium is isolat
ed from abscesses occurring
in the lungs, abdomen and pelvis. One variety occurs in patients with VINCENTS AN
GINA (trench mouth).
G GABA
GABA, or gamma aminobutyric acid, is an amino acid (see AMINO ACIDS) tha
t occurs in the central nervous
system, mainly in the brain tissue. It is a chemical substance that transmits in
hibitory impulses from
nerve endings across synapses to other nerves or tissues.
Gag A device that, when placed between a persons teeth, keeps the mouth o
pen.
Gag Reflex Assessment of victims of major trauma must include maintenanc
e of their airways and
breathing. Any false teeth, vomitus and foreign bodies should be removed, and th
e response to digital
stimulation of the posterior pharyngeal wall the gag reflex assessed. Even with a
normal gag reflex,
the airway may be seriously threatened if vomiting occurs. During the initial st
ages of resuscitation,
careful and constant supervision of the airway is essential, with a high-volume
sucker immediately
available. If the gag reflex is absent or impaired, an endotracheal tube should
be inserted (see
ENDOTRACHEAL INTUBATION).
In LOCOMOTOR ATAXIA or tabes dorsalis, the sensations derived from the l
ower 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,
they feel for the ground with a stick or keep their eyes constantly fixed upon i
t. In spastic paralysis the
limbs are moved with jerks. The foot first of all clings to the ground and then
leaves it with a spasmodic
movement, being raised much higher than is necessary. In PARKINSONISM the moveme
nts are tremulous, and as
the person takes very short steps, he or she has the peculiarity of appearing co
nstantly to fall forwards,
or to be chasing themselves. In CHOREA the walk is bizarre and jerky, the affect
ed child often seeming to
leave one leg a step behind, and then, with a screwing movement on the other hee
l, go on again.
Psychologically based idiosyncracies of gait are usually of a striking nature, q
uite different from those
occuring in any neurological conditions. They tend to draw attention to the pati
ent, and are worse when he
or she is observed.
Galactocele A cyst-like swelling in the breast which forms as a result o
f obstruction in the milk-duct
draining the swollen area.
Gait
Galactorrhoea
The way in which an individual walks. Gait may be affected by inherited
disorders; by illness
especially neurological disorders; by injury; or by drug and alcohol abuse. Chil
286 Gall
sugar that is changed in the liver to glucose. A rare genetic metabolic
disease, GALACTOSAEMIA, results
in infants being unable to achieve this conversion because the enzyme necessary
for the reaction is absent.
Gall Another name for BILE.
Gall-Bladder See LIVER.
Gall-Bladder, Diseases of G
The gall-bladder rests on the underside of the LIVER and joins the commo
n hepatic duct via the cystic
duct to form the common BILE DUCT. The gall-bladder acts as a reservoir and conc
entrator of BILE,
alterations in the composition of which may result in the formation of gallstone
s, the most common disease
of the gallbladder.
Gall-stones affect 22 per cent of women and 11 per cent of men. The inci
dence increases with age, but
only about 30 per cent of those with gall-stones undergo treatment as the majori
ty of cases are
asymptomatic. There are three types of stone: cholesterol, pigment and mixed, de
pending upon their
composition; stones are usually mixed and may contain calcium deposits. The caus
e of most cases is not
clear but sometimes gall-stones will form around a foreign body within the bile du
cts or gall-bladder,
such as suture material. BILIARY COLIC Muscle fibres in the biliary system contr
act around a stone in the
cystic duct or common bile duct in an attempt to expel it. This causes pain in t
he right upper quarter of
the abdomen, with nausea and occasionally vomiting. JAUNDICE Gall-stones small e
nough to enter the common
bile duct may block the flow of bile and cause jaundice. ACUTE CHOLECYSTITIS Blo
ckage of the cystic duct
may lead to this. The gall-bladder wall becomes inflamed, resulting in pain in t
he right upper quarter of
the abdomen, fever, and an increase in the white-blood-cell count. There is char
acteristically tenderness
over the tip of the right ninth rib on deep inhalation (Murphys sign). Infection
of the gall-bladder may
accompany the acute inflammation and occasionally an EMPYEMA of the gall-bladder
may result. CHRONIC
CHOLECYSTITIS A more insidious form of gall-bladder inflammation, producing nonspecific symptoms of
abdominal pain, nausea and flatulence which may be worse after a fatty meal.
Diagnosis Stones are usually diagnosed on the basis of the patients repor
ted symptoms, although
asymptomatic gall-stones are often an incidental finding when investigating anot
her complaint. Confirmatory
investigations include abdominal RADIOGRAPHY although many gall-stones are not c
alcified and thus do not
show up on these images; ULTRASOUND scanning; oral CHOLECYSTOGRAPHY which entail
s a patients swallowing
a substance opaque to Xrays which is concentrated in the gall-bladder; and endos
copic retrograde
cholangiopancreatography (ERCP) a technique in which an ENDOSCOPE is passed into
the duodenum and a
contrast medium injected into the biliary duct.
Treatment Biliary colic is treated with bed rest and injection of morphi
ne-like analgesics. Once the
pain has subsided, the patient may then be referred for further treatment as out
lined below. Acute
cholecystitis is treated by surgical removal of the gall-bladder. There are two
techniques available for
this procedure: firstly, conventional cholecystectomy, in which the abdomen is o
pened and the gall-bladder
cut out; and, secondly, laparoscopic cholecystectomy, in which fibreoptic instru
ments called endoscopes
(see FIBREOPTIC ENDOSCOPY) are introduced into the abdominal cavity via several
small incisions (see
MINIMALLY INVASIVE SURGERY (MIS)). Laparoscopic surgery has the advantage of red
ucing the patients
recovery time. Gall-stones may be removed during ERCP; they can sometimes be dis
solved using ultrasound
waves (lithotripsy) or tablet therapy (dissolution chemotherapy). Pigment stones
, calcified stones or
stones larger than 15 mm in diameter are not suitable for this treatment, which
is also less likely to
succeed in the overweight patient. Drug treatment is prolonged but stones can di
sappear completely after
two years. Stones may re-form on stopping therapy. The drugs used are derivative
s of bile salts,
particularly chenodeoxycholic acid; side-effects include diarrhoea and liver dam
age.
Other disorders of the gall-bladder These are rare. may form and, if sym
ptomatic, should be removed.
Malignant change is rare. CARCINOMA of the gall-bladder is a disease of the elde
rly and is almost
exclusively associated with gall-stones. By the time such a cancer has produced
symptoms, the prognosis is
bleak: 80 per cent of these patients die within one year of diagnosis. If the tu
mour is discovered early,
60 per cent of patients will survive five years. POLYPS
Gangrene
Gall-Stones See under GALL-BLADDER, DISEASES OF.
Gamete A sexual or germ cell: for example, an OVUM or SPERMATOZOON.
Gamete Intrafallopian Transfer (GIFT) See ASSISTED CONCEPTION.
Gamgee Tissue A surgical dressing composed of a thick layer of cotton-wo
ol between two layers of
absorbent gauze, introduced by the Birmingham surgeon, Sampson Gamgee (18281886).
Gamgee tissue has been a
registered trademark since 1911.
287
should be prescribed only when the potential benefits outweigh the risks
. It is also used for the
prevention of cytomegalovirus infection in patients who have had a liver transpl
ant.
Ganglion This term is used in two senses. In anatomy, it means an aggreg
ation of nerve cells found in
the course of certain nerves. In surgery, it means an enlargement of the sheath
of a tendon, containing
fluid. The latter occurs particularly in connection with the tendons in front of
, and behind, the wrist.
A drug that is used in the treatment of PEDICULOSIS and SCABIES.
Causes The cause of these dilatations on the tendon-sheaths is either so
me irregular growth of the
SYNOVIAL MEMBRANE which lines them and secretes the fluid that lubricates their
movements, or the
forcing-out of a small pouch of this membrane through the sheath in consequence
of a strain. In either case
a bag-like swelling forms, whose connection with the synovial sheath becomes cut
off, so that synovial
fluid collects in it and distends it more and more.
Gamma-Globulin
Symptoms A soft, elastic, movable swelling
Gamma Aminobutyric Acid See GABA.
Gamma Benzene Hexachloride
Gamma-globulin describes a group of proteins present in the blood PLASMA
. They are characterised by
their rate of movement in an electrical field, and can be separated by the proce
ss of ELECTROPHORESIS. Most
gamma-globulins are IMMUNOGLOBULINS. Gamma-globulin injection provides passive o
r active immunity against
HEPATITIS A. (See also GLOBULIN; IMMUNITY; IMMUNOLOGY.)
Gamma Rays Short-wavelength penetrating electromagnetic rays produced by
some radioactive compounds.
More powerful than X-rays, they are used in certain RADIOTHERAPY treatments and
to sterilise some
materials.
Gammexane The proprietary name for a synthetic insecticide which is a fo
rmulation of benzene
hexachloride. It is active against a large range of insects and pests, including
mosquitoes, fleas, lice,
cockroaches, house-flies, clothes moths, bed-bugs, ants, and grain pests.
Ganciclovir A drug used in the treatment of life- or sightthreatening in
fection with CYTOMEGALOVIRUS
(CMV) in patients whose immune systems (see IMMUNITY) are compromised. Administe
red by intravenous
transfusion, the drug is toxic and
forms, most often on the back of the wrist. It is usually small and give
s no problems. Sometimes
weakness and discomfort may develop. A ganglion which forms in connection with t
he flexor tendons in front
of the wrist sometimes attains a large size, and extends down to form another sw
elling in the palm of the
hand.
Treatment Sudden pressure with the thumbs may often burst a ganglion and
disperse its contents beneath
the skin. If this fails, surgical excision is necessary but, as the ganglion may
disappear spontaneously,
there should be no rush to remove it unless it is causing inconvenience or pain.
Gangrene The death and decay of body tissues caused by a deficiency or c
essation of the blood supply.
There are two types: dry and moist. The former is a process of mummification, wi
th the blood supply of the
affected area of tissue stopping and the tissue withering up. Moist gangrene is
characterised by
putrefactive tissue decay caused by bacterial infection. The dead part, when for
med of soft tissues, is
called a slough and, when part of a bone, is called a sequestrum.
Causes These include injury especially that sustained in war disease,
FROSTBITE,
severe
G
288 Gargles
burns, ATHEROMA in large blood vessels, and diseases such as DIABETES ME
LLITUS and RAYNAUDS DISEASE.
Gas gangrene is a form that occurs when injuries are infected with soil contamin
ated with gas-producing
bacilli such as Clostridium welchii, which are found in wellcultivated ground.
Treatment Dry gangrene must be kept dry, and AMPUTATION of the dead tiss
ue performed when a clear
demarcation line with healthy tissue has formed. Wet gangrene requires urgent su
rgery and prompt use of
appropriate antibiotics. G
Gargles Gargling is a process by which various substances in solution ar
e brought into contact with the
throat without being swallowed. The watery solutions used for the purpose are ca
lled gargles. Gargles are
used in the symptomatic treatment of infections of the throat: for example, sore
throat, pharyngitis and
tonsillitis.
The operation is sometimes still done if the patient has failed to respo
nd to dietary treatment and
treatment with H2-blocking drugs (see CIMETIDINE; RANITIDINE) along with antibio
tics to combat Helicobacter
pylori, an important contributary factor to ulcer development. Partial gastrecto
my is usually accompanied
by VAGOTOMY, which involves cutting the VAGUS nerve controlling acid secretion i
n the stomach. Among the
side-effects of gastrectomy are fullness and discomfort after meals; formation o
f ulcers at the new
junction between the stomach and duodenum which may lead to GASTRITIS and oesoph
agitis (see OESOPHAGUS,
DISEASES OF); dumping syndrome (nausea, sweating and dizziness because the food
leaves the stomach too
quickly after eating); vomiting and diarrhoea. The sideeffects usually subside b
ut may need dietary and
drug treatment.
Gastric Relating to or affecting the example, gastric ulcer.
STOMACH:
for
Gargoylism
Gastric Lavage
Also known as Hurlers syndrome, gargoylism is a rare condition due to lac
k of a specific ENZYME. It is
a progressive disorder usually leading to death before the age of 10 years. The
affected child is usually
normal during the first few months of life; mental and physical deterioration th
en set in. The
characteristic features include coarse facial features (hence the name of the co
ndition), retarded growth,
chest deformity, stiff joints, clouding of the cornea (see EYE), enlargement of
the liver and spleen,
deafness, and heart murmurs, with mental deterioration. It occurs in about one i
n 100,000 births.
A method of gastric decontamination used in the treatment of poisoning.
It is not used routinely.
Lavage involves the passage of a lubricated tube via the mouth and OESOPHAGUS in
to the stomach. Patients
are positioned on their side with the head lower than the feet. A small quantity
of fluid (300 ml) is
passed into the stomach and the contents then drained out (by gravity) by loweri
ng the end of the tube.
This is repeated until the solution is clear of particulate matter. The procedur
e should be done only by an
experienced health professional.
Gas See ANAESTHESIA; CARBON MONOXIDE (CO); NITROUS OXIDE GAS.
Gas Gangrene See GANGRENE.
Gastrectomy A major operation to remove the whole or part of the STOMACH
. Total gastrectomy is a rare
operation, usually performed when a person has cancer of the stomach; the OESPHA
GUS is then connected to
the DUODENUM. Sometimes cancer of the stomach can be treated by doing a partial
gastrectomy: the use of
partial gastrectomy to treat PEPTIC ULCER used to be common before the advent of
effective drug therapy.
Gastric Ulcer See STOMACH, DISEASES OF.
Gastrin A hormone produced by the MUCOUS MEMBRANE in the pyloric part of
the STOMACH. The arrival of
food stimulates production of the hormone which in turn stimulates the productio
n of gastric juice.
Gastritis Inflammation of the STOMACH lining. This may take an acute for
m when excess alcohol or other
irritating substances have been taken, resulting in vomiting. Chronic gastritis
may be the result of
regular smoking and chronic alcoholism, or the condition may be caused by the ba
ck flow of BILE from the
DUODENUM. The common cause, however, is chronic infection
Gauchers Disease
with HELICOBACTER PYLORI. Symptoms are vague but victims are likely to d
evelop gastric ulcers or
sometimes cancer. Atrophic gastritis, when the mucosal lining of the stomach wit
hers away, may follow
chronic gastritis but sometimes occurs as an autoimmune disorder.
Gastrocnemius The large double muscle which forms the chief bulk of the
calf, and ends below in the
tendo calcaneus.
Gastroduodenostomy A surgical operation to join the DUODENUM to a hole m
ade in the STOMACH wall to
circumvent an obstruction in the gut for example, PYLORIC STENOSIS or to improve
the passage of food
from the stomach into the duodenum.
Gastroenteritis Inflammation of the STOMACH and intestines (see INTESTIN
E), usually resulting from an
acute bacterial or viral infection. The main symptoms are diarrhoea and vomiting
, often accompanied by
fever and especially in infants DEHYDRATION. Although generally a mild disease i
n western countries, it
is the number-one killer of infants in the developing world, with more than 15 mi
llion children dying
annually from the disease in India a situation exacerbated by early weaning and
malnutrition.
Complications may include CONVULSIONS, kidney failure, and, in severe cases, bra
in damage.
Treatment This involves the urgent correction of dehydration, using intr
avenous saline and dextrose
feeds initially, with continuing replacement as required. Antibiotics are not in
dicated unless systemic
spread of bacterial infection is likely. (See also FOOD POISONING.)
Gastroenterostomy An operation performed usually in order to relieve som
e obstruction to the outlet
from the STOMACH. One opening is made in the lower part of the stomach; another
in a neighbouring loop of
the small intestine. The two are then stitched together.
Gastrointestinal Tract The passage along which the food passes, in which
it is digested (see
DIGESTION), and from which it is absorbed by lymphatics and blood vessels into t
he circulation. The tract
consists of the mouth, pharynx or throat, oesophagus or gullet, stomach, small i
ntestine, and large
intestine, in this order. For details, see articles under
289
these headings. The total length in humans is about 9 metres.
Gastro-Oesophageal Reflux A disorder in which the contents of the STOMba
ck up into the OESOPHAGUS
because the usual neuromuscular mechanisms for preventing this are intermittentl
y or permanently failing to
work properly. If persistent, the failure may cause oesophagitis (see OESOPHAGUS
290 Gel
liver particularly of the former and ANAEMIA. It runs a chronic course.
Diagnosis is usually by
skin fibroblast glucocerebrosidase assay. Death often results from PNEUMONIA or
bleeding. Infantile
Gauchers often presents with marked neurological signs of rigid neck DYSPHAGIA, C
ATATONIA, hyper-reflexia
and low IQ. The disease can now be treated with enzyme replacement using algluce
rase. The annual cost per
patient is substantial several thousand pounds.
Gel G
The term applied to a COLLOID substance which is firm in consistency alt
hough it contains much water:
for example, ordinary GELATIN.
Gelatin This is derived from COLLAGEN, the chief constituent of CONNECTI
VE TISSUE. It is a colourless,
transparent substance which dissolves in boiling water, and on cooling sets into
a jelly. Such a jelly is a
pleasant addition to the invalid diet, especially when suitably flavoured, but i
t is of relatively little
nutritive value as not more than one ounce can be taken in the day (i.e. the amo
unt required to make one
pint of jelly). Although it is a protein, it is lacking in several of the vital
amino acids. The ordinary
household stock made from boiling bones contains gelatin. Mixed with about two and
a half times its
weight of glycerin, gelatin forms a soft substance used as the basis for many pa
stilles and suppositories.
Partially degraded gelatin is sometimes given as a PLASMA-substitute transfusion
for short-term emergency
treatment for patients in SHOCK as a result of a severe blood or fluid loss from
burns or SEPTICAEMIA.
Gemeprost One of the PROSTAGLANDINS administered vaginally as pessaries
for the medical induction of
late therapeutic ABORTION. Gemeprost also softens the cervix before surgical abo
rtion, being particularly
useful for women in their first pregnancy. Prostaglandins induce contractions of
the UTERUS while keeping
blood loss to a minimum.
Gender Identity Disorders Gender identity is the
ity or femininity, and gender
role is an individuals public expression of being male,
us). Most people have
no difficulty because their gender identity and role are
h a gender identity
disorder, however, has a conflict between anatomical sex
chromosome of the son must come from the mother; all his daughters, however, wil
l be carriers as the X
chromosome for the father must be transmitted to all his daughters. Hence sex-li
nked recessive
characteristics cannot be passed from father to son. Sporadic cases may be the r
esult of a new mutation, in
which case the mother is not the carrier and is not likely to have further affec
ted children. It is
probable that one-third of haemophiliacs arise as a result of fresh mutations, a
nd these patients will be
the first in the families to be affected. Sometimes the carrier of a sex-linked
recessive gene can be
identified. The sex-linked variety of retinitis pigmentosa (see EYE, DISORDERS O
F) can often be detected by
ophthalmoscopic examination. A few rare disorders are due to dominant genes carr
ied on the X chromosome. An
example of such a condition is familial hypophosphataemia with vitamin-D-resista
nt RICKETS.
Polygenic inheritance In many inherited conditions, the disease is due t
o the combined action of
several genes; the genetic element is then called multi-factorial or polygenic.
In this situation there
would be an increased incidence of the disease in the families concerned, but it
will not follow the
Mendelian (see MENDELISM; GENETIC CODE) ratio. The greater the number of indepen
dent genes involved in
determining a certain disease, the more complicated will be the pattern of inher
itance. Furthermore, many
inherited disorders are the result of a combination of genetic and environmental
influences. DIABETES
MELLITUS is the most familiar of such multi-factorial inheritance. The predispos
ition to develop diabetes
is an inherited characteristic, although the gene is not always able to express
itself: this is called
incomplete penetrance. Whether or not the individual with a genetic predispositi
on towards the disease
actually develops diabetes will also depend on environmental factors. Diabetes i
s more common in the
relatives of diabetic patients, and even more so amongst identical twins. Nongen
etic factors which are
important in precipitating overt disease are obesity, excessive intake of carboh
ydrate foods, and
pregnancy.
G
parents has the disease, is one in ten, but this figure is modified by the early
environment of the child.
Genetic Engineering
G
Genetic engineering, or recombinant DNA technology, has only developed i
n the past decade or so; it is
the process of changing the genetic material of a cell (see CELLS). GENES from o
ne cell for example, a
human cell can be inserted into another cell, usually a bacterium, and made to f
unction. It is now
possible to insert the gene responsible for the production of human INSULIN, hum
an GROWTH HORMONE and
INTERFERON from a human cell into a bacterium. Segments of DNA for insertion can
be prepared by breaking
long chains into smaller pieces by the use of restriction enzymes. The segments
are then inserted into the
affecting organism by using PLASMIDS and bacteriophages (see BACTERIOPHAGE). Pla
smids are small packets of
DNA that are found within bacteria and can be passed from one bacterium to anoth
er. Already genetic
engineering is contributing to easing the problems of diagnosis. DNA analysis an
d production of MONOCLONAL
ANTIBODIES are other applications of genetic engineering. Genetic engineering ha
s significantly contributed
to horticulture and agriculture with certain characteristics of one organism or
variant of a species being
transfected (a method of gene transfer) into another. This has given rise to hig
her-yield crops and to
alteration in colouring and size in produce. Genetic engineering is also contrib
uting to our knowledge of
how human genes function, as these can be transfected into mice and other animal
s which can then act as
models for genetic therapy. Studying the effects of inherited mutations derived
from human DNA in these
animal models is thus a very important and much faster way of learning about hum
an disease. Genetic
engineering is a scientific procedure that could have profound implications for
the human race.
Manipulating heredity would be an unwelcome activity under the control of maveri
ck scientists, politicians
or others in positions of power.
Genetic Fingerprinting This technique shows the relationships between in
dividuals: for example, it can
be used to prove maternity or paternity of a child. The procedure is also used in FORENSIC MEDICINE whereby any tissue left behind
by a criminal at the scene of a
crime can be compared genetically with the tissue of a suspect. DNA, the genetic
material in living cells,
can be extracted from blood, semen and other body tissues. The technique, pionee
red in Britain in 1984, is
now widely used.
Genetics The science which deals with the origin of the characteristics
of an individual or the study
of HEREDITY.
Giardiasis
Genito-Urinary Tract This consists of the KIDNEYS, ureters (see URETER),
URINARY BLADDER and URETHRA
and, in the male, also the genital organs.
297
age, and particularly their social consequences (see also AGEING).
German Measles See RUBELLA.
Genome A complete set of CHROMOSOMES derived from one parent, or the tot
al gene complement of a set of
chromosomes. An international study is well underway to produce a complete map o
f the HUMAN GENOME.
Genotype All of an individuals genetic information that is encoded in his
or her CHROMOSOMES. It also
means the genetic information carried by a pair of alleles which controls a part
icular characteristic. (See
GENES.)
Gentamicin An antibiotic derived from a species of microorganisms, Micro
monospora purpurea. Its main
value is that it is active against certain microorganisms such as Pseudomonas py
ocyanea, E. coli and
Aerobacter aerogenes which are not affected by other antibiotics, as well as sta
phylococci which have
become resistant to PENICILLIN.
Gentian Violet A dye belonging to the rosaniline group. It is a useful s
uperficial antiseptic for use
on unbroken skin.
Genu Valgum The medical term for knock-knee a deformity of the lower lim
bs in such a direction that
when the limbs are straightened, the legs diverge from one another. As a result,
in walking, the knees
knock against each other. The amount of knock-knee is measured by the distance b
etween the medial malleoli
of the ankles, with the inner surfaces of the knee touching and the knee-caps fa
cing forwards. The
condition is so common in children between the ages of 26 years that it may almos
t be regarded as a normal
phase in childhood. When marked, or persisting into later childhood, it can be c
orrected by surgery
(osteotomy).
Genu Varum Genu varum is the medical term for BOW LEG.
Geriatrics Now increasingly termed medicine of the elderly, this is a bran
ch of medicine that deals
with disorders and diseases associated with old
Germ Cell Those embryonic cells with the potential to develop into ova (
see OVUM) or spermatozoa (see
SPERMATOZOON).
Germ Layer Any one of the three discrete varieties of body tissue that d
298 Giddiness
Giddiness
lymphatic system) are sometimes called that. While they do not produce s
ecretions, lymph glands do
release white blood cells, an essential part of the bodys defence system.
See VERTIGO.
GIFT See ASSISTED CONCEPTION.
Glandular Fever
Gigantism
G
Excessive growth (mainly in height) caused by overproduction, during chi
ldhood or adolescence, of
GROWTH HORMONE by a tumour of the PITUITARY GLAND. Untreated, the affected indiv
idual may die in early
adulthood. Sometimes the tumour appears after the individual has stopped growing
and the result then is
ACROMEGALY rather than gigantism.
Gilles De La Tourettes Syndrome
Glans The term applied to the ends of the PENIS and the CLITORIS. In the
penis the glans is the distal,
helmet-shaped part that is formed by the bulbous corpus spongiosum (erectile tis
sue). In an uncircumcised
man the glans is covered by the foreskin or PREPUCE when the penis is flaccid.
Glasgow Coma Scale
Also known as Tourettes syndrome, this is a hereditary condition of sever
e and multiple tics (see TIC)
of motor or vocal origin. It usually starts in childhood and becomes chronic (wi
th remissions). With a
prevalance of one in 2,000, a dominant gene (see GENES) with variable expression
may be responsible. The
disorder is associated with explosive vocal tics and grunts, occasionally obscen
e (see COPROLALIA). The
patient may also involuntarily repeat the words or imitate the actions of others
(see PALILALIA).
HALOPERIDOL, pimozide (an oral antipsychotic drug similar to CHLORPROMAZINE hydr
ochloride) and clonidine
are among drugs that may help to control this distressing, but fortunately rare,
disorder.
Gingivitis Inflammation of the gums (see
See MONONUCLEOSIS.
TEETH, DISORDERS OF).
Gland A collection of CELLS or an ORGAN with a specialised ability to ma
Globin
not painful. The characteristic findings are that the intraocular pressu
re is raised (normal pressure
is up to 21 mm Hg) causing cupping of the optic disc and a glaucomatous visual-f
ield loss. The angle
between the iris and the cornea remains open. Treatment is aimed at decreasing t
he intraocular pressure
initially by drops, tablets and intravenous drug administration. Surgery may be
required later. A
trabeculectomy is an operation to create a channel through which fluid can drain
from the eye in a
controlled fashion in order to bring the pressure down.
Narrow-angle glaucoma affects one in 1,000 people over 40 years of age a
nd is more common in women.
Symptoms may start with coloured haloes around street lights at night. These may
then be followed by rapid
onset of severe pain in and around the eye accompanied by a rapid fall in vision
. One eye is usually
affected first; this alerts the surgeon so that action can be taken to prevent a
similar attack in the
other eye. Treatment must be started as an emergency with a topical beta blocker
(see
BETA-ADRENOCEPTOR-BLOCKING DRUGS) in eye drops with other drugs such as ADRENALI
NE or pilocarpine added as
necessary. Dorzolamide, a topical anhydrase inhibitor, can also be used. ACETAZO
LAMIDE, also an anhydrase
inhibitor, can be given by mouth. In an emergency before surgery, MANNITOL can b
e given through an
intravenous infusion; this is followed by surgery to prevent recurrence. Acute n
arrow-angle glaucoma occurs
because the peripheral iris is pushed against the back of the cornea. This close
s off the angle between
iris and cornea through which aqueous humour drains out of the eye. Since the aq
ueous humour cannot drain
away, it builds up inside the eye causing a rapid increase in pressure. Various
types of LASER treatment
trabeculoplasty (burning the trabecular network); iridotomy (cutting holes to reli
eve pressure); and
ciliary-body ablation by burning are sometimes used in preference to surgery.
SYSTEM.
Providing support and nutrition to neurones (see NEURON(E)), glia compri
ses various cells including
oligodendrocytes, astrocytes and ependymal cells. There are around ten times as
many glial cells as neurons
and they form about 40 per cent of the total volume of the brain and spinal cord
, playing an essential role
in the neurochemical transmission function of neurons (see BRAIN).
Glibenclamide A drug which stimulates the beta cells of the PANCREAS to
liberate INSULIN, and is used
to treat some patients with DIABETES MELLITUS. (See also SULPHONYLUREAS.)
Gliclazide See SULPHONYLUREAS.
Gliobastoma A type of brain tumour arising from tissue. It grows rapidly
, destroying brain cells and
causing a progressive loss of brain function. The patient suffers from headache
as a result of raised
cranial pressure, eventually vomiting regularly and becoming increasingly drowsy
. The prognosis is poor and
palliative treatment is required as surgical removal, radiotherapy and chemother
apy are not effective.
Glioma A tumour in the brain or spinal cord, composed of neuroglia, whic
h is the special connective
tissue that supports the nerve cells and nerve fibres (see GLIA). Low-grade mali
gnant gliomas cause
symptoms by putting pressure on surrounding tissues and organs. Highly malignant
gliomas are usually
invasive. Gliomas, like other spaceoccupying tumours in the brain, may present w
ith headaches, seizures,
neurological symptoms or symptoms of mental disturbance. Treatment may include s
urgery, radiotherapy and
chemotherapy and should be done in a specialist neurological centre. Gliomas ten
d to spread within the
brain and can be difficult to remove surgically.
Gleet
Glipizide
Gleet means a chronic form of GONORRHOEA.
See SULPHONYLUREAS.
Glenoid
Gliquidone
The term applied to the shallow socket on the shoulder-blade into which
the HUMERUS fits, forming the
shoulder-joint.
See SULPHONYLUREAS.
Glia Also called neuroglia, this is the specialised connective tissue of
the CENTRAL NERVOUS
299
Globin A protein which, when it combines with haem, forms HAEMOGLOBIN th
e molecule found in the red
blood cell that carries oxygen and carbon dioxide.
G
300 Globulin
Globulin A class of proteins which are insoluble in water and alcohol an
d soluble in weak salt
solution. (See also GAMMA-GLOBULIN.)
Globus A term applied generally to any structures of ball shape, but esp
ecially to the sensation of a
ball in the throat causing choking, which forms a common symptom of acute anxiet
y (globus hystericus).
Glomerular Filtration Rate (GFR) Each of the two
KIDNEYS
filters a large volume
G of blood 25 per cent of cardiac output, or around 1,300 ml through its
two million glomeruli (see
GLOMERULUS) every minute. The glomeruli filter out cell, protein, and fat-free f
luid which, after
reabsorption of certain chemicals, is excreted as urine. The rate of this ultraf
iltration process, which in
health is remarkably constant, is called the glomerular filtration rate (GFR). E
ach day nearly 180 litres
of water plus some small molecular-weight constituents of blood are filtrated. T
he GFR is thus an indicator
of kidney function. The most widely used measurement is CREATININE clearance and
this is assessed by
measuring the amount of creatinine in a 24-hour sample of urine and the amount o
f creatinine in the plasma;
a formula is applied that gives the GFR.
middle ear. It also supplies the PAROTID GLAND and one of the muscles on
the side of the throat.
Glottis The narrow opening at the upper end of the LARYNX. The glottis i
s made up of the true vocal
cords. (See AIR PASSAGES; CHOKING.)
Glucagon A hormone secreted by the alpha cells of the islets of Langerha
ns in the PANCREAS, which
increases the amount of glucose in the blood. This it does by promoting the brea
kdown of liver GLYCOGEN
(glycogenolysis). It is secreted in response to a lowered blood sugar and is use
d therapeutically to treat
HYPOGLYCAEMIA.
Glucocorticoids One of the two main groups of CORTICOSTEROIDS. CORTISOL,
CORTISONE and corticosterone
are part of this group and are essential for the body to utilise CARBOHYDRATE, F
AT and PROTEIN in
particular, when the body is reacting to stress. Glucocorticoids occur naturally
but can be synthesised,
and they have strong anti-inflammatory properties, being used to treat condition
s in which inflammation is
a part.
Gluconeogenesis The formation of sugar from amino acids in the
minimus; together the three muscles are responsible for moving the thigh.
Glycerin Glycerin, or glycerol, is an alcohol, C3H8O3, which occurs natu
rally in combination with
organic acids in the form of fats or triglycerides. It is a clear, colourless, t
hick liquid of sweet taste.
It dissolves many substances, and absorbs water effectively.
Uses Glycerin has many and varied uses. Numerous substances, such as car
bolic acid, tannic acid, alum,
borax, boric acid and starch, are dissolved in it for application to the body. I
t is frequently applied
along with other remedies to inflamed areas for its action in extracting fluid a
nd thus diminishing
inflammation.
Glycerol Another name for GLYCERIN.
Glyceryl Trinitrate Also known as trinitrin and nitroglycerin, this is a
drug used in the treatment of
ANGINA PECTORIS and left ventricular failure of the heart. It is normally given
as a sublingual tablet or
spray, though percutaneous preparations may be useful in the prophylaxis of angi
na particularly for
patients who suffer attacks at rest, and especially at night. Sublingually it pr
ovides rapid symptomatic
relief of angina, but is only effective for 2030 minutes. It is a potent vasodila
tor, and this may lead to
unwanted sideeffects such as flushing, headache, and postural HYPOTENSION. Its a
ntispasmodic effects are
also valuable in the treatment of ASTHMA, biliary and renal colic, and certain c
ases of VOMITING. (See also
COLIC.)
GlycoA prefix meaning of the nature of, or containing, sugar.
G
302 Glycogen
Glycogen
The cells produce the main constituents of
Glycogen, or animal starch, is a CARBOsubstance found specially in the l
iver, as well as in other
tissues. It is the form in which carbohydrates taken in the food are stored in t
he liver and muscles before
they are converted into GLUCOSE as the needs of the body require.
MUCUS.
HYDRATE
Glycoproteins Compounds comprising a PROTEIN and a CARBOHYDRATE, such as
mucins, mucoid and amyloid.
G Glycoside A compound of a sugar and a non-sugar unit. Glycosides are w
idespread throughout nature and
include many important drugs such as DIGOXIN.
Glycosylated Haemoglobin (HbA1c) This forms a small proportion of the to
tal HAEMOGLOBIN in the blood.
It differs from the major component, HbA, in that it has a glucose group attache
d. The rate of synthesis of
HbA1c is a function of the blood-glucose concentration, and since it accumulates
throughout the life span
of the red blood cell normally 120 days the concentration of HbA1c is related to
the mean blood-glucose
concentration over the past 34 months. It is thus a useful indicator of medium-te
rm diabetic control (see
DIABETES MELLITUS) a good target range would be a concentration of 58 per cent. W
hen interpreting the
HbA1c level, however, it is important to remember that wide fluctuations in bloo
dglucose concentration,
together with ANAEMIA or a reduced ERYTHROCYTES life span, may give misleading r
esults.
Goitre Goitre is a term applied to a swelling in the front of the neck c
aused by an enlargement of the
THYROID GLAND. The thyroid lies between the skin and the front of the windpipe a
nd in health is not large
enough to be seen. The four main varieties of goitre are the simple goitre, the
nodular, the lymphadenoid
goitre and the toxic goitre. (See THYROID GLAND, DISEASES OF.)
Gold Salts These are used in the treatment of RHEUMATOID ARTHRITIS. Gold
may be administered in various
forms for example, sodium aurothiomalate. It is injected in very small doses int
ramuscularly and produces
a reaction in the affected tissues which leads to their scarring and healing. Au
ranofin is a gold
preparation that can be given orally; if no response has been achieved within si
x months the drug should be
stopped. It is less effective than gold given by intramuscular injection. If gol
d is administered in too
large quantities, skin eruptions, albuminuria (see PROTEINURIA), metallic taste
in the mouth, JAUNDICE, and
Gonorrhoea ENDOMETRIOSIS, breast cancer (see BREASTS, DISEASES OF) and prostate
cancer (see PROSTATE
urethra is apt to lead to gradual formation of fibrous tissue around this channe
l. This contracts and
produces narrowing, so that urination becomes difficult or may be stopped for a
time altogether (the
condition known as stricture). Inflammation of some of the joints is a common co
mplication in the early
stage the knee, ankle, wrist, and elbow being the joints most frequently affecte
d and this form of
rheumatism is very intractable and liable to lead to permanent stiffness. The fibr
ous tissues elsewhere
may also develop inflammatory changes, causing pain in the back, foot, etc. In o
ccasional cases, during the
acute stage, SEPTICAEMIA may develop, with inflammation of the heart-valves (END
OCARDITIS) and abscesses in
various parts of the body. The infective matter occasionally is inoculated accid
entally into the eye,
producing a very severe form of conjunctivitis: in the newly born child this is
known as ophthalmia
neonatorum and, although now rare in the UK. has in the past been a major cause
of blindness (see EYE,
DISORDERS OF). WOMEN The course and complications of the disease are somewhat di
fferent in women. It begins
with a yellow vaginal discharge, pain on urination, and very often inflammation
or abscess of the
Bartholins glands, situated close to the vulva or opening of the vagina. The chie
f seriousness, however,
of the disease is due to the spread of inflammation to neighbouring organs, the
UTERUS, FALLOPIAN TUBES,
and OVARIES, causing permanent destructive changes in these, and leading occasio
nally to PERITONITIS
through the Fallopian tube with a fatal result. Many cases of prolonged ill-heal
th and sterility or
recurring miscarriages are due to these changes. MEN
Treatment The chances of cure are better the earlier treatment is instit
uted. PENICILLIN is the
antibiotic of choice but unfortunately the gonococcus is liable to become resist
ant to this. In patients
who are infected with
G
the serum urate concentration by preventing the formation of uric acid. A sensib
le weight-reducing diet is
usually helpful.
GP See GENERAL PRACTITIONER (GP).
Graft The term applied to a piece of tissue removed from one person or a
nimal and implanted in another,
or the same, individual in order to remedy some defect. Skin grafts are commonly
used, and artificial skin
for grafting has recently been developed. Bone grafts are also used to replace b
one which has been lost by
disease: for example, a portion of rib is sometimes removed in order to furnish
support for a spine
weakened by disease, after removal of the damaged bone. Also, the bone of young
animals is used to afford
additional growth and strength to a limb-bone which it has been necessary to rem
ove in part on account of
disease or injury. Research is also underway on artifical bone. Vein grafts are
used to replace stretches
of arteries which have become blocked, particularly in the heart and lower limbs
. The veins most commonly
used for this purpose are the saphenous veins of the individual in question, pro
vided they are healthy. An
alternative is specially treated umbilical vein. (See SKINGRAFTING.) When a repl
acement organ, such as
kidney, heart or liver, is grafted into someones body, it called a transplant (see TR
ANSPLANTATION).
Graft Versus Host Disease (GVHD) A condition that is a common complicati
on of BONE MARROW transplant
(see TRANSPLANTATION). It results from certain LYMPHOCYTES in the transplanted m
arrow attacking the
transplant recipients tissues, which they identify as foreign. GVHD may appear soon
after a transplant
or develop several months later. The condition, which is fatal in about a third
of victims, may be
prevented by immunosuppressant drugs such as ciclosporin.
Gram The unit of weight in the metric system, equal to a little over 154
grains. For the purposes of
weighing food, 30 grams are usually taken as being approximately equal to an
Grommet
305
forms of chronic inflammation, such as
SYPHounce. (See APPENDIX 6: MEASUREMENTS IN MEDICINE.)
ILIS and TUBERCULOSIS.
Gram-Positive/Negative
Gravel
See GRAMS STAIN.
Grams Stain Bacteria can be stained with an iodine-based chemical dye cal
led Grams stain (after the
scientist who discovered the technique). Different bacteria react differently to
exposure to the stain.
Broadly, the bacterial specimens are stained first with gentian violet, then wit
h Grams stain, and finally
counterstained with a red dye after a decolorising process. Bacteria that retain
the gentian stain are
called gram-positive; those that lose it but absorb the red stain are called gra
m-negative. Some species of
staphylococcus, streptococcus and clostridium are gram-positive, whereas salmone
lla and Vibrio cholerae are
gram-negative.
Grand Mal An out-of-date and now colloquial name for a tonic-clonic seiz
ure (in contrast to petit mal)
see EPILEPSY.
Granisetron One of several serotonin antagonists used to treat nausea an
d vomiting induced by CYTOTOXIC
chemotherapy.
Granulations Small masses of formative cells containing loops of newly f
ormed blood vessels which
spring up over any raw surface, as the first step in the process of healing of w
ounds. (See ULCER; WOUNDS.)
Granulocytes A variety of white blood cells, also called polymorphonucle
ar LEUCOCYTES, which, when
stained with Romanowsky stains containing thiazine dyes and eosin, are found to
contain granules in their
cytoplasm. The colour of the granules enables the cells to be further classified
as basophils, eosinophils,
and neutrophils. Neutrophils isolate and destroy invading bacteria pus comprises
mostly neutrophils.
Eosinophils are also involved in the bodys allergic response to foreign proteins,
and basophils are
involved in inflammatory and allergic reactions.
Granuloma A non-malignant or new growth made up of granulation tissue. T
his is caused by various
The name applied to any sediment which precipitates in the urine, but pa
rticularly to small crystal
masses of uric acid. It produces DYSURIA and other urinary symptoms. (See URINAR
Y BLADDER, DISEASES OF;
GOUT; URINE.)
Graves Disease See THYROID GLAND, DISEASES OF.
Gravid Pregnant (see PREGNANCY AND LABOUR).
Greenstick Fracture An incomplete fracture, in which the bone is not com
pletely broken across. It
occurs in the long bones of children and is usually due to indirect force. (See
BONE, DISORDERS OF Bone
fractures.)
Grey Matter Those parts of the BRAIN and SPINAL CORD that comprise mainl
y the interconnected and
tightly packed nuclei of neurons (nerve cells). The tissue is darker than that o
f the white matter, which
is made of axons from the nerve cells. In the brain, grey matter is mainly found
in the outer layers of the
cerebrum, which is the zone responsible for advanced mental functions. The inner
core of the spinal cord is
made up of grey matter.
Griseofulvin An antibiotic obtained from Penicillium griseofulvum Dierck
se, used to treat various forms
of RINGWORM.
Groin The region which includes the upper part of the front of the thigh
and lower part of the abdomen.
A deep groove runs obliquely across it, which corresponds to the inguinal ligame
nt, and divides the thigh
from the abdomen. The principal diseased conditions in this region are enlarged
glands (see GLAND), and
HERNIA.
Grommet A small bobbin-shaped tube used to keep open the incision made i
n the ear drum in the treatment
of secretory otitis media. It acts as a ventilation tube by allowing the Eustach
ian tube to recover its
normal function. The operation is now less commonly performed than 20 years ago.
(See EAR, DISEASES OF;
EUSTACHIAN TUBES.)
G
in the
of the ga
of the
and req
Gyrus
307
branes or submucosa, and the long bones. Although often painless, it may
produce marked symptoms by
interfering with the brain or other internal organs in which it may be located.
Treatment with penicillin
(or tetracycline if the patient is allergic) usually ensures a rapid disappearan
ce of the gumma.
fertilisation or IVF (see under ASSISTED CONCEPTION). Covering the full
age range, it is closely
related to OBSTETRICS, while involving aspects of both surgery and psychiatry.
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 moulded
to the appropriate shape to immobilise the broken bone (see BONE, DISORDERS OF B
one fractures.)
GVHD See GRAFT VERSUS HOST DISEASE (GVHD).
Gynaecology The branch of medicine dealing with the female pelvic and ur
ogenital organs, in both the
normal and diseased states. It encompasses aspects of CONTRACEPTION, ABORTION, a
nd in vitro
Gynaecomastia An abnormal increase in size of the male breast.
Gyrus Gyrus is the term applied to a convolution of the BRAIN.
G
H H2 Receptor Antagonists
These are drugs that block the action of HISTAMINE at the H2 receptor (w
hich mediates the gastric and
some of the cardiovascular effects of histamine). By reducing the production of
acid by the stomach, these
drugs chiefly cimetidine, ranitidine, famotidine and nizatidine are valuable in
the treatment of peptic
ulcers (healing when used in high dose; preventing relapse when used as maintena
nce therapy in reduced
dose), reflux oesophagitis (see OESOPHAGUS, DISEASES OF), and the ZOLLINGERELLIS
ON SYNDROME. These drugs
are now being supplanted by PROTON-PUMP INHIBITORS and HELICOBACTER PYLORI eradi
cation therapy. (See also
DUODENAL ULCER.)
Habit A behavioural response or practice
vidual frequently repeating the
same act. The process is called habituation, and
a particular stimulus, the
less is he or she aroused by it. People may also
ugs, requiring more and
more of a substance to produce the same effect
Haemoglobin
309
Haematocrit
Haemochromatosis
Also known as packed cell volume, this is an expression of the fraction
of blood volume occupied by the
ERYTHROCYTES. It is determined by centrifuging a sample of blood in a capillary
tube and measuring the
height of the resulting packed cells as a percentage of the total sample height.
Normal values: males 4253
per cent or 0.420.53 mL/dL females 3248 per cent or 0.360.48 mL/dL
A disease in which cirrhosis of the liver (see LIVER, DISEASES OF), enla
rgement of the SPLEEN,
pigmentation of the skin, and DIABETES MELLITUS are associated with the abnormal
and excessive deposit in
the organs of the body of the iron-containing pigment, haemosiderin. It is cause
d by an increase in the
amount of iron absorbed from the gastrointestinal tract.
Haematogenous
A method of removing waste products or poisons from the circulating bloo
d using the principle of
DIALYSIS. The procedure is used on patients with malfunctioning or nonfunctionin
g KIDNEYS. It is done using
an artificial kidney or dialyser which restores blood to its normal state. The p
rocess has to be repeated,
sometimes for many months, until a donor kidney is available for transplantation
to replace the patients
failing one.
An adjective applied to a biological process which produces blood, or to
an agent produced in or coming
from blood. For example, a haematogenous infection is one resulting from contact
with blood that contains a
virus or bacterium responsible for the infection.
Haematologist A doctor or scientist who specialises in the study and tre
atment of blood and blood
disorders.
Haematology The study of diseases of the blood.
Haematoma Haematoma means a collection of blood forming a definite swell
ing. It is found often upon the
head of newborn children after a protracted and difficult labour (cephalhaematom
a). It may occur as the
result of any injury or operation.
Haematuria Blood in the URINE. The blood may come from any part of the u
rinary tract. When the blood
comes from the kidney or upper part of the urinary tract, it is usually mixed th
roughout the urine, giving
the latter a brownish or smoky tinge. This condition is usually the result of gl
omerulonephritis, or it may
be present in persons suffering from high blood pressure or PYELITIS. Blood may
also appear in the urine
when a stone or gravel is present in the pelvis of the kidney setting up irritat
ion, especially after
exercise. The blood may also originate from a bladder that is inflamed or infect
ed or which contains benign
growths (papilloma) or malignant growths. Inflammation or injury to the URETHRA
can also cause haematuria.
Someone with haematuria should seek medical advice. (See also KIDNEYS, DISEASES
OF.)
Haemic Murmur Unusual sounds heard over the heart and large blood vessel
s in severe cases of ANAEMIA.
They disappear as the condition improves.
Haemodialysis
Haemofiltration A technique similar to HAEMODIALYSIS. Blood is dialysed
using ultrafiltration through a
membrane permeable to water and small molecules (molecular weight <12,000). Phys
iological saline solution
is simultaneously reinfused.
Haemoglobin The colouring compound which produces the red colour of bloo
d. Haemoglobin is a
chromoprotein, made up of a protein called globin and the iron-containing pigmen
t, haemin. When separated
from the red blood corpuscles each of which contains about 600 million haemoglob
in molecules it is
crystalline in form. Haemoglobin exists in two forms: simple haemoglobin, found
in venous blood; and
oxyhaemoglobin, which is a loose compound with oxygen, found in arterial blood a
fter the blood has come
into contact with the air in the lungs. This oxyhaemoglobin is again broken down
as the blood passes
through the tissues, which take up the oxygen for their own use. This is the mai
n function of haemoglobin:
to act as a carrier of oxygen from the lungs to all the tissues of the body. Whe
n the haemoglobin leaves
the lungs, it is 97 per cent saturated with oxygen; when it comes back to the lu
ngs in the venous blood, it
is 70 per cent saturated. The oxygen content of 100 millilitres of blood leaving
the lungs is 195
millilitres, and that of venous blood returning to the lungs, 145 millilitres. Th
us, each 100 millilitres
of blood delivers 5 millilitres of oxygen to the tissues of the body. Human male
blood contains 1318 grams
of
H
310 Haemoglobinopathies
haemoglobin per 100 millilitres; in women, there are 1216 grams per 100 m
illilitres. A man weighing 70
kilograms (154 pounds) has around 770 grams of haemoglobin circulating in his re
d blood corpuscles.
Haemoglobinopathies
H
Abnormal HAEMOGLOBIN formation occurs in the haemoglobinopathies, which
are hereditary haemolytic
anaemias, genetically determined and related to race. The haemoglobin may be abn
ormal because: (1) there is
a defect in the synthesis of normal adult haemoglobin as in THALASSAEMIA, when t
here may be an absence of
one or both of the polypeptide chains characteristic of normal adult haemoglobin
; or (2) there is an
abnormal form of haemoglobin such as haemoglobin S which results in sickle-cell
disease (see ANAEMIA). This
abnormality may involve as little as one amino acid of the 300 in the haemoglobi
n molecule. In sickle-cell
haemoglobin, one single amino-acid molecule that of glutamic acid is replaced by
another that of
valine; this results in such a deficient end product that the ensuing disease is
frequently severe.
Haemoglobinuria The presence of blood pigment in the URINE caused by the
destruction of blood
corpuscles in the blood vessels or in the urinary passages. It turns urine a dar
k red or brown colour. In
some people this condition, known as intermittent haemoglobinuria, occurs from t
ime to time, especially on
exposure to cold. It is also produced by various poisonous substances taken in t
he food. It occurs in
malarious districts in the form of one of the most fatal forms of MALARIA: BLACK
WATER FEVER. (See also
MARCH HAEMOGLOBINURIA.)
Haemolysis The destruction of red blood corpuscles by the action of pois
onous substances, usually of a
protein nature, circulating in the blood, or by certain chemicals. It occurs, fo
r example, gradually in
some forms of ANAEMIA and rapidly in poisoning by snake venom.
Haemolytic Disease of
ewborn, characterised by
haemolytic ANAEMIA (excessive
evere, it may be obvious
before birth because the baby
heart failure so-called
hydrops fetalis. It may first
naemia. The disease
Haemoptysis
and renal failure (resulting from fibrin deposition in renal arterioles
and glomerular capillaries).
The death rate is 210 per cent and the majority of patients survive without renal
failure. The longer the
period of OLIGURIA, the greater the risk of chronic renal failure. Treatment is
supportive, with
replacement of blood and clotting factors, control of HYPERTENSION, and careful
observation of fluid
balance.
Haemopericardium The presence of blood in the PERICARDIUM, the membranou
s sac which surrounds the
heart. The condition may result from a myocardial infarction (see HEART, DISEASE
S OF), leaking ANEURYSM,
injury, or tumour. Because the pericardial blood compresses the heart, the latte
rs pumping action is
impeded, reducing the blood pressure and causing cardiac failure. Urgent surgica
l drainage of the blood may
be required.
Haemophilia An inherited disorder of blood COAGULATION which results in
prolonged bleeding even after
minor injury. There is a deficiency of factor VIII, an essential clotting factor
in the coagulation cascade
the complex series of biochemical events that leads from injury of the wall of a
blood vessel to the
formation of a blood clot that checks bleeding. Haemophilia is a sex-linked rece
ssive disorder (though a
small number of cases arise by spontaneous mutation), so that, if females carry
the disease, onehalf of
their sons will be affected and one-half of their daughters will be carriers. Th
e sons of haemophiliacs are
unaffected but one-half of their daughters will be carriers. Haemophilia affects
approximately 1:4,000 of
the UK population but only 1:20,000 is severely affected. Severity of the diseas
e depends upon the
percentage, compared with normal, of factor VIII activity present. Less than 1 p
er cent and there will be
spontaneous bleeding into joints and muscles; 15 per cent and there will be occas
ional spontaneous
bleeding and severe bleeding after minor injury; 525 per cent and there will only
be severe bleeding after
major injury. Before treatment was available, severe haemophiliacs suffered from
acute pain and deformity
from bleeds into joints and muscles. Bleeding also occurred into the gut, kidney
s and brain, and few
survived past adolescence. Freeze-dried factor VIII may be kept in domestic refr
igerators. Haemophiliacs
can use it to abort minor bleeds by reconstituting it and injecting it intraveno
usly. More major bleeding
or preparation for surgery involves raising factor
311
VIII levels to 30100 per cent by giving cryoprecipitate. With treatment,
most haemophiliacs lead
normal lives, although obviously dangerous or contact sports should be avoided.
Before donors of blood were
screened for HEPATITIS B and C or for HIV infection (see AIDS/HIV), some individ
uals with haemophilia
receiving factor VIII were unwittingly infected with those diseases. Todays scree
ning procedures make such
infections very unlikely. There is a National Haemophilia Register and each regi
stered sufferer carries a
card with details about his or her condition. Information may also be obtained f
rom NHS haemophilia centres
and the Haemophilia Society.
Haemophilus Gram-negative (see GRAMS STAIN), rod-like, aerobic, non-spori
ng and non-motile parasitic
bacteria. Mostly found in the respiratory tract, they may be part of the normal
flora, but may also be
responsible for several diseases. The main pathogenic species of haemophilus is
H. influenzae, which may
cause severe exacerbations of chronic BRONCHITIS, as well as MENINGITIS, EPIGLOT
TITIS, SINUSITIS, and
otitis media (see EAR, DISEASES OF). Other species may cause conjunctivitis (see
EYE, DISORDERS OF) or
CHANCROID. Haemophilus species are sensitive to a wide range of antibiotics, tho
ugh generally resistant to
penicillin. Infants are routinely immunised with Haemophilus B vaccine to preven
t meningitis, septicaemia
and epiglottitis all potentially fatal disesases.
Haemopoietic Stem Cell This is the basic cell from which all types of bl
ood cells originate. Its
appearance is believed to be similar to that of a LYMPHOCYTE.
Haemopoiesis The formation of blood cells and PLATELETS a continuous pro
cess throughout life. As
ageing cells are removed from the circulation, new ones, generated in the BONE M
ARROW, replace them.
Haemoptysis The coughing-up of blood from the lungs. The blood is usuall
y bright red and frothy, thus
distinguishing it from blood brought up from the stomach. It is a potentially se
rious sign of lung disease,
although in elderly people haemoptysis may be due to a varicose condition of the
small veins in the throat.
In young people this condition is often due to bleeding from the nose, in which,
owing to the position of
the head, the
H
312 Haemorrhage
blood happens to run backwards instead of forwards through the nostrils.
(See also HAEMORRHAGE;
TUBERCULOSIS.)
Haemorrhage
H
The escape of blood from any of the blood vessels, normally in response
to some trauma, or as a result
of a clotting disorder such as HAEMOPHILIA. The bleeding may be external for exa
mple, following a skin
laceration; or it may be internal for example, haematemesis (bleeding into the s
tomach), haemoptysis
(bleeding from the lungs), or haematuria (bleeding from the kidneys or urinary t
ract). For more information
about these conditions, see separate entries. Bleeding into or around the brain
is a major concern
following serious head injuries, or in newborn infants following a difficult lab
our. Haemorrhage is
classified as arterial the most serious type, in which the blood is bright red a
nd appears in spurts (in
severe cases the patient may bleed to death within a few minutes); venous less s
erious (unless from torn
varicose veins) and easily checked, in which the blood is dark and wells up grad
ually into the wound; and
capillary, in which the blood slowly oozes out of the surface of the wound and s
oon stops spontaneously.
Haemorrhage is also classified as primary, reactionary, and secondary (see WOUND
S). Severe haemorrhage
causes SHOCK and ANAEMIA, and blood TRANSFUSION is often required. When a small
artery is cut across, the
bleeding stops in consequence of changes in the wall of the artery on the one ha
nd, and in the constitution
of the blood on the other. Every artery is surrounded by a fibrous sheath, and w
hen cut, the vessel
retracts some little distance within this sheath and a blood clot forms, blockin
g the open end (see
COAGULATION). When a major blood vessel is torn, such spontaneous closure may be
impossible and surgery is
required to stop the bleeding. Three main principles are applicable in the contr
ol of a severe external
haemorrhage: (a) direct pressure on the bleeding point or points; (b) elevation
of the wounded part; (c)
pressure on the main artery of supply to the part. Control of internal haemorrha
ge is more difficult than
that of external bleeding. First-aid measures should be taken while professional
help is sought. The
patient should be laid down with legs raised, and he or she should be reassured
and kept warm. The mouth
may be kept moist but no fluids should be given. (See APPENDIX 1: BASIC FIRST AI
D.)
Haemorrhoids Haemorrhoids, or piles, are varicose (swollen)
veins in the lining of the ANUS. They are very common, affecting nearly
half of the UK population at
some time in their lives, with men having them more often and for a longer time.
Hallux Rigidus
tively mild, but do not remedy the underlying disorder. If conservative
measures fail, then surgery may
be required. Piles may be injected, stretched or excised according to the patien
ts particular
circumstances. Where haemorrhoids are secondary to another disorder, such as can
cer of the rectum or colon,
the underlying condition must be treated hence the importance of medical advice
if piles persist.
Haemosiderosis An increase in the amount of iron stored in the body. Rar
ely, it may be due to ingestion
of too much iron, but a more likely cause is repeated blood transfusions. The ex
tra iron may affect the
function of the heart and liver.
Haemostasis The process by which bleeding stops. It involves constrictio
n of blood vessels, the
formation of a platelet plug, and blood clotting. The term is also used for surg
ical interventions to stop
bleeding for example, the use of diathermy. (See COAGULATION; HAEMORRHAGE.)
Haemostatics A group of drugs used to treat bleeding disorders such as H
AEMOPHILIA. Factor VIII is one
of the clotting factors available for treatment: preparations of it are injected
after abnormal bleeding or
before surgery. Vitamin K preparations are another haemostatic group used to tre
at an overdose of
ANTICOAGULANTS. Haemostatic preparations of gelatine and cellulose are used to s
tem bleeding from the skin
and gums, or as a result of tooth extractions.
Haemothorax An effusion of blood into the PLEURAL CAVITY.
Hair, Removal of See DEPILATION.
Hair See SKIN; WHITE HAIR.
Half Life The time taken for the PLASMA concentration of an administered
drug to decline by half as a
result of redistribution, METABOLISM and EXCRETION.
Halfway House A residential home for mentally ill individuals where they
can live under supervision
after discharge from hospital. They may be fit to work but cannot manage an inde
pendent life.
313
Halibut-Liver Oil The oil expressed from fresh, or suitably preserved, h
alibut liver. It is a
particularly rich source of vitamin A (30,000 international units per gram), and
also contains vitamin D
(2,300 2,500 units per gram). It is available in capsules as a means of providing
the two vitamins. (See
APPENDIX 5: VITAMINS.)
Halitosis Bad breath. This may be a sign of illness for example, lung di
sease or SINUSITIS; and a
person with DIABETES MELLITUS may have breath tainted with acetone if his or her
sugar metabolism is poorly
controlled. Usually, however, halitosis is caused by smoking, drinking alcohol,
eating certain foods
(garlic or onions), or inadequate oral and dental hygiene.
Hallucinations False perceptions arising without an adequate external st
imulus, as opposed to
illusions, which are misinterpretations of stimuli arising from an external obje
ct. Hallucinations come
from within, although the affected individual may see them as coming from without. N
evertheless, they
may occur at the same time as real perceptions, and may affect any sense (vision
, hearing, smell, taste,
touch, etc.).
Causes They may be the result of intense emotion or suggestion, sensory
deprivation (for example,
overwork or lack of sleep), disorders of sense organs, or disorders of the centr
al nervous system. Although
hallucinations may occur in perfectly sane people, they are more commonly an ind
ication of a MENTAL
ILLNESS. They may be deliberately induced by the use of HALLUCINOGENS. Hallucino
gens Compounds
characterised by their ability to produce distortions of perception, emotional c
hanges, depersonalisation,
and a variety of effects on memory and learned behaviour. They include CANNABIS,
LYSERGIC ACID DIETHYLAMIDE
(LSD) and MESCALINE. (See also DEPENDENCE.)
Hallux The anatomical name of the great toe.
Hallux Rigidus Stiffness of the joint between the great toe and the foot
, which induces pain on
walking. It is usually due to a crush injury or stubbing of the toe. Such stubbi
ng is liable to occur in
adolescents with a congenitally long toe. If troubleH
Hapten
315
ensure that these are user-friendly to such individuals. 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 th
e neck either suddenly, as in
judicial hanging (although not in the United Kingdom, as the death penalty is no
t used in the UK justice
system), so as to damage the spinal column and cord, or in such a way as to cons
trict the AIR PASSAGES and
the blood vessels to the brain. Death is, in any case, speedy, resulting in 23 mi
nutes if not
instantaneously. Apart from judicial hanging, and in the absence of any signs of
a struggle, hanging is
usually due to SUICIDE. 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 tender
condition; treatment
consists of reducing trauma, and the use of EMOLLIENTS and ANTIBIOTICS if necess
ary.
Hansens Disease The bones of the right hand and wrist (anterior view). Bo
nes marked (c) form the
carpal group of bones.
has no connection with foot and mouth disease in cattle, deer, pigs and
sheep.
Handicap The inability to carry out a social, occupational or other acti
vity that could normally be
done by a person without such a handicap. The handicap may be partial or complet
e, physical or mental, and
may result from disease, injury or inherited disorder. The extent of the handica
p is measured against the
normal function of those in a peer group. The impairment may be functionally rat
her than physically based,
in which case the affected person may not always be aware of it until revealed b
y a clinical examination.
Considerable government and voluntary community efforts have been made to lessen
the day-to-day
difficulties of living faced by disabled people. Increasingly, public buildings,
houses and vehicles are
being modified to
See LEPROSY.
Hantavirus A group of viruses that infect mice, rats and voles and can a
lso infect humans who come into
contact with the excreta or secretions of these animals. Widely distributed in A
sia, the USA and Europe, in
Britain hantavirus usually affects rural and sewage workers, as well as people e
ngaged in watersports. Many
victims have a mild feverish illness; severe cases are characterised by headache
, high temperature, nausea,
vomiting and even shock, accompanied by skin PETECHIAE. The kidneys and sometime
s the lungs are affected,
and in severely affected patients mortality is high.
Haploid An adjective describing organisms, cells or nuclei that have a s
ingle set of unpaired
CHROMOSOMES. Human beings have haploid gametes (see GAMETE) following MEIOSIS.
Hapten See ANTIGEN.
H
MINE DRUGS,
HDA See HEALTH DEVELOPMENT AGENCY (HDA).
Head See BRAIN; FACE; SCALP; SKULL.
Headache A very common condition which may vary considerably in severity
, type, significance and cause.
At one extreme, headache may indicate the presence of a tumour or MENINGITIS, wh
ile at the other it may
merely indicate a common cold or tiredness. Even so, persistent or recurrent hea
daches should always be
taken seriously. Although the brain itself is insensitive to pain, the surroundi
ng membranes meninges
are very sensitive, and changes in intracranial arteries, or spasm of the neck o
r scalp muscles, which may
occur for various reasons, may cause considerable pain. In most cases a clinical
diagnosis should be
possible; further investigations should only be necessary following head injury,
if headaches recur, or if
neurological signs such as drowsiness, vomiting, confusion, seizures or focal si
gns develop. Stress and
anxiety are probably the most common causes of headache and, where possible, the
reasons overwork, family
problems, unemployment, financial difficulties, etc. should be tackled. An unple
asant environment such as
traffic pollution or badly ventilated or overcrowded working conditions may prov
oke headaches in some
people, as may excessive smoking or caffeine intake. MIGRAINE is a characteristi
c and often disabling type
of headache; high blood pressure may cause the condition (see HYPERTENSION); and
, occasionally, refractive
errors of the eyes (see EYE, DISORDERS OF) are associated with headaches. SINUS
infections are often
characterised by frontal headaches. Rheumatism in the muscles of the neck and sc
alp produce headaches;
fever is commonly accompanied by a headache; and sunstroke and HEAT STROKE custo
marily result in headaches.
Finally, diseases in the brain such as meningitis, tumours and HAEMORRHAGE may f
irst manifest themselves as
persistent or recurrent headaches.
Treatment Obtaining a reliable diagnosis with the help of further invest
igations, including CT (see
COMPUTED TOMOGRAPHY) or MRI scanning when indicated should always be the
Health-Care Priorities
initial aim; treatment in most cases should then be aimed at the underly
ing condition. Particular
concerns include headache that worsens at night or in the early morning; ever-in
creasing headaches; those
associated with abnormal neurological signs on examination; or those associated
with fits (see FIT).
Whether the cause is physical or stressinduced, used sensibly and for a limited
period a low dose of
aspirin or paracetamol may be helpful. In many cases of stress-induced headache,
however, the most
effective treatment is relaxation. There are many specific treatments for migrai
ne and hypertension.
Sinusitis is treated with antibiotics and sometimes by surgery.
Head Injury Any injury to the head, whether associated with a skull frac
ture (see BONE, DISORDERS OF
Bone fractures) or not. Patients with head injuries should be assessed for signs
of neurological damage,
which may not develop at once. Patients who after a head injury are or have been
UNCONSCIOUS or who are
drowsy, vomiting, confused or have any focal neurological signs for example, blu
rred vision or a motor or
sensory malfunction should be seen by a doctor. Particular care should be taken
with individuals who have
consumed alcohol and sustained a head injury in a fight, fall or vehicle acciden
t. Symptoms indicative of a
severe head injury may be attributed (wrongly) to the effects of alcohol, and cr
ucial time thus lost in
treating the injury. In hospital the possible need for urgent action is monitore
d by use of the GLASGOW
COMA SCALE. People suffering the results of such injuries and their relatives ca
n obtain help and advice
from Headway the brain injury association.
Heaf Test A skin test to find out if a person is immune to TUBERCULOSIS.
TUBERCULIN (a preparation
derived from the TUBERCLE bacillus) is injected via punctures in the skin of the
forearm, using a
spring-loaded gunlike instrument with six very short needles set in circular for
m. A positive test is
indicated by a red raised reaction of the skin: this means that the subject is i
mmune. If the result is
negative, the subject can be given BCG VACCINE.
Healing See WOUNDS.
Health The state of health implies much more than
317
freedom from disease, and good health may be defined as the attainment a
nd maintenance of the highest
state of mental and bodily vigour of which any given individual is capable. Envi
ronment, including living
and working conditions, plays an important part in determining a persons health.
The UK government is now
placing much greater emphasis on health promotion and the prevention of disease,
and has published national
targets for reducing the incidence of some major diseases. The 1978 World Health
Organisation statement
declares that primary care should be made universally accessible to individuals a
nd families in the
community, by means acceptable to them, through their full participation, and at
the cost that the
community and country can afford to maintain in the spirit of self-reliance . .
. [and] addresses the main
health problems in the community, providing promotive, preventative, curative an
d rehabilitative services
accordingly. Factors affecting access to health include finance, ideology, and ed
ucation. (See PUBLIC
ENVIRONMENT AND HEALTH; HEALTH.)
Health and Safety Executive (HSE) The statutory body in Britain responsi
ble for the health and safety
of workers. The address of the HSE can be found in APPENDIX 7: STATUTORY ORGANIS
ATIONS.
Health-Care Priorities As the needs and demands of patients, and the cos
ts of health care of
populations, have risen sharply in recent years, governments and health-care pro
viders whether
tax-funded, insurance-based, employer-provided or a mix of these have had increa
singly to face the
dilemma of what services a country or a community can afford to provide. As a re
sult, various techniques
for deciding priorities of care and treatment are evolving. In the United Kingdo
m, priorities were for many
years based on the decisions of individual clinicians who had wide freedom to pr
escribe the most
appropriate care. Increasingly, this clinical freedom is being circumscribed by
managerial, community and
political decisions driven in part by the availability of resources and by what
people want. Rationing
services, however, is not popular and as yet no broadly agreed consensus has eme
rged, either in western
Europe or in North America, as to how priorities can be decided that have broad
community support and which
can be afforded. (See CLINICAL GOVERNANCE; EVIDENCE-BASED MEDICINE.)
H
bines a range of
qualitative and quantitative evidence in preparing conclusions. Applications of
the assessments include
appraisal of national policies, local urban planning, and the progress of transp
ort, water and agricultural
projects.
Health Promotion A surveillance plan based on a community, and aimed at
maintaining an optimum state of
health and quality of life for those who make up the community both as individua
ls and as a group.
Programmes would include immunisation targets, health education and screening te
sts, as well as
environmental procedures such as monitoring atmosphere, improving housing, water
and food supplies, and
encouraging safe and healthy working practices. (See ENVIRONMENT AND HEALTH; PUB
LIC HEALTH.)
Health Service Commissioner An official, responsible to the United Kingd
oms parliament, appointed to
protect the interests of National Health Service patients in matters concerning
the administration of the
health service and the delivery of health care (excluding clinical judgements).
Known colloquially as the
health ombudsman, the Commissioner presents regular reports on the complaints de
alt with.
Health-Service Management The administrative machinery for planning, del
ivering and monitoring health
care provided by health professionals and their supporting staff. This may range
from running a small
primary-care centre to organising a large hospital or being responsible for meet
ing the health needs of a
region or a nation. Whether the overall structure for proving care is statefunde
d, insurance-based,
private-practice or a mixture of these, health-service management is essential i
n an era of rapidly
evolving and expensive scientific medicine. Health-service managers are administ
rators with special
training and skills in managing health care; sometimes they are doctors, nurses
or other health
professionals, but many have been trained in management in commercial, civil ser
vice or industrial
environments.
Heart 319
Health Visitors Health visitors are community nurses with a special trai
ning who form an important part
of the primary health-care team. Working in close conjunction with general pract
itioners, they are
primarily responsible for illness prevention and health screening and education
of children and elderly
people in the community.
Healthcare Commission (Commission for Health Improvement) Launched in 19
99 in England and Wales as CHI,
this is an inspectorate charged with protecting patients from unacceptable failin
gs in the National Health
Service. A statutory body under the 1999 Health Act, it evaluates and refines loc
al systems designed to
safeguard standards of clinical quality. Working separately from the NHS and the
health departments, it
offers an independent safeguard that provides systems to monitor and improve cli
nical quality in primary
care, community services and hospitals. As of 2004 it became responsible for dea
ling with patients
complaints if they could not be settled by the trust concerned. The board member
s include health
professionals, academics and eight lay members. Scotland has set up a similar st
atutory body. (See APPENDIX
7: STATUTORY ORGANISATIONS.)
Hearing See DEAFNESS; EAR.
Hearing Aids Nearly two-thirds of people aged over 70 have some degree o
f hearing impairment (see
DEAFNESS). Hearing aids are no substitute for definitive treatment of the underl
ying cause of poor hearing,
so examination by an ear, nose and throat surgeon and an audiologist is sensible
before a hearing aid is
issued (and is essential before one can be given through the NHS). The choice of
aid depends on the age,
manipulative skills, and degree of hearing impairment of the patient and the und
erlying cause of the
deafness. The choice of hearing aid for a deaf child is particularly important,
as impaired hearing can
hinder speech development. Electronic aids consist, essentially, of a microphone
, an amplifier, and an
earphone. In postaural aids the microphone and amplifier are contained in a smal
l box worn behind the ear
or attached to spectacles. The earphone is on a specially moulded earpiece. Some
patients find it difficult
to manipulate the controls of an aid worn behind the ear, and they may be better
off with a device worn on
the body. Some hearing
aids are worn entirely within the ear and are very discreet. They are pa
rticularly useful for people
who have to wear protective headgear such as helmets. The most sophisticated aid
s sit entirely within the
ear canal so are virtually invisible. They may be tuned so that only the frequen
cies the wearer cannot hear
are amplified. Many have a volume control and a special setting for use with tel
ephone and in rooms fitted
with an inductive coupler that screens out background noise. In making a choice
therefore from the large
range of effective hearing aids now available, the expert advice of an ear speci
alist must be obtained. The
RNID (Royal National Institute for Deaf People) provides a list of clinics where
such a specialist can be
consulted. It also gives reliable advice concerning the purchase and use of hear
ing aids a worthwhile
function, as some aids are very expensive.
Heart A hollow muscular pump with four cavities, each provided at its ou
tlet with a valve, whose
function is to maintain the circulation of the blood. The two upper cavities are
known as atria; the two
lower ones as ventricles. The term auricle is applied to the ear-shaped tip of t
he atrium on each side.
Shape and size In adults the heart is about the size and shape of a clen
ched fist. One end of the heart
is pointed (apex); the other is broad (base) and is deeply cleft at the division
between the two atria. One
groove running down the front and up the back shows the division between the two
ventricles; a circular,
deeper groove marks off the atria above from the ventricles below. The capacity
of each cavity is somewhere
between 90 and 180 millilitres.
Structure The heart lies within a strong fibrous bag, known as the peric
ardium. Since the inner surface
of this bag and the outer surface of the heart are both covered with a smooth, g
listening membrane faced
with flat cells and lubricated by a little serous fluid (around 20 ml), the move
ments of the heart are
accomplished almost without friction. The main thickness of the heart wall consi
sts of bundles of muscle
fibres, some of which run in circles right around the heart, and others in loops
, first round one cavity,
then round the corresponding cavity of the other side. Within all the cavities i
s a smooth lining membrane,
continuous with that lining the vessels which open into the heart. The investing
smooth
H
Murmurs heard accompanying these sounds indicate defects in the valves, and may
be a sign of heart disease
(although many murmurs, especially in children, are innocent).
Action At each heartbeat the two atria contract and expel their contents
into the ventricles, which at
the same time they stimulate to contract together, so that the blood is driven i
nto the arteries, to be
returned again to the atria after having completed a circuit in about 15 seconds
through the body or lungs
as the case may be. The heart beats from 60 to 90 times a minute, the rate in an
y given healthy person
being about four times that of the respirations. The heart is to some extent reg
ulated by a nerve centre in
the MEDULLA, closely connected with those centres which govern the lungs and sto
mach, and nerve fibres pass
to it in the vagus nerve. The heart rate and force can be diminished by some of
these fibres, by others
increased, according to the needs of the various organs of the body. If this ner
ve centre is injured or
poisoned for example, by lack of oxygen the heart stops beating in human beings;
although in some of
the lower animals (e.g. frogs, fishes and reptiles) the heart may under favourab
le conditions go on beating
for hours even after its entire removal from the body.
Heart, Artificial A mechanical device in the chest that enhances or take
s over the pumping action of
the HEART, thus maintaining the necessary level of circulation of blood through
the lungs and other body
structures. An artificial heart was first used in humans in 1985 and the three t
ypes in use are: an
intra-aortic balloon pump, driven by compressed air, which inflates a balloon in
the AORTA with every
heartbeat, increasing the volume of circulating blood; an electrical device that
assists the left VENTRICLE
by pumping blood into the abdominal aorta; and a mechanical artificial heart tha
t replaces a diseased heart
that has been removed. As yet there is no artificial heart suitable for long-ter
m use. Existing devices are
intended to tide over a patient who is extremely ill until a live heart can be t
ransplanted from a donor.
The results from artificial hearts have been disappointing because of complicati
ons and also because the
patients have usually been already dangerously ill.
Heart, Diseases of Heart disease can affect any of the structures of the
HEART and may affect more than
one at a
Heart, Diseases of
time. Heart attack is an imprecise term and may refer to ANGINA PECTORIS
(a symptom of pain originating
in the heart) or to coronary artery thrombosis, also called myocardial infarctio
n.
Arrhythmias An abnormal rate or rhythm of the heartbeat. The reason is a
disturbance in the electrical
impulses within the heart. Sometimes a person may have an occasional irregular h
eartbeat: this is called an
ECTOPIC beat (or an extrasystole) and does not necessarily mean that an abnormal
ity exists. There are two
main types of arrhythmia: bradycardias, where the rate is slow fewer than 60 bea
ts a minute and sometimes
so slow and unpredictable (heartblock) as to cause blackouts or heart failure; a
nd tachycardia, where the
rate is fast more than 100 beats a minute. A common cause of arrhythmia is coron
ary artery disease, when
vessels carrying blood to the heart are narrowed by fatty deposits (ATHEROMA), t
hus reducing the blood
supply and damaging the heart tissue. This condition often causes myocardial inf
arction after which
arrhythmias are quite common and may need correcting by DEFIBRILLATION (applicat
ion of a short electric
shock to the heart). Some tachycardias result from a defect in the electrical co
nduction system of the
heart that is commonly congenital. Various drugs can be used to treat arrhythmia
s (see ANTIARRHYTHMIC
DRUGS). If attacks constantly recur, the arrhythmia may be corrected by electric
al removal of dead or
diseased tissue that is the cause of the disorder. Heartblock is most effectivel
y treated with an
artificial CARDIAC PACEMAKER, a battery-activated control unit implanted in the
chest.
321
the muscle of the heart ventricles. This reduces the muscles efficiency,
the ventricles fail to relax
properly and do not fill sufficiently during DIASTOLE. In the dilated type of ca
rdiomyopathy, both
ventricles overdilate, impairing the efficiency of contraction and causing conge
stion of the lungs. In the
restrictive variety, proper filling of the ventricles does not occur because the
muscle walls are less
elastic than normal. The result is raised pressure in the two atria (upper cavit
ies) of the heart: these
dilate and develop FIBRILLATION. Diagnosis can be difficult and treatment is sym
ptomatic, with a poor
prognosis. In suitable patients, heart TRANSPLANTATION may be considered. Disord
ers of the heart muscle may
also be caused by poisoning for example, heavy consumption of alcohol. Symptoms
include tiredness,
palpitations (quicker and sometimes irregular heartbeat), chest pain, difficulty
in breathing, and swelling
of the legs and hands due to accumulation of fluid (OEDEMA). The heart is enlarg
ed (as shown on chest
X-ray) and ECHOCARDIOGRAPHY shows thickening of the heart muscle. A BIOPSY of he
art muscle will show
abnormalities in the cells of the heart muscle. Where the cause of cardiomyopath
y is unknown, as is the
case with most patients, treatment is symptomatic using DIURETICS to control hea
rt failure and drugs such
as DIGOXIN to return the heart rhythm to normal. Patients should stop drinking a
lcohol. If, as often
happens, the patients condition slowly deteriorates, heart transplantation should
be considered.
Cardiomyopathy Any disease of the heart muscle that results in weakening
of its contractions. The
consequence is a fall in the efficiency of the circulation of blood through the
lungs and remainder of the
body structures. The myopathy may be due to infection, disordered metabolism, nu
tritional excess or
deficiency, toxic agents, autoimmune processes, degeneration, or inheritance. Of
ten, however, the cause is
not identified. Cardiomyopathies are less common than other types of heart disea
ses, and the incidence of
different types of myopathy (see below) is not known because patients or doctors
are sometimes unaware of
the presence of the condition. The three recognised groups of cardiomyopathies a
re hypertrophic, dilated
and restrictive. Hypertrophic myopathy, a familial condition, is characterised b
y great enlargement of
Congenital heart disease accounts for 12 per cent of all cases of organic
heart disease. It may be
genetically determined and so inherited; present at birth for no obvious reason;
or, in rare cases, related
to RUBELLA in the mother. The most common forms are holes in the heart (atrial s
eptal defect, ventricular
septal defect see SEPTAL DEFECT), a patent DUCTUS ARTERIOSUS, and COARCTATION OF
THE AORTA. Many complex
forms also exist and can be diagnosed in the womb by fetal echocardiography whic
h can lead to elective
termination of pregnancy. Surgery to correct many of these abnormalities is feas
ible, even for the most
severe abnormalities, but may only be palliative giving rise to major difficulti
es of management as the
children become older. Heart transplantation is now increasingly employed for th
e uncorrectable lesions.
H
Heart-Lung Machine
coronary thrombosis, provided that the patient does not have a high bloo
d pressure and is not
overweight. Following recovery, there should be a gradual return to work, care b
eing taken to avoid any
increase in weight, unnecessary stress and strain, and to observe moderation in
all things. Smoking must
stop. In uncomplicated cases patients get up and about as soon as possible, most
being in hospital for a
week to ten days and back at work in three months or sooner.
Valvular heart disease primarily affects the mitral and aortic valves wh
ich can become narrowed
(stenosis) or leaking (incompetence). Pulmonary valve problems are usually conge
nital (stenosis) and the
tricuspid valve is sometimes involved when rheumatic heart disease primarily aff
ects the mitral or aortic
valves. RHEUMATIC FEVER, usually in childhood, remains a common cause of chronic
valvular heart disease
causing stenosis, incompetence or both of the aortic and mitral valves, but each
valve has other separate
causes for malfunction. Aortic valve disease is more common with increasing age.
When the valve is
narrowed, the heart hypertrophies and may later fail. Symptoms of angina or brea
thlessness are common and
dizziness or blackouts (syncope) also occur. Replacing the valve is a very effec
tive treatment, even with
advancing age. Aortic stenosis may be caused by degeneration (senile calcific),
by the inheritance of two
valvular leaflets instead of the usual three (bicuspid valve), or by rheumatic f
ever. Aortic incompetence
again leads to hypertrophy, but dilatation is more common as blood leaks back in
to the ventricle.
Breathlessness is the more common complaint. The causes are the same as stenosis
but also include
inflammatory conditions such as SYPHILIS or ANKYLOSING SPONDYLITIS and other dis
orders of connective
tissue. The valve may also leak if the aorta dilates, stretching the valve ring
as with HYPERTENSION,
aortic ANEURYSM and MARFANS SYNDROME an inherited disorder of connective tissue t
hat causes heart
defects. Infection (endocarditis) can worsen acutely or chronically destroy the
valve and sometimes lead to
abnormal outgrowths on the valve (vegetations) which may break free and cause de
vastating damage such as a
stroke or blocked circulation to the bowel or leg.
Mitral valve disease leading to stenosis is rheumatic in origin. Mitral
incompetence may be rheumatic
but in the absence of stenosis can be due to ISCHAEMIA, INFARCTION, inflamma323
tion, infection and a congenital weakness (prolapse). The valve may also
leak if stretched by a
dilating ventricle (functional incompetence). Infection (endocarditis) may affec
t the valve in a similar
way to aortic disease. Mitral symptoms are predominantly breathlessness which ma
y lead to wheezing or
waking at night breathless and needing to sit up or stand for relief. They are m
ade worse when the heart
rhythm changes (atrial fibrillation) which is frequent as the disease becomes mo
re severe. This leads to a
loss of efficiency of up to 25 per cent and a predisposition to clot formation a
s blood stagnates rather
than leaves the heart efficiently. Mitral incompetence may remain mild and be of
no trouble for many years,
but infection must be guarded against (endocarditis prophylaxis).
Endocarditis is an infection of the heart which may acutely destroy a va
lve or may lead to chronic
destruction. Bacteria settle usually on a mild lesion. Antibiotics taken at vuln
erable times can prevent
this (antibiotic prophylaxis) for example, before tooth extraction. If establish
ed, lengthy intravenous
antibiotic therapy is needed and surgery is often necessary. The mortality is 30
per cent but may be higher
if the infection settles on a replaced valve (prosthetic endocarditis). Complica
tions include heart
failure, shock, embolisation (generation of small clots in the blood), and cereb
ral (mental) confusion.
PERICARDITIS is an inflammation of the sac covering the outside of the heart. Th
e sac becomes roughened and
pain occurs as the heart and sac rub together. This is heard by stethoscope as a
scratching noise
(pericardial rub). Fever is often present and a virus the main cause. It may als
o occur with rheumatic
fever, kidney failure, TUBERCULOSIS or from an adjacent lung problem such as PNE
UMONIA or cancer. The
inflammation may cause fluid to accumulate between the sac and the heart (effusi
on) which may compress the
heart causing a fall in blood pressure, a weak pulse and circulatory failure (ta
mponade). This can be
relieved by aspirating the fluid. The treatment is then directed at the underlyi
ng cause.
Heart-Lung Machine A device that temporarily takes over the function of
the heart and lungs. It is used
in certain operations in the chest, giving the surgeon more time for operations
such as open-heart surgery,
heart transplants and heart-lung transplants. The machine also ensures an operat
ing area largely free of
blood, which helps the surgeon to work more quickly. A pump replaces the heart
H
HELLP Syndrome
Heat collapse is characterised by fatigue, giddiness, and temporary loss
of consciousness. It is
accompanied by HYPOTENSION and BRADYCARDIA; there may also be vomiting and muscu
lar cramps. Urinary volume
is diminished. Recovery is usual.
Heat
exhaustion is
characterised by increasing weakness, dizziness and insomnia. In the maj
ority of sufferers, sweating is
defective; there are few, if any, signs of dehydration. Pulse rate is normal, an
d urinary output good. Body
temperature is usually 378383 C.
Heat cramps (usually in the legs, arms or back, and occasionally involvi
ng the abdominal muscles) are
associated with hard physical work at a high temperature. Sweating, pallor, head
ache, giddiness and intense
anxiety are present. Body temperature is only mildly raised. Heat hyperpyrexia i
s heralded by energy loss
and irritability; this is followed by mental confusion and diminution of sweatin
g. The individual rapidly
becomes restless, then comatose; body temperature rises to 4142 C or even higher.
The condition is fatal
unless expertly treated as a matter of urgency.
Treatment With the first two syndromes, the affected individual must be
removed immediately to a cool
place, and isotonic saline administered intravenously in a severe case. The four
th syndrome is a medical
emergency. The patient should be placed in the shade, stripped, and drenched wit
h water; fanning should be
instigated. He or she should be wrapped in a sheet soaked in cool water and fann
ing continued. When rectal
temperature has fallen to 39 C, the patient is wrapped in a dry blanket. Immediat
ely after consciousness
returns, normal saline should be given orally; this usually provokes sweating. T
he risk of circulatory
collapse exists. Convalescence may be protracted and the patient should be repat
riated to a cool climate.
Prophylactically, personnel intended for work in a tropical climate must be very
carefully selected.
Adequate acclimatisation is also essential; severe physical exertion must be avo
ided for several weeks, and
light clothes should be worn. The diet should be light but nourishing, and fluid
intake adequate. Those
performing hard physical work at a very high ambient temperature should receive
sodium chloride
supplements. Attention to ventilation and air-conditioning is essential; fans ar
e also of value.
325
Hebephrenia A form of SCHIZOPHRENIA that comes on in youth and is marked
by depression and gradual
failure of mental faculties with egotistic and self-centred delusions.
Heberdens Nodes Small hard knobs which appear at the sides of the last ph
alanges of the fingers in
people who have OSTEOARTHRITIS.
Heel The heel is the hind part of the foot, formed by the CALCANEUS and
the especially thick skin
covering it. It is not subject to many diseases. Severe pain in the heel is some
times a sign of gout or
rheumatism.
Height See WEIGHT AND HEIGHT.
Helicobacter Pylori A bacterium which colonises the stomach. While it ma
y cause no disease, it has a
tendency to produce inflammation gastritis. This may progress in some people to
peptic ulceration (see
PEPTIC ULCER), and even to gastric cancer. The bacterium can be identified on bl
ood testing or, more
accurately, by obtaining a biopsy of the stomach wall by ENDOSCOPY. It can be er
adicated by treatment with
PROTON-PUMP INHIBITORS and antibiotics.
Heliotherapy Sunbathing; the exposure of the body to sunlight to promote
healing.
Helium This is the lightest gas known, with the exception of hydrogen. T
his property renders it of
value in ANAESTHESIA, as its addition to the anaesthetic means that it can be in
haled with less effort by
the patient. Thus it can be used in the presence of any obstruction to the entry
of air to the lungs.
HELLP Syndrome A type of severe PRE-ECLAMPSIA (a disorder affecting some
pregnant women) that affects
various systems in the body. HAEMOLYSIS, raised concentration of the enzymes in
the LIVER, and a low blood
platelet count are among the characteristics (and explain the name HELLP); patie
nts are acutely ill and
immediate termination of pregnancy is necessary. (See also PREGNANCY AND LABOUR.
)
H
326 Helminths
Helminths
H
Another name for parasitic worms such as FLUKES, tapeworms (see TAENIASI
S) and nematodes (see
ASCARIASIS).
body. This most commonly follows a STROKE and occurs when parts of the b
rain serving motor function on
the opposite side of the body are damaged.
Hemianaesthesia
Hemiplegia
Loss of the sense of touch down one side of the body.
PARALYSIS that is limited to one side of the body.
Hemianopia
See CANNABIS.
A term meaning loss of half the usual area of vision. The affected perso
n may see everything clearly to
the left or to the right, the field of vision stopping abruptly at the middle li
ne; they may see things
only when straight ahead of them; or, thirdly, they may see objects far out on b
oth sides, although there
is a wide area straight in front for which they are quite blind. The position of
the blind area is
important in localising the position in the brain of the disease responsible for
the condition.
Hemiatrophy
Hemp Henle, Loop of That part of the nephron (see KIDNEYS) between the p
roximal and distal convoluted
tubules. It extends into the renal medulla as a hairpinshaped loop. The ascendin
g link of the loop actively
transports sodium from the lumen of the tube to the interstitium, and this, comb
ined with the
counter-current flow of fluid through the two limbs of the loop, plays a part in c
oncentrating the urine.
Henoch-Schnlein Purpura
Involuntary movements similar to choreiform (see CHOREA) movements, but
of much greater amplitude and
force. The violent, throwing movements of the limbs are usually unilateral, and
tend to occur acutely as a
result of vascular damage to the mid-brain.
This is an inflammatory condition of the small blood vessels, the cause
of which is not known but may
be an allergic response to food or drugs. Most common among young children, the
inflammation causes blood
to leak into joints, kidneys, intestine and skin. The child presents with a purp
uric rash and stomach pains
which may come and go for weeks. Paracetamol alone is often sufficient to allevi
ate the condition, but
severely ill patients may need corticosteroid drugs. All sufferers need followup
for 12 months to ensure
that they have not developed kidney disease.
Hemicolectomy
Heparin
Atrophy of one side of the body, or of part of the body on one side: for
example, facial hemiatrophy,
in which one-half of the face is smaller than the other, either in the course of
development or as a result
of some nervous disorder.
Hemiballismus
An operation to remove the right or left half of the COLON, usually with
end-to-end ANASTOMOSIS of the
remaining portion of the intestine. This is often used for the treatment of mali
gnant or inflammatory
diseases of the colon.
Hemicrania A headache limited to one side of the head. (See also MIGRAIN
E.)
Hemimelia This consists of defects in the distal part of the extremities
: for example, the absence of a
forearm or hand. Hemimelia is a congenital defect; large numbers of cases result
ed from the administration
of THALIDOMIDE during pregnancy (see also PHOCOMELIA; TERATOGENESIS).
Hemiparesis Paralysis affecting the muscles of one side of the
Heparin is one of the naturally produced ANTICOAGULANTS with a rapid eff
ect, which is thought to act by
neutralising thrombin (see COAGULATION). Inactive when taken orally, it is norma
lly given intravenously
it may be given for a few days, combined with an oral anticoagulant such as warf
arin, to initiate
anticoagulation. Low-dose heparin may be given by subcutaneous injection for lon
ger periods, for the
prophylaxis of DEEP VEIN THROMBOSIS (DVT) or PULMONARY EMBOLISM in high-risk patie
nts, such as those with
obesity or a history of thrombosis, or post-operatively. If haemorrhage occurs,
withdrawal of heparin is
usually sufficient, but protamine sulphate is a rapidly active and specific anti
dote. Prolonged treatment
with heparin may cause osteoporosis (see under BONE, DISORDERS OF).
Hepatitis
Hepatectomy The operation for removal of the LIVER, or part of it.
Hepatic Encephalopathy A neuropsychiatric syndrome caused by disease of
the LIVER, and occurring most
often in patients with CIRRHOSIS see also LIVER, DISEASES OF; it also occurs in
acute form in acute
failure of liver function. The disorder is believed to be the result of biochemi
cal disturbance of brain
function, because the condition is reversible and pathological changes in brain
tissue are rarely found.
The patients intellect, personality, emotions and consciousness are altered but n
eurological signs may or
may not be identified. Apathy, confusion, drowsiness, sometimes CONVULSIONS, spe
ech disturbance and
eventually COMA mark the progress of the condition. The principles of treatment
are to remove the
precipitating causes. These include: URAEMIA; sedative, antidepressant and hypno
tic drugs; gastrointestinal
bleeding; too much protein in the diet; infection; and trauma (including surgica
l operations).
Hepatitis Inflammation of the LIVER which damages liver cells and may ul
timately kill them. Acute
injury of the liver is usually followed by complete recovery, but prolonged infl
ammation after injury may
result in FIBROSIS and CIRRHOSIS. Excluding trauma, hepatitis has several causes
: Viral infections by any
of hepatitis A, B, C, D, or E viruses and also CYTOMEGALOVIRUS (CMV), EPSTEIN BA
RR VIRUS, and HERPES
SIMPLEX. Autoimmune disorders such as autoimmune chronic hepatitis, toxins, alco
hol and certain drugs
ISONIAZID, RIFAMPICIN, HALOTHANE and CHLORPROMAZINE. WILSONS DISEASE. Acute viral
hepatitis causes damage
throughout the liver and in severe infections may destroy whole lobules (see bel
ow). Chronic hepatitis is
typified by an invasion of the portal tract by white blood cells (mild hepatitis
). If these mononuclear
inflammatory cells invade the body (parenchyma) of the liver tissue, fibrosis an
d then chronic disease or
cirrhosis can develop. Cirrhosis may develop at any age and commonly results in
prolonged ill health. It is
an important cause of premature death, with excessive alcohol consumption common
ly the triggering factor.
Sometimes, cirrhosis may be asymptomatic, but common symptoms are weakness, tire
dness, poor appetite,
weight loss, nausea, vomiting, abdominal
327
discomfort and production of abnormal amounts of wind. Initially, the li
ver may enlarge, but later it
becomes hard and shrunken, though rarely causing pain. Skin pigmentation may occ
ur along with jaundice, the
result of failure to excrete the liver product BILIRUBIN. Routine liver-function
tests on blood are used to
help diagnose the disease and to monitor its progress. Spider telangiectasia (ca
328 Hepatocyte
which is very infectious, spreading by faecal contamination from patient
s suffering from (or
incubating) the infection; victims excrete viruses into the faeces for around fi
ve weeks during incubation
and development of the disease. Overcrowding and poor sanitation help to spread
hepatitis A, which
fortunately usually causes only mild disease. Hepatitis B (HBV) is caused by a h
epadna virus, and humans
are the only reservoir of infection, with blood the main agent for transferring
it. Transfusions of
infected blood or blood products, and injections using contaminated needles (com
mon among habitual drug
abusers), are common modes of transfer. Tattooing and ACUPUNCTURE may spread hep
atitis B unless high
standards of sterilisation are maintained. Sexual intercourse, particularly betw
een male homosexuals, is a
significant infection route. Hepatitis C (HCV) is a flavivirus whose source of i
nfection is usually via
blood contacts. Effective screening of blood donors and heat treatment of blood
factors should prevent the
spread of this infection, which becomes chronic in about 75 per cent of those in
fected, lasting for life.
Although most carriers do not suffer an acute illness, they must practise life-l
ong preventive measures.
Hepatitis D (HDV) cannot survive independently, needing HBV to replicate, so its
sources and methods of
spread are similar to the B virus. HDV can infect people at the same time as HBV
, but it is capable of
superinfecting those who are already chronic carriers of the B virus. Acute and
chronic infection of HDV
can occur, depending on individual circumstances, and parenteral drug abuse spre
ads the infection. The
disease occurs worldwide, being endemic in Africa, South America and the Mediter
ranean littoral. Hepatitis
E virus (HEV) is excreted in the stools, spreading via the faeco-oral route. It
causes large epidemics of
water-borne hepatitis and flourishes wherever there is poor sanitation. It resem
bles acute HAV infection
and the patient usually recovers. HEV does not cause chronic infection. The clin
ical characteristics of the
five hepatic viruses are broadly similar. The initial symptoms last for up to tw
o weeks (comprising
temperature, headache and malaise), and JAUNDICE then develops, with anorexia, n
ausea, vomiting and
diarrhoea common manifestations. Upper abdominal pain and a tender enlarged live
r margin, accompanied by
enlarged cervical lymph glands, are usual.
As well as blood tests to assess liver function, there are specific viro
logical tests to identify the
five infective agents, and these are important contributions to diagnosis. Howev
er, there is no specific
treatment of any of these infections. The more seriously ill patients may requir
e hospital care, mainly to
enable doctors to spot at an early stage those developing acute liver failure. I
f vomiting is a problem,
intravenous fluid and glucose can be given. Therapeutic drugs especially sedativ
es and hypnotics should
be avoided, and alcohol must not be taken during the acute phase. Interferon is
the only licensed drug for
the treatment of chronic hepatitis B, but this is used with care. Otherwise-fit
patients under 40 with
acute viral hepatitis have a mortality rate of around 0.5 per cent; for those ov
er 60, this figure is
around 3 per cent. Up to 95 per cent of adults with acute HBV infection recover
fully but the rest may
develop life-long chronic hepatitis, particularly those who are immunodeficient
(see IMMUNODEFICIENCY).
Infection is best prevented by good living conditions. HVA and HVB can be preven
ted by active immunisation
with vaccines. There is no vaccine available for viruses C, D and E, although HD
V is effectively prevented
by immunisation against HBV. At-risk groups who should be vaccinated against HBV
include: Parenteral drug
abusers. Close contacts of infected individuals such as regular sexual partners
and infants of infected
mothers. Men who have sex with men. Patients undergoing regular haemodialysis. S
elected health
professionals, including laboratory staff dealing with blood samples and product
s.
Hepatocyte The main cell type present in the LIVER. A large cell, it has
several important metabolic
functions: these include synthesis and storage of biochemical products; detoxifi
cation of poisons and
unwanted substances; and the manufacture of BILE, the liver secretion that passe
s through the bile ducts to
the small intestine and helps in the digestion of fat.
Hepatolenticular Degeneration See WILSONS DISEASE.
Hepatoma A primary malignant tumour of LIVER cells. It has marked geogra
phical variation, being most
common in parts of Africa and the Far East. It is
Hernia 329
more common in men and with those who have pre-existing CIRRHOSIS.
Hepatomegaly Enlargement of the LIVER. This may be caused by congestion
(e.g. in heart failure),
infection (e.g. HEPATITIS), malignancy, inflammation, or early CIRRHOSIS.
Hepolenticular Degeneration See WILSONS DISEASE.
Herbal Medicine The use of herbs as medicines is probably as old as mank
ind; every culture has its own
traditions. Herbalism was formally established in England by an Act of Parliamen
t during Henry VIIIs
reign. Different parts of a variety of plants are used to treat symptoms and to
restore functions.
Heredity
involve the organs of the abdomen which can herniate externally through
the abdominal wall, or
internally usually through a defect in the diaphragm. External hernias appear as
a swelling, covered with
skin, which bulges out on coughing or straining but which can normally be made t
o disappear with gentle
pressure.
Types Inguinal hernia appears in the groin; less common is femoral herni
a, which appears just below the
groin. Incisional hernia may occur through a defect in any abdominal surgical sc
ar, a paraumbilical hernia
arising just to the side of the umbilicus and an epigastric hernia in the mid li
ne above the umbilicus. In
children, herniation may occur through the umbilicus itself, which is a natural
weak spot. The commonest
internal hernia is a hiatus hernia, when part of the stomach slips upwards into
the chest through the
DIAPHRAGM (see diagram).
The principle on which various peculiarities of bodily form or structure
, or of physical or mental
activity, are transmitted from parents to offspring. (See also GENES.)
Hermaphrodite An individual in whom both ovarian (see OVARand testicular
(see TESTICLE) tissue is
present. 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 s
ides. Both gonads are
usually intra-abdominal. The true hermaphrodite usually has a UTERUS and at leas
t one Fallopian tube (see
FALLOPIAN TUBES) on the side of the ovary, and on the side of the testis there i
s usually a VAS DEFERENS.
Most true hermaphrodites are raised as males, but external virilisation is not u
sually complete. Even when
significant phallic development is present, HYPOSPADIAS and CRYPTORCHIDISM are c
ommon. At puberty,
GYNAECOMASTIA develops and MENSTRUATION is common, as ovarian function is usuall
y more nearly normal than
testicular function. The condition is rare. A more common condition is pseudoher
330 Hernioplasty
H
Diaphragmatic or hiatus hernia showing the stomach pushing through the d
iaphragm 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 spontan
eously 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 the
ir blood supply is cut off,
then strangulation occurs. This is a surgical emergency because the strangulated
organs will soon die or
rupture. When strangulation usually of a loop of intestine does occur, the herni
a becomes irreducible,
red, and very painful. If the hernia contains bowel, then the bowel may also bec
ome obstructed. Treatment
Conservative treatment with a Site of inguinal hernia (shaded).
Causes Hernias may be due to a defect present at birth (congenital), or
may develop later in life
(acquired). Acquired hernias arise due to the development of a defect or injury
of the abdominal wall or
due to increased pressure within the abdominal cavity, which forces the organ th
rough a potential weakness.
Such causes include chronic coughing or excessive straining due to constipation.
compression belt, or truss, is now used only for those unfit for surgery
or while awaiting surgery.
Surgical repair can be at an open operation or by laparoscope, and consists of r
eturning the herniated
organs to their proper place and then repairing the defect through which the her
nia occurred. This may be
done safely under local or general anaesthetic, often as a day-case procedure, a
nd most operative repairs
result in a permanent cure.
Hernioplasty A surgical technique for repair of a
HERNIA.
Herpes Simplex
The abnormal opening is sewn up or the weakness strengthened with suture
s or the insertion of a
polypropylene mesh.
Herniorraphy Surgical repair of a HERNIA. This may be done as an open op
eration or as MINIMALLY
INVASIVE SURGERY (MIS) using a LAPAROSCOPE.
Herniotomy The surgical removal of the sac of connective tissue surround
ing a HERNIA. In children or
healthy young adults with an inguinal hernia, a herniotomy is usually sufficient
to cure the condition.
Heroin Also known as diacetyl morphine or diamorphine, this Class A cont
rolled drug is an opiate a
group which includes morphine, codeine, pethidine and methadone. It is a powerfu
l analgesic and cough
suppressant, but its capacity to produce euphoria rapidly induces DEPENDENCE. Po
pular with addicts, its
mostly pleasant effects soon produce TOLERANCE; the need to inject the drug, wit
h associated risks of HIV
infection, has affected its use by addicts. Withdrawal symptoms include restless
ness, insomnia, muscle
cramps, vomiting and diarrhoea; signs include dilated pupils, raised pulse rate,
and disturbed temperature
control. Although rarely life-threatening, the effects of withdrawal may cause g
reat distress, and for this
reason methadone, which has a slower and less severe withdrawal syndrome, is com
monly used when weaning
addicts off heroin. Legally still available to doctors in the UK, heroin is norm
ally only used in patients
with severe pain, or to comfort the dying.
Herpangina Herpangina is a short febrile illness in which minute vesicle
s or punched-out ulcers develop
in the posterior parts of the mouth. It is due to infection with the group A COX
SACKIE VIRUSES.
Herpes Genitalis An infection of the genitals (see GENITALIA) of either
sex, caused by HERPES SIMPLEX
virus type 2. It is mostly acquired as a result of sexual activity; some cases a
re caused by simplex type
1. After initial infection the virus lies latent in the dorsal nerve root gangli
on (of the spinal cord)
which enervates the affected area of the skin. Latent virus is never cured and r
eactivation results in
either a recurrence of symptoms or in asymptomatic shedding of the virus which t
hen infects a sexual
partner. Around 30,000
331
cases of genital herpes are reported annually from clinics dealing with
SEXUALLY TRANSMITTED DISEASES
(STDS) in England, but there are also many unrecognised (by either patient or do
ctor) infections. Patients
may have a history of painful attacks of ulceration of the genitals for many yea
rs before seeking medical
advice. All patients with a first episode of the infection should be given oral
antiviral treatment, and
those who suffer more than six attacks a year should be considered for suppressi
ve antiviral treatment.
ACICLOVIR, valaciclovir and famciclovir are all effective antiviral drugs. If a
woman in the final three
months of her pregnancy contracts herpes genitalis, this can have serious conseq
uences for the baby as he
or she will be at risk of herpes encephalitis after delivery.
Herpes Simplex An acute infectious disease, characterised by the develop
ment of groups of superficial
vesicles, or blebs, in the skin and mucous membrane. It is due to either simplex
type 1 or 2 virus, and
infection can occur at any time from birth onwards; however the usual time for p
rimary infection with type
1 is between the second and 15th year. Once an individual is infected, the virus
persists in the body for
the rest of their life. It is one of the causes of scrum-pox. Type 2 causes HERP
ES GENITALIS.
Symptoms Symptoms vary with the age of infection. In young infants, herp
es simplex may cause a
generalised infection which is sometimes fatal. In young children the infection
is usually in the mouth,
and this may be associated with enlargement of the glands in the neck, general i
rritability and fever. The
condition usually settles in 710 days. In adults the vesicles may occur anywhere
in the skin or mucous
membranes: the more common sites are the lips, mouth and face, where they are kn
own as cold sores. The
vesicles may also appear on the genitalia (herpes genitalis) or in the conjuncti
va or cornea of the EYE,
and the brain may be infected, causing ENCEPHALITIS or MENINGITIS. The first sig
n is the appearance of
small painful swellings; these quickly develop into vesicles which contain clear
fluid and are surrounded
by a reddened area of skin. Some people are particularly liable to recurrent att
acks, and these often tend
to be associated with some debilitating condition or infection, such as pneumoni
a. Except in the case of
herpes of the cornea, the eruption clears completely unless it becomes contamina
ted with some other
organism. In the
H
Hippocratic Oath
333
Hexamine
Hindbrain
A substance which, when excreted by the kidneys, releases formaldehyde w
hich has an antiseptic action.
It is given to patients with recurrent CYSTITIS. It acts only in urine with an a
cid reaction, and, if the
urine is alkaline, ascorbic acid may acidify it. Hexamine is used prophylactical
ly and for long-term
treatment of recurrent urinary-tract infections.
That part of the BRAIN comprising the cerebellum, pons and medulla oblon
gata.
Hg
The joint formed by the head of the thigh bone and the deep, cup-shaped
hollow on the side of the
pelvis which receives it (acetabulum). The joint is of the ball-and-socket varie
ty, is dislocated only by
very great violence, and is correspondingly difficult to reduce to its natural s
tate after dislocation. It
is enclosed by a capsule of fibrous tissue, strengthened by several bands, of wh
ich the principal is the
ilio-femoral or Y-shaped ligament placed in front of the joint. A round ligament
also unites the head of
the thigh bone to the margin of the acetabulum. For hip-joint disease, see under
JOINTS, DISEASES OF.
The chemical symbol for mercury. BLOOD PRESSURE was traditionally measur
ed in millimetres (mm) of
mercury using a SPHYGMOMANOMETER consisting of an inflatable cuff (usually wrapp
ed round the upper arm)
connected by a rubber tube to a column of mercury calibrated in mm of mercury.
Hiatus Hernia A displacement of a portion of the stomach through the ope
ning in the diaphragm through
which the oesophagus passes from the chest to the abdominal cavity (see HERNIA).
Hiccup An involuntary spasmodic contraction of the DIAPHRAGM which produ
ces an indrawing of breath
during which there is a sudden closure of the vocal cords. This results in the w
ell-known sound and
sensation. It is usually of benign cause (e.g. indigestion) but may be a symptom
of medullary brain damage,
URAEMIA, typhoid fever (see ENTERIC FEVER) or ENCEPHALITIS lethargica. There are
many folk remedies for
hiccups, but most cases subside spontaneously. Prolonged hiccups due to disease
may respond to treatment
with CHLORPROMAZINE or HALOPERIDOL.
High Dependency Unit A hospital unit equipped and staffed to nurse patie
nts who require a high level of
technically supported care. Patients are usually moved to such units when they h
ave made satisfactory
progress in an INTENSIVE THERAPY UNIT (ITU) and do not require the one-to-one nu
rsing necessary in ITUs.
Patients who have undergone major surgery are often transferred from the recover
y ward to a high dependency
unit until they are well enough to be cared for in a standard ward.
Hilum A term applied to the depression on organs such as the lung, kidne
y, and spleen, at which the
vessels and nerves enter it and around which the lymphatic glands cluster. The h
ilum of the lung is also
known as its root.
Hip That part of the body on each side of the pelvis where it articulate
s with the head of the femur
(thigh bone).
Hip-Joint
Hippocrates A famous Greek physician who lived from c.460 to 377 BC and
who taught students at the
medical school in Cos. Often called the father of medicine, he is renowned for dra
wing up the HIPPOCRATIC
OATH, some of which may have been derived from the ancient oath of the Aesclepia
ds. Apart from his oath,
Hippocrates has about 60 other medical works attributed to him, forming a corpus
which was collected around
250 BC in the famous library of Alexandria in Egypt. Hippocratic medicine appeal
ed to reason rather than
to rules or to supernatural forces is how the late Roy Porter, the English social
historian, summed up its
ethos in his medical history, The Greatest Benefit to Mankind (Harper Collins, 1
997). Porter also commended
Hippocrates as being patientcentred rather than disease-orientated in his practi
ce of medicine.
Hippocratic Oath An oath once (but no longer) taken by doctors on qualif
ication, setting out the moral
precepts of their profession and binding them to a code of behaviour and practic
e aimed at protecting the
interests of their patients. The oath is named after HIPPOCRATES (460377 BC), the
Greek father of
medicine. Almost half of British medical students and 98 per cent of American one
s make a ceremonial
commitment to assume the responsibilities and obligations of
H
334 Hippus
the medical profession, but not by reciting this oath.
Hippus Hippus is a tremor of the iris which produces alternating contrac
tion and dilatation of the
pupil (see EYE).
Hirschsprungs Disease
H
Hirschsprungs disease, or MEGACOLON, is a rare congenital disorder charac
terised by great hypertrophy
and dilatation of the colon (see INTESTINE). The RECTUM and lower colon have fai
led to develop a normal
nerve network, thus disturbing normal contraction and expansion of these structu
res. Treatment is surgical
removal of the affected sections, with the remaining colon being joined to the a
nus.
Hirsutism The growth of hair of the male type and distribution in women.
It is due either to the excess
production of androgens (see ANDROGEN), or to undue sensitivity of the hair foll
icle to normal female
levels of circulating androgens. The latter is called idiopathic hirsutism, beca
use the cause is unknown.
The increased production of androgens in the female may come from the ovary (see
OVARIES) and be due to
POLYCYSTIC OVARY SYNDROME or an ovarian tumour, or the excess androgen may come
from the adrenal cortex
(see ADRENAL GLANDS) and be the result of congenital adrenal HYPERPLASIA, an adr
enal tumour or CUSHINGS
SYNDROME. However, there is a wide range of normality in the distribution of fem
ale body hair. It varies
with different racial groups: the Mediterranean races have more body hair than N
ordic women, and the
Chinese and Japanese have little body hair. It is not abnormal for many women, e
specially those with dark
hair, to have hair apparent on the upper lip, and a few coarse hairs on the chin
and around the nipples are
not uncommon. Extension of the pubic hair towards the umbilicus is also frequent
ly found. Dark hair is much
more apparent than fair hair, and this is why bleaching is of considerable benef
it in the management of
hirsutism. The treatment of hirsutism is that of the primary cause. Idiopathic h
irsutism must be managed by
simple measures such as bleaching the hair and the use of depilatory waxes and c
reams. Coarse facial hairs
can be removed by electrolysis, although this is time-consuming. Shaving is ofte
n the most effective remedy
and neither increases the rate of hair growth nor causes the hairs to become coa
rser.
Histamine An amine (see AMINES) derived from HISTIDINE. It is widely dis
tributed in the tissues of
plants and animals, including humans. It is a powerful stimulant of gastric juic
e, a constrictor of smooth
muscle including that of the bronchi, and a dilator of arterioles and capillarie
s. It is this last action
Hookworm
HLA incompatibility causes the immune response, or rejection reaction, t
hat occurs with unmatched
tissue grafts. Strong associations between HLA and susceptibility to certain dis
eases notably the
AUTOIMMUNE DISORDERS such as rheumatoid arthritis, insulin-dependent diabetes, a
nd thyrotoxicosis have
been described. Certain HLA antigens occur together more frequently than would b
e expected by chance
(linkage disequilibrium), and may have a protective effect, conferring resistanc
e to a disease. (See
IMMUNITY.)
Hodgkins Disease See LYMPHOMA.
Holistic A term used for a method of medical care in which patients are
treated as a whole, and which
takes into account their physical and mental state as well as social background
rather than just treating
the disease alone.
Homatropine Homatropine is an alkaloid derived from ATROPINE, which is u
sed to produce dilatation of
the pupil (see EYE) and to paralyse ACCOMMODATION temporarily for the purpose of
examining the interior of
the eye. It is used in 1 per cent solution, and its effects last a few hours.
Homeopathy A system of medicine founded by Hahnemann at the end of the 1
8th century. It is based upon
the theory that diseases are curable by those drugs which produce effects on the
body similar to symptoms
caused by the disease (similia similibus curantur). In administering drugs, the
theory is also held that
their effect is increased by giving them in minute doses obtained by substantial
ly diluting them.
Homeostasis The normal physiological process which ensures that the bodys
internal systems, such as
its metabolism, blood pressure and body temperature, maintain an equilibrium wha
tever the conditions of the
outside environment. For example, the body temperature remains at around 37 C (98
.4 F) in a cold or a hot
climate.
Homocysteine An intermediate product in the bodys synthesis of the amino
acid CYSTEINE.
Homocystinuria Homocystinuria is a congenital disease due to
335
the inability of the affected individual to metabolise, or to utilise pr
operly, one of the essential
AMINO ACIDS known as methionine. The main features of the condition are abnormal
ity of the lens of the EYE,
learning disability, and a tendency to thromboses (blood clots).
Homograft A piece of tissue or an organ, such as a kidney, transplanted
from one animal to another of
the same species: for example, from person to person. It is also known as an all
ograft.
Homosexuality Sexual activity with a member of the same sex. There has b
een considerable debate among
psychiatrists as to whether homosexuality should be regarded as a normal sexual
variant or as a
psycho-pathological development or deviation. Although homosexuality is found in
virtually every society
and culture, there is no society in which it is the predominant or preferred mod
e of sexual activity.
Various attempts have been made to link homosexuality to hormonal factors, parti
cularly lowered
TESTOSTERONE levels, or to find a genetic explanation, but there is no evidence
for either. Psychoanalytic
theories link homosexuality to early child-rearing influences, in particular the
close-binding and intimate
mother. The number of homosexual men and women in the UK is unknown. Re-analysis
of the Kinsey report
suggests that only 3 per cent of adult men have exclusively homosexual leanings
and a further 3 per cent
have extensive homosexual and heterosexual experience. Homosexuality among women
(lesbianism) seems to be
less common. Some homosexual men have high rates of sexual activity and multiple
partners and, as with
heterosexual men and women, this increases the risk of acquiring sexually transm
itted diseases, unless
appropriate precautionary measures are taken for example, the use of condoms for
penetrative sex, whether
vaginal or anal. It was in homosexual males that the virus responsible for AIDS
(see AIDS/HIV) was first
identified, but the infection now occurs in both sexes.
Homozygous An individual having identical members of the pair of genes c
oding for a given
characteristic (see GENES).
Hookworm See ANCYLOSTOMIASIS.
H
Human Genome
337
Hospital Chaplaincy
Housemaids Knee
A service provided by a religious denomination, primarily aimed at meeti
ng the spiritual and religious
needs of patients in hospitals. In the UK, NHS hospital trusts employ both fulltime and part-time
chaplains, usually representing the mainline Christian churches (Anglican, Free
and Roman Catholic). Their
duties vary but always at the least involve meeting the specifically religious n
eeds of patients as well as
of relatives and staff who may ask for help. Public services in chapels, the bed
side administration of the
Word and Sacraments, and prayers and radio services are among chaplains duties. W
hen requested by
patients, chaplains also liaise with representatives of other world faiths. Chap
lains have a broad
responsibility for the spiritual health care of all in hospital. They share this
with other staff members,
particularly the nursing staff, for whom the chaplains can be a resource. Chapla
ins also train and use
volunteers from local churches to help with ward visiting and other chaplaincy d
uties. Much of the time
spent with patients takes the form of a listening ministry, helping patients to
find their own answers to
what is happening to them in hospital and in life generally. Spiritual health ca
n be seen as a quest for
the right relationships in four areas with other people; with oneself; with the
world around; and with
Life itself. The religious person subsumes all that in his/ her relationship to Go
d. The link between
spiritual disease and physical ill-health is well established; the chaplain ther
efore helps a hospital to
provide a HOLISTIC approach to health care. Chaplains also give time to the care
of staff who face
increasing levels of stress at work, making use of support groups, counselling,
meditation, etc. Chaplains
support patients relatives facing a crisis, for example, by being with them over
the period of a death,
and by providing regular bereavement services for those who have lost babies. So
me chaplains have a
particular expertise in ETHICS and are members of the various hospital ethics co
mmittees. A chaplain may
have a nonmanagement view of the health of the hospital itself, which can be of us
e to hospital
management. (See also SPIRITUAL PAIN.)
An inflammation of the bursa in front of the knee-cap, often mistaken fo
r some disease in the joint
itself (see BURSITIS).
Host An organism on which a parasite lives.
Hour-Glass Stomach The term given to the X-ray appearance of a stomach w
hich is constricted in its
middle part due either to spasm of the stomach muscle or to contraction of scar
tissue from a gastric
ulcer.
HRT Hormone Replacement Therapy
see under
MENOPAUSE.
HSE See HEALTH AND SAFETY EXECUTIVE (HSE).
Human Chorionic Gonadotrophin A glycoprotein hormone secreted by the PLA
CENTA in early pregnancy, and
stimulating the CORPUS LUTEUM within the ovary (see OVARIES) to secrete OESTROGE
NS, PROGESTERONE, and
relaxin. The hormone is essential for the maintenance of pregnancy up to about 68
weeks of gestation. A
RADIOIMMUNOASSAY can be used to detect its presence, and pregnancy can be diagno
sed as early as six days
after conception by testing for it in the urine. Some tumours also secrete human
chorionic gonadotrophin,
particularly HYDATIDIFORM MOLE, which produces large amounts.
Human Fertilisation & Embryology Act 1990 See ASSISTED CONCEPTION.
Human Fertilisation & Embryology Authority (HFEA) See ASSISTED CONCEPTIO
N.
Human Genome In simple terms, this is the genetic recipe for making a hu
man being. GENOME is a
combination of the words gene and chromosome, and a genome is defined as all the
genetic material known
as deoxyribonucleic acid, or DNA in a cell. Most genes encode sequences of AMINO
ACIDS, the constituents
of proteins, thus initiating and controlling the replication of an organism. The
identification and
characterisation of the human genetic puzzle have been a key bioscience research
target. The Human Genome
Project was launched in 1990 (and completed in 2003) to produce a full sequence
of the three million base
pairs that make up the human genome. Carried out as two separate exercises one b
y a privately funded
American team; another by an international joint venture between taxfunded Ameri
can laboratories, a
charitably funded British one and several other smaller research teams from arou
nd the world the
H
at its lower end presents a wide pulley-like surface for union with the radius a
nd ulna. Its epicondyles
form the prominences at the sides of the elbow.
Humidification The air we breathe must be moist for the efficient workin
g of the lungs (see
RESPIRATION). Humidification, or moistening of the air, is achieved largely by t
he NOSE, which acts as an
air-conditioner, warming, moistening and filtering the 10,000 litres of air whic
h we inhale daily in the
process of which, incidentally, it produces around 15 litres of secretion daily.
Humidity is expressed as
relative humidity (RH). This is the amount of moisture in the air expressed as a
percentage of the maximum
possible at that temperature. If the temperature of a room is raised without inc
reasing the moisture
content, the RH falls. The average outdoor RH in Britain is around 7080 per cent;
with central heating it
may drop to 25 per cent or lower. This is why humidification, as it is known, of
the air is essential in
buildings heated by modern heating systems. The aim should be to keep the RH at
around 3050 per cent. In
houses this may be achieved quite satisfactorily by having a jug or basin of wat
er in the room, or some
receptacle that can be attached to the heater. In offices, some more elaborate f
orm of humidifier is
necessary. Those suffering from chronic BRONCHITIS are particularly susceptible
to dry air, as are those
individuals with disorders of the EYE because the secretions that bathe the eyes
and keep them moist are
unnaturally dried out. (See also VENTILATION.)
Humidifier Fever A form of ALVEOLITIS caused by contamination of the wat
er used to humidify, or
moisten, the air in air-conditioning plants. The breathing of the contaminated a
ir results in infection of
the lung, which is characterised by fever, cough, shortness of breath and malais
e worse on Monday and
tending to improve during the
Hydradenitis Suppurativa
course of the week. (See
also LEGIONNAIRES
DISEASE.)
Humour An archaic term once used for a theory regarding the causation of
disease as due to an improper
mixture in the body of blood, bile, phlegm and black bile. The term remains in d
escribing some body fluids,
such as the aqueous and vitreous humours of the EYE.
339
when stained and viewed under the microscope. It occurs in a variety of
tissues and diseases,
particularly ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS), hyaline degeneration of
arterioles, and alcoholic
liver disease.
Hyaline Membrane Disease A form of ACUTE RESPIRATORY DISTRESS SYNDROME (
ARDS) found in premature
infants and some of those born by CAESAREAN SECTION,
A craving for food or other substance necessary to bodily activity. Hung
er for food is supposed to be
directly produced by strong contractions of the stomach which occur when it is e
mpty, or nearly so. (See
also THIRST.) Air hunger is an instinctive craving for oxygen resulting in breat
hlessness, either when a
person ascends to great heights where the pressure of air is low, or in some dis
eases such as pneumonia and
DIABETES MELLITUS which affect the bodys METABOLISM and therefore its need for ox
ygen an essential
constituent in this process.
characterised by the onset of difficulty in breathing a few hours after
birth. Most require extra
oxygen and many need mechanical ventilation for a few days or even weeks. Recove
ry is the rule, although
the most severely affected may die or suffer damage from oxygen lack. In this co
ndition the ALVEOLITIS and
the finer BRONCHIOLES of the lungs are lined with a dense membrane. The cause of
the condition is a
deficiency of SURFACTANT in the lung passages which adversely affects gas exchan
ges in the alveoli.
Treatment includes the full gamut of neonatal intensive care, as well as specifi
c therapy with PULMONARY
SURFACTANT.
Huntingtons Chorea
Hyaluronidase
A hereditary disease characterised by involuntary movements and DEMENTIA
. Each child of a parent with
the disease has a 50:50 chance of developing it. Onset is most common between th
e ages of 35 and 45, but 10
per cent of cases occur under the age of 20. Some patients show more severe ment
al disturbance; others more
severe disturbances of movement; but in all it pursues an inexorable downward co
urse over a period of 1020
years to a terminal state of physical and mental helplessness. It is estimated t
hat there are around 6,000
cases in Britain. The defective gene (located on chromosome no. 4) has now been
identified and GENETIC
SCREENING is possible for those at risk. People with Huntingtons chorea and their
relatives can obtain
help and guidance from Huntingtons Disease Association.
Hyaluronidase is an ENZYME which hydrolyses hyaluronic acid. The latter
is a gel-like substance which
is widely distributed throughout the body and which helps to bind together the t
issue cells and also acts
as a lubricant in joints. By virtue of its action in hydrolysing hyaluronic acid
, hyaluronidase is now used
in subcutaneous injections of fluid as it facilitates the spread of the injected
fluid and therefore its
absorption.
Hunger
Hurlers Syndrome See GARGOYLISM.
Hutchinsons Teeth The term applied to the narrowed and notched permanent
incisor teeth which occur in
congenital SYPHILIS. They are so-named after Sir Jonathan Hutchinson (18281913),
the London physician who
first described them.
Hyaline Tissue material that has a glass-like appearance
Hydatid A cyst produced by the growth of immature forms of a tapeworm. (
See TAENIASIS.)
Hydatidiform Mole A rare complication of pregnancy, in which there is tr
emendous proliferation of the
epithelium of the chorion (the outer of the two fetal membranes). It seldom occu
rs during a first
pregnancy. Treatment consists of immediate evacuation of the womb.
Hydradenitis Suppurativa A chronic inflammatory disease of the apocrine
sweat glands (see
PERSPIRATION). It is more common in women in whom it usually occurs in the armpi
t than in men, in whom
it is most common in the perineum of the drivers of lorries and taxis. It occurs
in the form of painful,
tender lumps underneath the skin, which burst
H
340 Hydrallazine
often in a week or so. Treatment consists of removal by operation. A vas
odilator hypotensive drug,
useful as an adjunct to other treatment for HYPERTENSION.
cephalus. The most satisfactory of these utilise unidirectional valves a
nd shunts (tubes), whereby the
cerebrospinal fluid is bypassed from the brain into the right atrium of the hear
t or the peritoneal cavity.
The shunt may have to be left in position indefinitely.
Hydramnios
Hydrochloric Acid
A condition characterised by excess of fluid in the amniotic cavity (see
AMNION).
A colourless, pungent, fuming liquid. Secreted by the parietal cells in
the lining of the stomach, it
aids in the digestion of the food.
Hydrallazine
Hydrocarbamide
H
A drug used to treat chronic myeloid leukaemia (see MYELOID; LEUKAEMIA).
Hydrochlorothiazide
Hydrocephalus
Hydrocoele
An abnormal accumulation of CEREBROSPINAL FLUID, or CSF, within the skul
l, as a result of one or more
of three main causes: (i) excessive CSF production; (ii) defective CSF absorptio
n; (iii) blockage of the
circulation of CSF. Such disturbances in the circulation of the fluid may be due
to congenital reasons
(most commonly associated with SPINA BIFIDA), to MENINGITIS, or to a tumour.
A collection of fluid connected with the testis (see TESTICLE) or sperma
tic cord. When there is no
obvious cause, it is classified as primary: such hydrocoeles are usually large a
nd tense, and are commonly
found in middle-aged and younger men, presenting as a large, painless scrotal sw
elling. Congenital
hydrocoeles may occur in infants, when they are often associated with a hernial
sac (see HERNIA).
Hydrocoele of the cord is rare. Secondary hydrocoele is generally smaller and la
x; it is usually secondary
to a tumour or inflammation of the underlying testis or epididymis.
Symptoms In children, the chief symptoms observed are the gradual increa
se in size of the upper part of
the head, out of all proportion to the face or the rest of the body. The head is
Hyperbaric
fludrocortisone
(see CORTICOSTEROIDS).
ADRENAL
GLANDS;
Hydrogen Peroxide A thick colourless liquid with the formula H2O2 (water
is H2O, possessing only one
oxygen atom in its molecule). Available in solution with water and as a cream, i
t is readily reduced to
water giving up oxygen in the process, which causes the characteristic frothing
seen when used. H2O2 has
antiseptic and deodorising properties; thus it is used as a mouthwash, to clean
wounds and ulcers, and
occasionally to disinfect body cavities at operation. It is also a bleach.
341
Hymen The thin membranous fold partially closing the lower end of the vi
rginal VAGINA. If the opening
is small, the hymen will tear at the time of first intercourse, usually with a l
ittle bleeding.
Hyoid A U-shaped bone at the root of the tongue. The hyoid can be felt f
rom the front of the neck,
lying about 25 cm above the prominence of the thyroid cartilage.
Hyoscine
A recently introduced opioid analgesic drug used to relieve severe pain
in cancer. A controlled drug,
it is taken in capsule form or the powder may be sprinkled over soft food.
Also called scopalamine, this is an alkaloid (see ALKALOIDS) obtained fr
om the plant henbane
(hyoscyamus). It is an ANTICHOLINERGIC drug sometimes used as a premedicant in p
atients undergoing
ANAESTHESIA for its sedative and antiemetic effects and for its ability to reduc
e saliva production. It may
cause confusion in the elderly.
Hydronephrosis
HyperSee KIDNEYS, DISEASES OF.
Prefix denoting abnormally increased or excessive.
Hydromorphone Hydrochloride
Hydrophobia Another name for RABIES.
Hyperactivity
Hydrops Fetalis See HAEMOLYTIC DISEASE OF THE NEWBORN.
342 Hypercalcaemia
gas GANGRENE and serious breathing disorders. Occasionally it is used fo
r patients undergoing cardiac
surgery.
Hypercholesterolaemia
Hypercalcaemia
A rare condition (less than 02 per cent) of pregnancy, in which there is
severe vomiting. If untreated
it can result in severe dehydration, ketoacidosis (an excess of KETONE acids) an
d liver damage. More common
in multiple pregnancy, it may recur in subsequent pregnancies.
A state in which the PLASMA calcium concentration is significantly raise
d. The most important causes
are HYPERPARATHYROIDISM, malignant bone disease and other (non-metastatic) cance
rs, and chronic renal
failure. Less common causes include SARCOIDOSIS, MYELOMATOSIS, vitamin D overdos
age (see APPENDIX 5:
VITAMINS), hyperthyroidism (see THYROID GLAND, DISEASES OF), and immobilisation.
Signs and symptoms A general malaise and H depression are common, with g
eneralised muscular weakness,
anorexia and vomiting. Disturbed renal function causes increased urine output an
d thirst, with calcium
deposits eventually leading to renal stones. Primary bone disease may cause pain
and weakness, with an
increased incidence of fractures, and there may be gritty deposits of calcium in
the eyes. Severe
hypercalcaemia produces ANURIA, with confusion and COMA leading to death.
Treatment The patient should be rehydrated and a diuretic (see DIURETICS
) given. Attention should then
be focused on the underlying cause usually a parathyroid adenoma or bone tumour
and surgical removal
should produce complete clinical cure, provided that advanced renal disease is n
ot already present.
Hypercalciuria An abnormally large amount of calcium in the urine. It is
the most common single cause
of stones in the KIDNEYS in Britain. (See HYPERCALCAEMIA.)
Hypercapnia An abnormal increase in the amount of carbon dioxide in the
blood or in the lungs (see
BLOOD GASES). It may be caused by a reduced respiratory rate or effort, diseases
of the chest wall and lung
(affecting breathing), and cyanotic heart disease.
Hyperchlorhydria Excessive production of hydrochloric acid in the stomac
h. It is a characteristic
finding in certain forms of DYSPEPSIA, particularly that associated with a duode
nal ulcer, and causes
HEARTBURN and WATERBRASH. (See also DUODENAL ULCER; STOMACH, DISEASES OF.)
See CHOLESTEROL; HYPERLIPIDAEMIA.
Hyperemesis Gravidarum
Hypertension
Treatment There is evidence that therapy which lowers the lipid concentr
ation reduces the progression
of premature atheroma, particularly in those who suffer from the familial disord
er. Treatment should
include appropriate diets, usually food that is low in cholesterol and saturated
fats. There are a number
of drugs available for lowering the lipid content of the plasma, but these shoul
d be reserved for patients
in whom severe hyperlipidaemia is inadequately controlled by weight reduction. A
nion-exchange resins
clofibrate, bezafibrate and gemfibrozil, for example and statins such as atorvas
tatin and simvastatin, as
well as nicotinic acid, all lower plasma cholesterol and plasma triglyceride con
centration through their
effect on reducing the hepatic production of lipoproteins. Cholestyramine and co
lestipol, both of which are
anion-exchange resins, bind bile salts in the gut and so decrease the absorption
of the cholesterol that
these bile salts contain hence lowering plasma cholesterol concentrations. Probu
col lowers plasma
cholesterol concentrations by increasing the metabolism of low-density lipoprote
ins. The statins
(atorvastatin, cerivastatin, fluvastatin, pravastatin and simvastatin) inhibit a
n enzyme involved in
synthesising cholesterol, especially in the liver. They are more effective than
anion-exchange resins in
lowering LDL (low-density lipoprotein) cholesterol a form of low-density cholest
erol carried in the
bloodstream, high levels of which are believed to be the main cause of atheroma.
Statins are, however, less
effective than the clofibrate group in reducing triglycerides and raising HDL (h
ighdensity lipoprotein)
cholesterol (high-density cholesterol).
Hypermetropia Hypermetropia, or hyperopia, is a term applied to long-sig
htedness, in which the eye is
too flat from front to back and rays of light are brought to a focus behind the
retina. (See EYE; VISION.)
Hypernatraemia A SERUM sodium concentration that is above normal. The co
ndition is usually caused by
dehydration (either from inadequate intake or excessive loss of water); occasion
ally it may be caused by
excessive sodium intake, and rarely by a raised level of ALDOSTERONE hormone.
Hypernephroma Now named renal cell carcinoma, this is a malignant tumour
resembling the tissue of the
suprarenal gland and occurring in the KIDNEYS. Fever, loin pain, HAEMATURIA and
swelling are
343
among the presenting symptoms, but the tumour may be symptomless for man
y years. Surgical removal is
the initial treatment; hypernephromas are fairly insensitive to CYTOTOXIC drugs
and RADIOTHERAPY although
hormone treatment may help and are prone to spread via the bloodstream, for exam
ple, to the lungs.
344 Hypertension
H
the average for his or her age group is usually symptomless although som
etimes such people may
develop headaches. The identification of people with hypertension is important b
ecause it is a signal that
they will be more likely to have a STROKE or myocardial infarct (coronary thromb
osis or heart attack) than
someone whose pressure is in the normal range. Preventive steps can then be taken
to lessen the
likelihood of their developing these potentially life-threatening conditions. Bl
ood pressure is measured
using two values. The systolic pressure the greater of the two represents the pr
essure when blood is
pumped from the left VENTRICLE of the heart into the AORTA. The diastolic pressu
re is the measurement when
both ventricles relax between beats. The pressures are measured in millimetres (
mm) of mercury (Hg).
Despite the grey area between normal and raised blood pressure, the World Health
Organisation (WHO) has
defined hypertension as a blood pressure consistently greater than 160 mm Hg (sy
stolic) and 95 mm Hg
(diastolic). Young children have readings well below these, but blood pressure r
ises with age and a healthy
person may well live symptom free with a systolic pressure above the WHO figure.
A useful working
definition of hypertension is the figure at which the benefits of treating the c
ondition outweigh the risks
and costs of the treatment. Between 10 and 20 per cent of the adult population i
n the UK has hypertension,
with more men than women affected. Incidence is highest in the middle-aged and e
lderly. Because most people
with hypertension are symptomless, the condition is often first identified durin
g a routine medical
examination, otherwise a diagnosis is usually made when complications occur. Man
y peoples blood pressure
rises when they are anxious or after exercise, so if someones pressure is above n
ormal at the first
testing, it should be taken again after, say, 10 minutes rest, by which time the
reading should have
settled to the persons regular level. BP measurements should then be taken on two
subsequent occasions. If
the pressure is still high, the cause needs to be determined: this is done using
a combination of personal
and family histories (hypertension can run in families), a physical examination
and investigations,
including an ECG and blood tests for renal disease. Over 90 per cent of hyperten
sive people have no
immediately identifiable cause for their condition. They are described as having
essential hypertension. In
those patients with an identifiable cause, the hypertension is described as secondary. Among the causes of secondary hypertension are: Lifestyle factor
s such as smoking, alcohol,
stress, excessive dietary salt and obesity. Diseases of the KIDNEYS. Pregnancy (
ECLAMPSIA). Various
ENDOCRINE disorders for example, PHAEOCHROMOCYTOMA, CUSHINGS DISEASE, ACROMEGALY,
thyrotoxicosis (see
under THYROID GLAND, DISEASES OF). COARCTATION OF THE AORTA. Drugs for example,
oestrogen-containing oral
contraceptives (see under CONTRACEPTION), ANABOLIC STEROIDS, CORTICONON-STEROIDA
L ANTISTEROIDS,
INFLAMMATORY DRUGS (NSAIDS).
Treatment People with severe hypertension may need prompt admission to h
ospital for urgent
investigation and treatment. Those with a mild to moderate rise in blood pressur
e for which no cause is
identifiable should be advised to change their lifestyle: smokers should stop th
e habit, and those with
high alcohol consumption should greatly reduce or stop their drinking. Obese peo
ple should reduce their
food consumption, especially of animal fats, and take more exercise. Everyone wi
th hypertension should
follow a low-salt diet and take regular exercise. Patients should also be taught
how to relax, which helps
to reduce blood pressure and, if they have a stressful life, working patterns sh
ould be modified if
possible. If these lifestyle changes do not reduce a persons blood pressure suffi
ciently, drugs to achieve
this will be needed. A wide range of anti-hypertensive drugs are available on pr
escription. A first-line
treatment is one of the THIAZIDES, effective at a low dosage and especially usef
ul in the elderly. Beta
blockers (see BETAADRENOCEPTOR-BLOCKING DRUGS), such as oxprenolol, acebutol or
atenolol, are also
first-line treatments. ACE inhibitors (see ANGIOTENSIN-CONVERTING ENZYME (ACE) a
nd CALCIUM-CHANNEL
INHIBITORS) BLOCKERS can be used if the first-line choices
are not effective. The drug treatment of hypertension is complex, and so
metimes various drugs or
combinations of drugs have to be tried to find what regimen is effective and sui
ts the patient. Mild to
moderate hypertension can usually be treated in general practice, but patients w
ho do not respond or have
complications will normally require specialist advice. Patients on anti-hyperten
sive treatments require
regular monitoring, and, as treatment may be necessary for several years, partic
ular attention should be
paid to identifying side-
Hyperventilation
effects. Nevertheless, effective treatment of hypertension does enable a
ffected individuals to live
longer and more comfortable lives than would otherwise be the case. Older people
with moderately raised
blood pressure are often able to live with the condition, and treatment with ant
i-hypertensive drugs may
produce symptoms of HYPOTENSION. In summary, hypertension is a complex disorder,
with different patients
responding differently to treatment. So the condition sometimes requires careful
assessment before the most
effective therapy for a particular individual is identified, and continued monit
oring of patients with the
disorder is advisable.
Complications Untreated hypertension may eventually result in serious co
mplications. People with high
blood pressure have blood vessels with thickened, less flexible walls, a narrowe
d LUMEN and convoluted
shape. Sometimes arteries become rigid. ANEURYSM may develop and widespread ATHE
ROMA (fat deposits) is
apparent in the arterial linings. Such changes adversely affect the blood supply
to body tissues and organs
and so damage their functioning. Patients suffer STROKE (haemorrhage from or thr
ombosis in the arteries of
the BRAIN) and heart attacks (coronary thrombosis see HEART, DISEASES OF). Those
with hypertension may
suffer damage to the retina of the EYE and to the OPTIC DISC. Indeed, the diagno
sis of hypertension is
sometimes made during a routine eye test, when the doctor or optician notices ch
anges in the retinal
arteries or optic disc. Kidney function is often affected, with patients excreti
ng protein and excessive
salt in their urine. Occasionally someone with persistent hypertension may suffe
r an acceleration of damage
to the blood vessels a condition described as malignant hypertension, and one requ
iring urgent hospital
treatment. Hypertension is a potentially dangerous disease because it develops i
nto a cycle of
selfperpetuating damage. Faulty blood vessels lead to high blood pressure which
in turn aggravates the
damage in the vessels and thus in the tissues and organs they supply with blood;
this further raises the
affected individuals blood pressure and the pathological cycle continues.
Hypertensive Encephalopathy A complication of severe HYPERTENSION, this
serious but uncommon condition
is characterised by neurological symptoms which include transient verbal and vis
ual disturbances,
PARAESTHESIA, disorientation, fits and sometimes loss of consciousness. It also
affects the eyes,
345
causing PAPILLOEDEMA. Haemorrhages may occur in the brain, usually in th
e area of the BASAL GANGLIA.
Neurological symptoms can usually be treated effectively by controlling the pati
ents hypertension.
346 Hypervolaemia
Hyperventilation is a manifestation of chest and heart diseases which ra
ise carbon dioxide tension or
cause HYPOXIA (e.g. severe CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) or PULMO
NARY OEDEMA). Mechanically
ventilated patients may be hyperventilated to lower carbon dioxide tension in or
der to reduce INTRACRANIAL
PRESSURE. (See also HYPOCAPNIA.)
Hypervolaemia An increase in the volume of circulating blood above the n
ormal range.
Hypnotics H
These are drugs that induce SLEEP. Before a hypnotic is prescribed, it i
s vital to establish and,
where possible, treat the cause of the insomnia (see under SLEEP, DISORDERS OF).
Hypnotics are most often
needed to help an acutely distressed patient (for example, following bereavement
), or in cases of jet lag,
or in shift workers. If required in states of chronic distress, whether induced
by disease or environment,
it is especially important to limit the drugs to a short time to prevent undue r
eliance on them, and to
prevent the use of hypnotics and sedatives from becoming a means of avoiding the
patients real problem. In
many cases, such as chronic depression, overwork, and alcohol abuse, hypnotics a
re quite inappropriate;
some form of counselling and relaxation therapy is preferable. Hypnotics should
always be chosen and
prescribed with care, bearing in mind the patients full circumstances. They are g
enerally best avoided in
the elderly (confusion is a common problem), and in children apart from special
cases. Barbiturates
should not now be used as they tend to be addictive. The most commonly used hypn
otics are the
BENZODIAZEPINES such as nitrazepam and temazepam; chloral derivatives, while saf
er for the few children who
merit them, are generally second choice and should be used in the lowest possibl
e dose for the minimum
period. Side-effects include daytime drowsiness which may interfere with driving
and other skilled tasks
and insomnia following withdrawal, especially after prolonged use, is a hazard.
Occasionally
benzodiazepines will trigger hostility and aggression. Zolpidem and zopiclone ar
e two drugs similar to the
benzodiazepines, indicated for short-term treatment of insomnia in the elderly.
Adverse effects include
confusion, incoordination and unsteadiness, and falls have been reported.
is a tranquilliser/hypnotic that has been misused as a recreational drug
.
FLUNITRAZEPAM
Hypnotism The process of producing a state of mind known as hypnosis. Al
though recognised for hundreds
of years, the precise nature of this process is still poorly understood. One mod
ern writer has defined
Hypoglycaemic Agents
347
malabsorption, renal failure or acute pancreatitis (see PANCREAS, DISORD
ERS OF).
largely comprises antibodies (IMMUNOGLOBULINS) so deficiency of the prot
ein reduces
Hypocapnia
an individuals natural resistance to infection (see IMMUNOLOGY).
5: VITAMINS),
A blood tension of carbon dioxide below normal. It is produced by HYPERV
ENTILATION which may be
voluntary, mechanical (if the patient is on a ventilator) or in response to a ph
ysiological insult such as
metabolic acidosis or brain injury.
Hypogastric A term means pertaining to the lower middle part of the abdo
men, just above the pubis.
Hypoglossal Nerve
An insufficient secretion of HYDROCHLORIC from the digestive cells of th
e stomach lining.
The 12th cranial nerve, which supplies the muscles of the tongue, togeth
er with some others lying near
it. This nerve is responsible for movements required for swallowing and talking.
(See also NERVOUS SYSTEM.)
Hypochondriasis
Hypoglycaemia
Obsession with the bodys functions and a DELUSION of ill health, often se
vere, such that patients may
believe they have a brain tumour or incurable insanity. Furthermore, patients ma
y believe that they have
infected others, or that their children have inherited the condition. It is a ch
aracteristic feature of
DEPRESSION, but may also occur in SCHIZOPHRENIA, when the delusions may be secon
dary to bodily
HALLUCINATIONS, and a sense of subjective change. Chronic hypochondriasis may be
the result of an abnormal
personality development: for example, the insecure, bodily-conscious person. Del
usional preoccupations with
the body usually the face may occur, such that the patient is convinced that his
or her face is
twisted, or disfigured with acne.
A deficiency of glucose in the blood the normal range being 3575 mmol/l (se
e DIABETES MELLITUS).
It most commonly occurs in diabetic patients for example, after an excessive dos
e of INSULIN and heavy
exercise, particularly with inadequate or delayed meals. It may also occur in no
Hypoprothrombinaemia
confused, drowsy and uncoordinated, finally lapsing into a COMA. Hypogly
caemia is infrequent in people
whose diabetes is controlled with diet and oral HYPOGLYCAEMIC AGENTS.
Treatment of acute hypoglycaemia depends upon the severity of the condit
ion. Oral carbohydrate, such as
a sugary drink or chocolate, may be effective if the patient is conscious enough
to swallow; if not,
glucose or GLUCAGON by injection will be required. Comatose patients who recover
after an injection should
then be given oral carbohydrates. An occasional but dangerous complication of co
ma is cerebral oedema (see
BRAIN, DISEASES OF Cerebral oedema), and this should be considered if coma persi
sts. Emergency treatment
in hospital is then needed. When the patient has recovered, management of his or
her diabetes should be
assessed in order to prevent further hypoglycaemic attacks.
tions intravenously), excessive water retention (inappropriate secretion
of antidiuretic hormone),
excessive sodium loss, and, rarely, by inadequate salt intake.
Hypoparathyroidism Underactivity of the parathyroid glands (see under EN
DOCRINE GLANDS). Thus there is
a lack of parathyroid hormone resulting in HYPOCALCAEMIA. It may be caused by in
advertent removal of the
glands when the thyroid gland is surgically removed, or by failure of the glands
because of autoimmune
disease.
Hypophysectomy Surgical excision of the PITUITARY GLAND. This can be don
e by opening the skull, by
inserting very low-temperature needles (CRYOSURGERY) into the gland, or by inser
ting needles of radioactive
YTTRIUM-90.
Hypophysis
Hypogonadism
Another name for the PITUITARY GLAND.
A condition characterised by underactivity of the testes (see TESTICLE)
or OVARIES the gonads. The
condition may be caused by a genetically based disorder resulting in an abnormal
ly functioning gonad
(primary hypogonadism) or by a malfunctioning PITUITARY GLAND that fails to prod
uce an adequate amount of
gonadotrophin hormone (see GONADOTROPHINS) secondary hypogonadism. Those affecte
d may fail to develop
adequately the secondary characteristics of their sex: males will have delayed p
uberty, erectile impotence
and infertility and also develop GYNAECOMASTIA; females also have delayed pubert
y, infertility, and
sometimes HIRSUTISM.
Hypopiesis
350 Hypospadias
Anticoagulant therapy will also cause a fall in prothrombin levels.
Hypospadias A developmental abnormality in the male, in which the URETHR
A opens on the undersurface of
the penis or in the PERINEUM. The condition is treatable with surgery, but sever
al operations over a period
of years may be required to ensure normal urinary and sexual functions.
Hypostasis
H
The term applied to the condition in which blood accumulates in a depend
ent part of the body as a
result of poor circulation. Congestion of the base of the lungs in old people fr
om this cause, and
infection, is called hypostatic PNEUMONIA.
Hypotension Low blood pressure (see HYPERTENSION for raised blood pressu
re). Some healthy individuals
with a normal cardiovascular system have a permanently low arterial blood pressu
re for their age. What
blood-pressure reading constitutes hypotension is arguable, but a healthy young
person with figures below
100 mm Hg systolic and 65 mm Hg diastolic could be described as hypotensive. For
a healthy 60 year old,
comparative figures might be 120/80. The most common type of hypotension is call
ed postural, with symptoms
occurring when a person suddenly stands up, particularly after a period of rest
or a hot bath. It results
from the muscular tone of blood vessels becoming relaxed and being unable to res
pond quickly enough to the
changing posture, the consequence being a temporary shortage of arterial blood t
o the brain and organs in
the chest. Symptoms of dizziness, occasionally fainting, and nausea occur. Older
people are especially
vulnerable and may fall as a result of the sudden hypotension. Some drugs anti-h
ypertensives and
antidepressant ones cause hypotension. People with DIABETES MELLITUS occasionall
y develop hypotension
because of nerve damage that affects the reflex impulses controlling blood press
ure. Any severe injury or
burn that results in serious loss of blood or body fluid will cause hypotension
and SHOCK. Myocardial
infarction (see HEART, DISEASES OF) or failure of the ADRENAL GLANDS can cause h
ypotension and shock. A
severe emotional event that causes shock may also result in hypotension and fain
ting. Hypotension in
healthy people does not require treatment, although affected individuals should
be advised not to stand up
suddenly or
get out of a bath quickly. Someone who faints as a result of a hypotensi
ve incident should be laid down
for a few minutes to allow the circulation to return to normal. Hypotension resu
lting from burns, blood
loss, heart attack or adrenal failure (shock) requires medical attention for the
causative condition.
Hypothalamus That part of the fore-brain situated beneath and linked wit
h the THALAMUS on each side and
forming the floor of the third ventricle (see BRAIN). Also linked to the PITUITA
RY GLAND beneath it, the
hypothalamus contains collections of nerve cells believed to form the controllin
g centres of (1) the
sympathetic and (2) the parasympathetic nervous systems (see under NERVOUS SYSTE
M). The hypothalamus is the
nervous centre for primitive physical and emotional behaviour. It contains nerve
centres for the regulation
of certain vital processes: the metabolism of fat, carbohydrate and water; sleep
; body temperature and
sexual functions.
Hypothermia A core body temperature of less than 35 C. As the temperature
of the body falls, there is
increasing dysfunction of all the organs, particularly the central nervous and c
ardiovascular systems. The
patient becomes listless and confused, with onset of unconsciousness between 3328
C. Cardiac output at
first rises with shivering but then falls progressively, as do the oxygen requir
ements of the tissues.
Below 17 26 C, cardiac output is insufficient even to supply this reduced demand f
or oxygen by the
tissues. The heart is susceptible to spontaneous ventricular FIBRILLATION below
28 C. Metabolism is
disturbed and the concentration of blood GLUCOSE and POTASSIUM rises as the temp
erature falls. Cooling of
the kidneys produces a DIURESIS and further fluid loss from the circulation to t
he tissues causes
HYPOVOLAEMIA. Severe hypothermia is sometimes complicated by gastric erosions an
d haemorrhage, as well as
pancreatitis (see PANCREAS, DISORDERS OF). Infants and the elderly are less effi
cient at regulating
temperature and conserving heat than other age groups, and are therefore more at
risk from accidental
hypothermia during cold weather if their accommodation is not warm enough. Appro
ximately half a million
elderly people are at risk in Britain each winter from hypothermia. The other ma
jor cause of accidental
hypothermia is near-drowning in icy water. Deliberate hypothermia is sometimes u
sed to reduce metabolic
rate so that prolonged periods of cardiac arrest may occur without
Hysterotomy
tissue HYPOXIA developing. This technique is used for some cardiac and n
eurosurgical operations and is
produced by immersion of the anaesthetised patient in iced water or by cooling a
n extracorporeal
circulation. Treatment of hypothermia is by warming the patient and treating any
complications that arise.
Passive warming is usual, with conservation of the patients own body heat with in
sulating blankets. If the
core temperature is below 28 C, then active rewarming should be instituted by mea
ns of warm peritoneal,
gastric or bladder lavage or using an extracorporeal circulation. Care must be t
aken in moving hypothermic
patients, as a sudden rush of cold peripheral blood to the heart can precipitate
ventricular fibrillation.
Prevention of hypothermia in the elderly is important. Special attention must be
paid to diet, heating the
home and adequate clothing in several layers to limit heat loss.
Hypothyroidism Underactivity of the thyroid gland (see THYROID GLAND, DI
SEASES OF).
Hypotonic (1) Referring to a solution which has a lower osmotic pressure
(see OSMOSIS) than another.
Physiologically it describes a solution with a lower osmotic pressure than body
fluids. (2) Muscles with
abnormally reduced tone.
Hypoventilation Shallow and/or slow breathing, often caused by the effec
ts of injury or drugs on the
respiratory centre. It causes HYPERCAPNIA and HYPOXIA.
Hypovolaemia A reduced circulating blood volume. Acutely, it is caused b
y unreplaced losses from
bleeding, sweating, diarrhoea, vomiting or diuresis. Chronically it may be cause
d by inadequate fluid
intake.
Hypoxaemia A fall in the concentration of OXYGEN in the arterial blood.
Symptoms are those of CYANOSIS
and, if severe, the affected individual will show signs of respiratory failure.
Hypoxia A shortage of OXYGEN in the body tissues. It may be caused by lo
w inspired concentration of
oxygen, an abnormal breathing pattern, lung disease or heart disease. If severe
and prolonged
351
it will cause organ damage and death, as cellular function is dependent
on oxygen. (See also
HYPOXAEMIA.)
Hysterectomy Surgical removal of the UTERUS. Hysterooophorectomy is the
term applied to removal of the
uterus and OVARIES. (See also UTERUS, DISEASES OF.)
Hysteria An out-of-date description for a symptom (or symptoms) with no
obvious organic cause, which is
an unconscious reaction and from which the person may benefit. It is now recogni
sed as a dissociative
disorder: such disorders AMNESIA, FUGUE, multiple personality states and trancel
ike conditions are
powerful defence mechanisms against severe stress when a patient is unable to co
pe with a particular
problem or problems. Symptoms can also mimic physical conditions: for example, a
pparent paralysis or
inability to speak (mutism). Mass hysteria is a phenomenon characterised by extr
eme suggestibility in a
group of often emotionally charged people. The name originates from the ancient
idea that hysteria a
Greek-based word for UTERUS was in some way associated with the womb. Hence the ol
d-fashioned
association of hysteria with women, and with supposed sexual disturbances. Docto
rs should make sure there
is not a physical disease present to explain the symptoms before diagnosing a di
ssociative disorder. Most
subside spontaneously, but if not, the individual needs psychiatric advice. Trea
tment is difficult. Reasons
for stress should be explored and, if possible, resolved. Hypnosis (see HYPNOTIS
M) to help the person to
relive stressful episodes known as ABREACTION may be of value.
Hysteroscopy Hysteroscopy is the direct visualisation of the interior of
the UTERUS using FIBREOPTIC
ENDOSCOPY. The technique, which allows minor surgical procedures to be carried o
ut at the same time, has
transformed the management of uterine disorders.
Hysterotomy An operation in which the UTERUS is opened to remove a FETUS
before 28 weeks gestation.
After 28 weeks it would be called a CAESAREAN SECTION. It is now seldom used as
a means of abortion.
H
appearance at birth is of the so-called collodion baby; in the dominant form the b
aby is born with
universally red, moist and eroded skin with an unpleasant smell. Gradually, over
several months, thick
Ichthammol
Idiopathic Idiopathic is a term applied to diseases to indicate that the
ir cause is unknown.
Idiopathic Facial Nerve Palsy Idiopathic Thrombocytopenic Purpura (ITP)
Common and inherited as a dominant trait. Beginning in early childhood,
it is often associated with
atopic eczema (see DERMATITIS). The limb flexures and face are spared.
Sometimes described as thrombocytopenia, this is an autoimmune disorder
in which blood PLATELETS are
destroyed. This disturbs the bloods coagulative properties (see COAGULATION) and
spontaneous bleeding
(PURPURA) occurs into the skin. The disease may be acute in children but most re
cover without treatment.
Adults may develop a more serious, chronic variety which requires treatment with
CORTICOSTEROIDS and
sometimes SPLENECTOMY. Should the disease persist despite these treatments, intr
avenous immunoglobulin or
immunosuppressive drugs (see IMMUNOSUPPRESSION) are worth trying. Should the ble
eding be or become
life-threatening, concentrates of platelets should be administered.
X-linked ichthyosis is much less common,
Idiosyncrasy
more severe and appears earlier than ichthyosis vulgaris. The fish-like
scales are larger and darker
and do not spare the flexures and face.
A generally unexpected, so unpredictable, abnormal reaction to a drug ca
used by a constitutional defect
in the patient. In some cases the underlying disorder is already known or discov
ered after the first event,
so that the drug in question can be avoided thereafter. The
Ichthammol is ammonium ichthosulphonate an almost black, thick liquid of
fishy smell, prepared from a
bituminous shale. It is used in chronic eczema (see DERMATITIS).
Ichthyosis A disorder in which the skin is permanently dry and scaly. It
is usually genetically
determined and several different forms are recognised:
Ichthyosis vulgaris
Ichthyosiform erythroderma Of two types and very rare: in the recessive
form, the
354 Immunisation
Age 3 days
Disease and mode of administration BCG (Bacille Calmette-Guerin) by inje
ction if tuberculosis in family
in past 6 months. Poliomyelitis (oral); adsorbed diphtheria, whooping-cough (per
tussis)1 and tetanus2
(triple vaccine given by injection); HiB injection.3 Poliomyelitis (oral); dipht
heria, whooping-cough
(pertussis)1 and tetanus2 (triple vaccine given by injection); HiB injection.3 P
oliomyelitis (oral);
diphtheria, whooping-cough (pertussis)1 and tetanus2 (triple vaccine given by in
jection); HiB injection.3
Measles, mumps, and rubella (German measles)4 (given together live by injection)
.
2 months 3 months 4 months 1218 months (SCHOOL ENTRY) 45 years
Poliomyelitis (oral); adsorbed diphtheria and tetanus (given together by
injection); give MMR vaccine
if not already given at 1218 months. Rubella (by injection) if they have missed M
MR. BCG (Bacille
Calmette-Guerin) by injection to tuberculin-negative children to prevent tubercu
losis. Poliomyelitis single
booster dose (oral); tetanus (by injection).
1014 females 1014 1518
I
1
Pertussis may be excluded in certain susceptible individuals. Known as D
PT 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 imm
unised with
singleconstituent vaccines because of controversy over possible side-effects yet
to be confirmed
scientifically of the combined MMR vaccine.) 2
Recommended immunisation schedules in the United Kingdom
Immunisation The introduction of antigens (see ANTIGEN) into a body to p
roduce IMMUNITY. The table
above gives the immunisation programme recommended by the UK departments of heal
th.
Immunity The bodys defence against foreign substances such as bacteria, v
iruses and parasites.
Immunity also protects against drugs, toxins and cancer cells. It is partly nonspecific that is, it does
not depend on previous exposure to the foreign substance. For example, micro-org
anisms are engulfed and
inactivated by polymorphonuclear LEUCOCYTES as a first line of defence before sp
ecific immunity has
developed. Acquired immunity depends upon the immune system recognising a substa
nce as foreign the first
Immunoglobulins
which fits only that peptide. The responsive T-cell clone induces a spec
ific response in other T- and
B-lymphocyte populations. For example, CYTOTOXIC T-cells penetrate infected tiss
ues and kill cells which
express peptides derived from invading micro-organisms, thereby helping to elimi
nate the infection.
B-lymphocytes secrete ANTIBODIES which are collectively termed IMMUNOGLOBULINS (
Ig) see also
GAMMA-GLOBULIN. Each B-cell population (clone) secretes antibody uniquely specif
ic for antigens encountered
in the blood, extracellular space, and the LUMEN of organs such as the respirato
ry passages and
gastrointestinal tract. Antibodies belong to different Ig classes; IgM antibodie
s are synthesised
initially, followed by smaller and therefore more penetrative IgG molecules. IgA
antibodies are adapted to
cross the surfaces of mucosal tissues so that they can adhere to organisms in th
e gut, upper and lower
respiratory passages, thereby preventing their attachment to the mucosal surface
. IgE antibodies also
contribute to mucosal defence but are implicated in many allergic reactions (see
ALLERGY). Antibodies are
composed of constant portions, which distinguish antibodies of different class;
and variable portions,
which confer unique antigen-binding properties on the product of each B-cell clo
ne. In order to match the
vast range of antigens that the immune system has to combat, the variable portio
ns are synthesised under
the instructions of a large number of encoding GENES whose products are assemble
d to make the final
antibody. The antibody produced by a single B-cell clone is called a monoclonal
antibody; these are now
synthesised and used for diagnostic tests and in treating certain diseases. Popu
lations of lymphocytes with
different functions, and other cells engaged in immune responses, carry distinct
ive protein markers. By
convention these are classified and enumerated by their CD markers, using monoclon
al antibodies specific
for each marker. Immune responses are influenced by cytokines which function as
HORMONES acting over a
short range to accelerate the activation and proliferation of other cell populat
ions contributing to the
immune response. Specific immune responses collaborate with nonspecific defence
mechanisms. These include
the COMPLEMENT SYSTEM, a protein-cascade reaction designed to eliminate antigens
neutralised by antibodies
and to recruit cell populations which kill micro-organisms.
355
Immunoassay Procedures which measure the concentration of any antigenic
material (see ANTIGEN) to which
an antibody (see ANTIBODIES) can be created. The amount of antigen bound to this
antibody is proportional
to the parent substance. Enzymes (see ENZYME-LINKED IMMUNOSORBENT ASSAY (ELISA))
or radioactive labels
(RADIOIMMUNOASSAY) are used to measure the concentration of antigenic material.
356 Immunologist
IgE, IgG and IgM. In the laboratory these are separated and identified b
y a chemical process called
electrophoresis. Most antibodies have a molecular weight of 160,000. Certain imm
unoglobulins can be used in
the active or passive immunity of people against infectious diseases such as RAB
IES and viral HEPATITIS
(see also IMMUNITY and GAMMAGLOBULIN). They are also used in treating certain im
munological conditions such
as KAWASAKI DISEASE.
Immunologist A specialist (medically or scientifically qualified) who pr
actises or researches
IMMUNOLOGY.
Immunology I
The study of immune responses to the environment. Its main clinical appl
ications include improving
resistance to microbial infections (see IMMUNITY), combating the effects of impa
ired immunity (see
IMMUNODEFICIENCY), controlling harmful immune reactions (see ALLERGY), and manip
ulating immune responses
(see IMMUNOTHERAPY) to prevent harmful immunological responses such as graft rej
ection and autoimmune
diseases (see AUTOIMMUNITY). The clinical study of disordered immunity now forms
the allied discipline of
clinical immunology, which is closely linked to the laboratorybased discipline o
f immunopathology.
Immunosuppressant A drug that reduces the bodys resistance to infection a
nd other foreign agents. It
does so by suppressing the activity of the immune system (see IMMUNITY). Example
s of such drugs are
AZATHIOPRINE, CYCLOPHOSPHAMIDE and CICLOSPORIN A. Immunosuppressants are used to
help transplanted organs
and tissues to survive the potential immune reaction from the host. They are als
o used to treat AUTOIMMUNE
DISORDERS such as RHEUMATOID ARTHRITIS.
Immunosuppression The term given to suppression of harmful immune respon
ses (see IMMUNITY), the most
obvious application being the prevention of organ rejection by people who receiv
e kidney, heart or
bone-marrow transplants (see TRANSPLANTATION). Immunosuppression is also used in
certain diseases in a way
that is non-specific that is, it inhibits the entire immune system, not just har
mful reactions.
CORTICOSTEROIDS are the commonest dugs used in this way, as are METHOTREXATE and
AZATHIOPRINE. Tacrolimus,
a macrolide (see MACROLIDES) IMMUNOSUPPRESSANT, is used not only for
engrafted patients but also in treating eczema (see DERMATITIS). There h
as been a rapid introduction in
recent years of monoclonal antibodies which prevent T-cells from proliferating.
They can be recognised by
the suffix mab (standing for monoclonal antibody) and include rituximab and alemtu
zumab. Infliximab, used
in CROHNS DISEASE and RHEUMATOID ARTHRITIS, inhibits tumour necrosis factor alpha
.
Immunotherapy The manipulation of IMMUNITY by immunological (see IMMUNOL
OGY) means to reduce harmful
reactions or to boost beneficial responses. Severe ALLERGY to wasp or bee stings
is often treated by a
course of injections with allergen purified from insect venom. There are current
attempts to treat
autoimmune diseases (see AUTOIMMUNITY) with monoclonal antibodies to the T-cell
populations or cytokines
implicated in the immunopathogenesis of the disorder. Strategies are also being
evaluated for treating
cancer by boosting the patients own immunity to cancer cells. One approach is imm
unisation with cancer
cells manipulated in vivo to increase a T-lymphocyte attack on antigens expresse
d by tumour cells. Another
method is to manipulate the cytokine network into encouraging an immune attack o
n, or self-destruction
(apoptosis) of, malignant cells. Immunotherapy is however a developing science, an
d its place in the
routine treatment of immunological and malignant diseases is still evolving.
Impaction A term applied to a condition in which two things are firmly l
odged together. For example,
when one piece of bone is driven within another following a fracture, this is kn
own as an impacted
fracture; when a tooth is firmly lodged in its socket so that its eruption is pr
evented, this is known as
dental impaction. Intractable constipation is termed faecal impaction.
Imperforate An adjective meaning lack of an opening. For example, occasi
onally the ANUS fails to
develop properly, resulting in partial or complete obstruction of the opening. S
ometimes pubertal girls
have an imperforate HYMEN which obstructs the opening to the VAGINA and prevents
menstrual flow of blood
draining to the exterior.
Impetigo An infectious skin disease caused usually by
Inbreeding
Staphylococcus aureus and less often by Streptococcus pyogenes. The itch
ing rash is seen especially on
the face but may spread widely. Vesicles and pustules erupt and dry to form yell
ow-brown scabs. Untreated,
the condition may last for weeks. In very young infants, large blisters may form
(bullous impetigo).
Treatment Crusts should be gently removed with SALINE. Mild cases respon
d to frequent application of
mupiricin or NEOMYCIN/BACITRACIN ointment; more severe cases should be treated o
rally or, sometimes,
intravenously with FLUCLOXACILLIN or one of the CEPHALOSPORINS. If the patient i
s allergic to penicillin,
ERYTHROMYCIN can be used. For severe, intractable cases, an oral retinoid drug c
alled isotretinoin
(commercially produced as Roaccutane ) can be used. It is given systemically but t
reatment must be
supervised by a consultant dermatologist as serious sideeffects, including possi
ble psychiatric
disturbance, can occur. The drug is also teratogenic (see TERATOGENESIS), so wom
en who are, or who may
become, pregnant must not take isotretinoin. It acts mainly by suppressing SEBUM
production in the
sebaceous glands and can be very effective. Recurrent bouts of impetigo should r
aise suspicion of
underlying SCABIES or head lice. Bactericidal soaps and instilling an antibiotic
into the nostrils may also
help.
severe disturbance of health, such as
357
DIABETES
MELLITUS; and addiction to alcohol.
An oral drug for treating erectile function is sildenafil citrate (Viagr
a ), the first in a new class
of drugs called phosphodiesterase type 5 inhibitors, also including tadalafil (C
ialis ) and vardenafil
(Levitra ). They work by improving blood flow to the penis. They can be taken an h
our before intercourse
(up to 12 hours before, in the case of tadalafil). These drugs are not aphrodisi
acs, and side-effects
include headache, facial flushing and indigestion. There are some suggestions th
at they may affect retinal
function. Intracavernosal injection or urethral application of alprostadil, a dr
ug which increases local
blood supply to the penis, has been used for some years under medical supervisio
n, but success has been
variable and oral sildenafil seems to be a more convenient and effective treatme
nt for a man with this
disorder.
Impression In dentistry, a mould (using a rubber or alginate compound) o
f the teeth and gums from which
a plaster-of-Paris model is prepared. This model provides a base on which to con
358 Incidence
Incidence One of the main ways to measure the frequency of a disease in
a particular population. The
incidence of a disease is the number of new cases that occur during a particular
time. PREVALENCE, the
other measure, is the total number of cases of disease present at any one time a
nd covers both old and new
cases.
Incision A cut or wound; a term especially applied to surgical openings.
Incisor The term for the four front TEETH of each jaw.
Inclusion Bodies I
Particles found in the CYTOPLASM and NUCLEUS of CELLS, usually a consequ
ence of a viral infection. This
phenomenon can be helpful in the diagnosis of such an infection.
Incompatibility (1) In the pharmacological context, the use of two or mo
re drugs in treatment which
together produce adverse consequences for the patient. The British National Form
ulary carries an appendix
devoted to drug interactions. (2) In the haematological context, an adverse reac
tion in a patient given a
blood TRANSFUSION in which the donor blood is incompatible with that of the reci
pient.
Incompetence Incompetence is a term applied to the valves of the heart w
hen, as a result of disease in
the valves or alterations in size of the chambers of the heart, the valves becom
e unable to close the
orifices which they should protect. (See HEART, DISEASES OF.)
Incontinence Urinary incontinence The International Continence Society d
efines urinary incontinence as
an involuntary loss of URINE that is objectively shown and is a social and hygie
ne problem. The elderly
suffer most from this disorder because the effectiveness of the sphincter muscle
s surrounding the URETHRA
declines with age. Men are less often affected than women; 20 per cent of women
over 40 years of age have
problems with continence. It is estimated that around three million people are r
egularly incontinent in the
UK, a prevalence of about 40 per 1,000 adults. Incontinence can be divided broad
ly into two groups: stress
incontinence and incontinence due to an overactive URINARY BLADDER also called detrusor instabili
ty which affects one-third
of incontinent women, prevalence increasing with age. Bladder symptoms do not ne
cessarily correlate with
the underlying diagnosis, and accurate diagnosis may require urodynamic studies
examination of urine
within, and the passage of urine through and from, the urinary tract. However, s
uch studies are best
deferred until conservative treatment has failed or when surgery is planned. Inc
ontinence causes
embarassment, inconvenience and distress in women, and men are reluctant to seek
Indinavir
sor muscle of the bladder. The bladder contracts (spontaneously or on pr
ovocation) during the filling
phase while the patient attempts to stop passing any urine. Hyperexcitability of
the muscle or a disorder
of its nerve supply are likely causes. The symptoms include urgency (acute wish
to pass urine), frequency
and stress incontinence. Diagnosis can be confirmed with CYSTOMETRY. Bladder tra
ining is the first step in
treatment, with the aim of reducing the frequency of urination to once every thr
ee to four hours.
BIOFEEDBACK, using visual, auditory or tactile signals to stop bladder contracti
ons, will assist the
bladder training. Drug treatments such as CALCIUM-CHANNEL BLOCKERS, antimuscarin
ic agents (see
ANTIMUSCARINE), TRICYCLIC ANTIDEPRESSANT DRUGS, and oestrogen replacement can be
effective. Surgery is
rarely used and is best reserved for difficult cases. OVERFLOW INCONTINENCE Chro
nic urinary retention with
consequent overflow more common in men than in women. The causes include antispa
smodic drugs, continence
surgery, obstruction from enlargement and postprostatectomy problems (in men), P
SYCHOSIS, and disease or
damage to nerve roots arising from the spinal cord. Urethral dilatation or ureth
rotomy may be required when
obstruction is the cause. Management is intermittent selfcatheterisation or a su
prapubic catheter and
treatment of any underlying cause.
Faecal incontinence is the inability to control bowel movements and may
be due to severe CONSTIPATION,
especially in the elderly; to local disease; or to injury or disease of the spin
al cord or nervous supply
to rectum and anal muscles. Those with the symptom require further investigation
.
Incoordination A term applied to irregularity of movements produced eith
er by loss of the sensations by
which they are governed, or by defects in the muscles themselves or somewhere in
the nervous system.
Incubation The period elapsing between the time when a person becomes in
fected by some agent and the
first appearance of the symptoms of the disease. Most acute infectious diseases
have fairly definite
periods of incubation, and it is of great importance that people who have run th
e risk of infection should
know the length of time which must elapse before they can be sure whether or not
they are to contract the
disease
359
in question. A person who has been exposed to infection is, during the i
ncubation period, technically
known as a contact. By isolating and watching contact cases, medical officers ca
n often successfully check
a threatened EPIDEMIC. It must be noted that diseases are not communicated to ot
hers by a person who is
of disability. The onus is on the individual to claim, and trade unions and repr
esentative organisations
can advise on procedures. Injured employees should always report details of an a
ccident to their employer
and record it in the accident book promptly: even seemingly minor injuries may s
ubsequently lead to some
disability. Relevant information leaflets are available for example, from local
benefit agencies,
local-authority advice centres and public libraries.
Infant A baby who is under one year old.
Infant Feeding The newborn infant may be fed naturally from the breast,
or artificially from a bottle.
Breast feeding Unless there is a genuine contraindication, every baby sh
ould be breast fed. The
nutritional components of human milk are in the ideal proportions to promote the
healthy growth of the
human newborn. The mothers milk, especially colostrum (the fluid secreted before
full lactation is
established) contains immune cells and antibodies that increase the babys resista
nce to infection. From
the mothers point of view, breast feeding helps the womb to return to its normal
size and helps her to
lose excess body fat gained during pregnancy. Most importantly, breast feeding p
romotes intimate contact
between mother and baby. A final point to be borne in mind, however, is that dru
gs taken by a mother can be
excreted in her milk. These include antibiotics, sedatives, tranquillisers, alco
hol, nicotine and high-dose
steroids or vitamins. Fortunately this is rarely a cause of trouble. (See also m
ain entry on BREAST
FEEDING.)
Artificial feeding Unmodified cows milk is not a satisfactory food for th
e human newborn and may cause
dangerous metabolic imbalance. If breast feeding is not feasible, one of the man
y commerciallly available
formula milks should be used. Most of these are made from cows milk which has bee
n modified to reflect the
composition of human milk as
Infantile Spasms
closely as possible. For the rare infant who develops cows-milk-protein i
ntolerance, a milk based on
soya-bean protein is indicated.
Feeding and weight gain The main guide as to whether an infant is being
adequately fed is the weight.
During the first days of life a healthy infant loses weight, but should by the e
nd of the second week
return to birth weight. From then on, weight gain should be approximately 6oz. (
170g) each week. The timing
of feeds reflects social convention rather than natural feeding patterns. Among
the most primitive
hunter-gatherer tribes of South America, babies are carried next to the breast a
nd allowed to suckle at
will. Fortunately for developed society, however, babies can be conditioned to i
ntermittent feedings. As
the timing of breast feeding is flexible little or no preparation time being req
uired mothers can
choose to feed their babies on demand. Far from spoiling the baby, demand feedin
g is likely to lead to a
contented infant, the only necessary caution being that a crying baby is not alw
ays a hungry baby. In
general, a newborn will require feeding every two to four hours and, if well, is
unlikely to sleep for more
than six hours. After the first months, a few lucky parents will find their infa
nt sleeping through the
night.
361
can arouse extreme maternal anxiety by refusing to eat. This can lead to
force-feeding and battles of
will which may culminate in a breakdown of the mother-child relationship. To avo
id this, parents must
resist the temptation to coax the child to eat. If the child refuses solid food,
the meal should be taken
away with a minimum of fuss. Childrens appetites reflect their individual genetic
structure and a well
child will eat enough to grow and maintain satisfactory weight gain. If a child
is not eating properly,
weight gain will be inadequate over a prolonged period and an underlying illness
is the most likely cause.
Indeed, failure to thrive is the paediatricians best clue to chronic illness.
Advice on feeding Many sources of conflicting advice are available to ne
w parents. It is impossible to
satisfy everyone, and ultimately it is the well-being of the mother and infant a
nd the closeness of their
relationship that matter. In general, mothers should be wary of rigid advice. An
experienced midwife,
health visitor or well-baby-clinic nursing sister are among the most reliable so
urces of information.
Protein per cent Human milk 11 Cows milk 35
Fat per cent 42 39
Sugar per cent 70 46
362 Infantilism
aggressive treatment might prevent further brain damage leading to learn
ing disability.
Infantilism The condition characterised by imperfect sexual development
at puberty. It may or may not
be associated with small stature, and may be due to lack of development of certa
in of the ENDOCRINE GLANDS:
for example, the gonads, pituitary gland or adrenal glands. In other cases it ma
y be associated with a
generalised disease such as diabetes mellitus, asthma, ulcerative colitis and rh
eumatoid arthritis (for
more information, see under separate entries).
Infant Mortality Rate (IMR) I
The number of deaths of infants under one year of age. The IMR in any gi
ven year is calculated as the
number of deaths in the first year of life in proportion to every 1,000 register
ed live births in that
year. Along with PERINATAL MORTALITY, it is accepted as one of the most importan
t criteria for assessing
the health of the community and the standard of the social conditions of a count
ry. The improvement in the
infant mortality rate has occurred mainly in the period from the second month of
life. There has been much
less improvement in the neonatal mortality rate that is, the number of infants d
ying during the first
four weeks of life, expressed as a proportion of every 1,000 live births. During
the first week of life the
main causes of death are asphyxia, prematurity, birth injuries and congenital ab
normalities. After the
first week the main cause of death is infection. Social conditions also play an
important role in infant
mortality. In England and Wales the infant mortality rate in 193032 was: Social C
lass I (professional),
327; Social Class III (skilled workers), 576; Social Class V (unskilled workers),
771. Many factors come
into play in producing these social variations, but overcrowding is undoubtedly
one of the most important.
It is thus evident that for a reduction of the infant mortality rate to
the minimum figure, the
following conditions must be met. Mothers and potential mothers must be housed a
dequately in healthy
surroundings, particularly with regard to safe water supplies and sewage disposa
l. The pregnant and nursing
mother must be ensured an adequate diet. Effective antenatal supervision must be
available to every mother,
as well as skilled supervision during labour (see PREGNANCY AND LABOUR). The new
born infant must be
adequately nursed and fed and mothers encouraged to breast feed. Environmental a
nd public-health measures
must be taken to ensure adequate housing, a clean milk supply and full availabil
ity of medical care
including such protective measures as IMMUNISATION against diphtheria, measles,
poliomyelitis and
whooping-cough. (See also PERINATAL MORTALITY.)
Infertility 363
contact with the infected individual (called fomites). Some people who h
ave recovered from a disease,
or who have simply been in contact with an infectious case, harbour the infectio
us agent. This is
particularly the case in typhoid fever (see ENTERIC FEVER), the bacillus continu
ing to develop in the
gall-bladder of some people who have had the disease for years after the symptom
s have disappeared. In the
case of CHOLERA, which is ENDEMIC in some developing countries with hot climates
, 80 per cent or more of
the population may harbour the bacillus and spread infection when other circumst
ances favour this.
Similarly in the case of DYSENTERY, people who have completely recovered may sti
ll be capable of infecting
dust and drinking-water by their stools. DIPHTHERIA and meningococcal MENINGITIS
, which is particularly
liable to infect children, are other examples. Flies can infect milk and other f
ood with the organisms
causing typhoid fever and food poisoning. Mosquitoes carry the infective agents
of MALARIA, DENGUE and
YELLOW FEVER, these undergoing part of their development in the body of the mosq
uito. Fleas convey the germ
of plague from rats to humans, and lice are responsible for inoculating TYPHUS F
EVER and one form of
RELAPSING FEVER by their bite. A tick is responsible for spreading another form
of relapsing fever, and
kala-azar (LEISHMANIASIS) is spread by the bites of sandflies.
Notifiable diseases Certain of the common and most serious infectious di
seases are notifiable in the
United Kingdom. A doctor diagnosing someone infected by a notifiable disease mus
t inform the authorities.
For the current list of notifiable infectious diseases in the UK, see the main e
ntry for NOTIFIABLE
DISEASES. Prevention is an important aspect of the control of infectious disease
s, and various steps can be
taken to check the spread of such infections as dysentery, tuberculosis, malaria
and others. (See also
IMMUNITY; INCUBATION.)
partners are affected. Couples should be investigated together as effici
ently and quickly as possible
to decrease the distress which is invariably associated with the diagnosis of in
fertility. In about 1015
per cent of women suffering from infertility, ovulation is disturbed. Mostly the
y will have either
irregular periods or no periods at all (see MENSTRUATION). Checking a hormone pr
ofile in the womans blood
will help in the diagnosis of ovulatory disorders like polycystic ovaries, an ea
rly menopause, anorexia or
other endocrine illnesses. Ovulation itself is best assessed by ultrasound scan
at mid-cycle or by a blood
hormone progesterone level in the second half of the cycle. The FALLOPIAN TUBES
may be damaged or blocked
in 2030 per cent of infertile women. This is usually caused by previous pelvic in
fection or ENDOMETRIOSIS,
where menstrual blood is thought to flow backwards through the fallopian tubes i
nto the pelvis and seed
with cells from the lining of the uterus in the pelvis. This process often leads
to scarring of the pelvic
tissues; 510 per cent of infertility is associated with endometriosis. To assess
the Fallopian tubes
adequately a procedure called LAPAROSCOPY is performed. An ENDOSCOPE is inserted
through the umbilicus and
at the same time a dye is pushed through the tubes to assess their patency. The
procedure is performed
under a general anaesthetic. In a few cases the mucus around the cervix may be h
ostile to the partners
sperm and therefore prevent fertilisation. Defective production is responsible f
or up to a quarter of
infertility. It may result from the failure of the testes (see TESTICLE) to desc
end in early life, from
infections of the testes or previous surgery for testicular torsion. The semen i
s analysed to assess the
numbers of sperm and their motility and to check for abnormal forms. In a few ca
ses the genetic make-up of
one partner does not allow the couple ever to achieve a pregnancy naturally. In
about 25 per cent of
couples no obvious 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 be repaired by tubal su
rgery. If the tubes are
destroyed beyond repair a pregnancy may be achieved with in vitro fertilisation
(IVF) see under ASSISTED
CONCEPTION. Endometriosis may be treated either with drugs or laser therapy, and
pregnancy rates after both
forms of treatment are between 4050 per cent, depending on the severity of the di
sease.
Infertility This is diagnosed when a couple has not achieved a pregnancy
after one year of regular
unprotected sexual intercourse. Around 1520 per cent of couples have difficulties
in conceiving; in half
of these cases the male partner is infertile, while the woman is infertile also
in half; but in one-third
of infertile couples both
I
364 Infestation
I
Few options exist for treating male-factor infertility. These are artifi
cial insemination by husband or
donor and more recently in vitro fertilisation. Drug treatment and surgical repa
ir of VARICOCELE have
disappointing results. Following investigations, between 30 and 40 per cent of i
nfertile couples will
achieve a pregnancy usually within two years. Some infertile men cannot repair a
ny errors in the DNA in
their sperm, and it has been found that the same DNA repair problem occurs in ma
lignant cells of some
patients with cancer. It is possible that these mens infertility might be natures
way of stopping the
propagation of genetic defects. With the assisted reproduction technique called
intracytoplasmic sperm
injection, some men with defective sperm can fertilise an ovum. If a man with su
ch DNA defects fathers a
child via this technique, that child could be sterile and might be at increased
risk of developing cancer.
(See ARTIFICIAL INSEMINATION; ASSISTED CONCEPTION.)
Infestation A term applied to the occurrence of animal parasites in the
intestine, hair or clothing.
Infibulation The most extensive form of female CIRCUMCISION, involving r
emoval of CLITORIS and both
LABIA.
Infiltration The invasion of tissues or organs by cells or fluid not nor
mally present for example,
local anaesthetic is infiltrated into an area of tissue to produce analgesia in
a defined area.
Inflammation The reaction of the tissues to any injury, which may be the
result of trauma, infection or
chemicals. Local blood vessels dilate, thus increasing blood flow to the injured
site. White blood cells
invade the affected tissue, engulfing bacteria or other foreign bodies; related
cells consume any dead
cells, thus producing PUS after which the site starts to heal. The patient feels
pain and the affected
tissue becomes hot, red and swollen, with its functioning affected. If the infec
tion is severe it may
persist locally chronic inflammation or spread elsewhere in the body systemic in
fection.
Inflammatory Bowel Disease (IBD) and ULCERATIVE COLITIS are chronic infl
ammatory diseases characterised
by relapsing and remitting episodes over many CROHNS DISEASE
years. The diseases are similar and are both classified as IBD, but a si
gnificant distinction is that
Crohns disease can affect any part of the GASTROINTESTINAL TRACT from mouth to an
us, whereas ulcerative
colitis affects only the COLON. The incidence of IBD varies widely between count
ries, being rare in the
developing world but much more common in westernised nations, where the incidenc
e of Crohns disease is
around 57 per 100,000 (and rising) and that of ulcerative colitis at a broadly st
able 10 per 100,000. It
is common for both disorders to develop in young adults, but there is a second s
pike of incidence in people
in their 70s. Details about the two disorders are given under the individual ent
ries elsewhere in the
dictionary. Inflammatory bowel disease should not be confused with IRRITABLE BOW
EL SYNDROME (IBS) which has
some of the same symptoms of IBD but a different cause and outcome.
Infliximab An IMMUNOSUPPRESSANT monoclonal antibody (see ANTIBODIES) des
igned to inhibit the
pro-inflammatory cytokine (see CYTOKINES), tumour necrosis factor alpha. It is u
sed in treating CROHNS
DISEASE and RHEUMATOID ARTHRITIS.
Influenza Influenza is an acute infectious disease, characterised by a s
udden onset, fever and
generalised aches and pains. It usually occurs in epidemics and pandemics (see E
PIDEMIC; PANDEMIC).
Cause The disease is caused by a VIRUS of the influenza group. There are
at least three types of
influenza virus, known respectively as A, B and C. One of their most characteris
tic features is that
infection with one type provides no protection against another. Equally importan
t is the ease with which
the influenza virus can change its character. It is these two characteristics wh
ich explain why one attack
of influenza provides little, if any, protection against a subsequent attack, an
d why it is so difficult to
prepare an effective vaccine against the disease. Epidemics of influenza due to
virus A occur in Britain at
two- to four-year intervals, and outbreaks of virus B influenza in less frequent
cycles. Virus A influenza,
for instance, was the prevalent infection in 1949, 1951, 1955 and 1956, whilst v
irus B influenza was
epidemic in 1946, 1950, 1954 and, along with virus A, in 195859. The pandemic of
1957, which swept most of
the world, although fortunately not in a severe form, was due to a new variant o
f virus A the so-called
Asian virus and it has been suggested that it was this variant that was
plicated attack of
influenza, treatment is symptomatic: that is, rest in bed, ANALGESICS to relieve
the pain, sedatives, and a
light diet. A linctus is useful to sooth a troublesome cough. The best analgesic
s are ASPIRIN or
PARACETAMOL. None of the sulphonamides or the known antibiotics has any effect o
n the influenza virus; on
the other hand, should the lungs become infected, antibiotics should be given im
mediately, because such an
infection is usually due to other organisms. If possible, a sample of sputum sho
uld be examined to
determine which organisms are responsible for the lung infection. The choice of
antibiotic then depends
upon which antibiotic the organism is most sensitive to.
Information Technology in Medicine The advent of computing has had wides
pread effects in all areas of
society, with medicine no exception. Computer systems are vital as they are in a
ny modern enterprise
for the administration of hospitals, general practices and health authorities, s
upporting payroll, finance,
stock ordering and billing, resource and bed management, word-processing corresp
ondence, laboratory-result
reporting, appointment and record systems, and management audit. The imaging sys
tems of COMPUTED TOMOGRAPHY
(CT) and magnetic resonance imaging (see MRI) have powerful computer techniques
underlying them.
Computerised statistical analysis of study data, population databases and diseas
e registries is now
routine, leading to enhanced understanding of the interplay between diseases and
the population. And the
results of research, available on computerised indexes such as MEDLINE, can be o
btained in searches that
take only seconds, compared with the hours or days necessary to accomplish the s
ame task with its paper
incarnation, Index Medicus.
Medical informatics The direct computerisation of those activities which
are uniquely medical
history-taking, examination, diagnosis and treatment has proved an elusive goal,
although one hotly
pursued by doctors, engineers and scientists working in the
I
presentation of information. Many other issues stand in the way of the developme
nt towards computerisation:
standard systems of nomenclature for medical concepts have proved surprisingly d
ifficult to develop, but
are crucial for successful information-sharing between users. Sharing informatio
n between existing legacy
systems is a major challenge, often requiring customised software and extensive
human intervention to
enable the previous investments that an organisation has made in individual syst
ems (e.g. laboratory-result
reporting) to be integrated with newer technology. The beginnings of a global so
lution to this substantial
obstacle to networking progress is in sight: the technology that enables the Int
ernet an international
network of telephonically linked personal computers also enables the establishme
nt of intranets, in which
individual servers (computers dedicated to serving information to other computer
s) act as repositories of
published data, which other users on the network may browse as necessary in a client
-server
environment. Systems that support this process are still in early stages of deve
lopment, but the key
conceptualisations are in place. Developments over the next 510 years will centre
on the electronic
patient record available to the clinician on an integrated clinical workstation.
The clinical workstation
in essence a personal computer networked to the hospital or practice system will
enable the clinician to
record clinical data and diagnoses, automate the ordering of investigations and
the collection of the
results, and facilitate referral and communication between the many professional
s and departments involved
in any individual patients care. Once data is digitised and that includes text, s
tatistical tables,
graphs, illustrations and radiological images, etc. it may be as freely networke
d globally as locally.
Consultations in which live video and sound transmissions are the bonds of the d
octor-patient relationship
(the techniques of telemedicine) are already reality, and have proved particular
ly convenient and
cost-effective in linking the patient and the generalist to specialists in remot
e areas with low population
density. As with written personal medical records,
Ingestion
confidentiality of personal medical information on computers is essentia
l. Computerised data are
covered by the Data Protection Act 1984. This stipulates that data must: be obta
ined and processed fairly
and lawfully. be held only for specified lawful purposes. not be used in a manne
r incompatible with those
purposes. only be recorded where necessary for these purposes. be accurate and u
p to date. not be stored
longer than necessary. be made available to the patient on request. be protected
by appropriate security
and backup procedures. As these problems are solved, concerns about privacy and
confidentiality arise.
While paper records were often only confidential by default, the potential for b
reaches of security in
computerised networks is much graver. External breaches of the system by hackers
are one serious concern,
but internal breaches by authorised users making unauthorised use of the data ar
e a much greater risk in
practice. Governing network security so that clinical users have access on a nee
d-to-know basis is a
difficult business: the software tools to enable this encryption, and anonymisat
ion (ensuring that
clinical information about patients is anonymous to prevent confidential informa
tion about them leaking
out) of data collected for management and research processes exist in the techni
cal domain but remain a
complex conundrum for solution in the real world. The mushroom growth of website
s covering myriad subjects
has, of course, included health information. This ranges from clinical details o
n individual diseases to
facts about medical organisations and institutes, patient support groups, etc. S
ome of this information
contains comments and advice from orthodox and unorthodox practitioners. This op
en access to health
information has been of great benefit to patients and health professionals. But
web browsers should be
aware that not all the medical information, including suggested treatments, has
been subject to PEER
REVIEW, as is the case with most medical articles in recognised medical journals
.
Informed Consent Patients rights are a growing concern for doctors and pa
tients. A controversial
aspect of their clinical relationship is consent: doctors need signed agreement
from patients before
carrying out operations or procedures; before entering patients in clinical tria
ls; and before publishing
clinical details or photographs of patients for
367
medical education in print or electronic media. Consent is said to be in
formed when patients are fully
aware of the consequences and risks of the procedure in question. For example, d
octors and other health
professionals should tell patients of the complications of a treatment and the l
ol a suspension of very
small liquid or solid particles in the air. The latter are now usually delivered
by devices in which the
aerosol is kept under pressure in a small hand-held cylinder and delivered in re
quired doses by a release
mechanism.
Aerosols Asthmatic patients (see ASTHMA) find aerosol devices to be of v
alue in controlling their
attacks. They provide an effective and convenient way of applying drugs directly
to the bronchi, thus
reducing the risks of unwanted effects accompanying SYSTEMIC therapy. BRONCHODIL
ATOR aerosols contain
either a beta-sympathomimetic agent or ipratropium bromide, which is an ANTICHOL
INERGIC drug. ISOPRENALINE
was the first compound to be widely used as an aerosol. It did however stimulate
beta1 receptors in the
heart as well as beta2 receptors in the bronchi, and so produced palpitations an
d even dangerous cardiac
arrhythmias. Newer beta-adrenoceptor agonists are specific for the beta2 recepto
rs and thus have a greater
safety margin. They include SALBUTAMOL, TERBUTALINE, rimiterol, fenoterol and re
proterol. Unwanted effects
such as palpiInhaler A mechanism for administering a drug in the form of a powder or
aerosol. mainly used by
patients with ASTHMA. Inhalers are basically of two types: aerosol, and dry-powd
er inhaler. The former
delivers the drug as an aerosol spray when the patient presses the top of the ca
nister containing the drug;
the latter works by putting a drug capsule in the end of the chamber and, when t
he patient presses the top,
the capsule is pierced and the drug released. A variety of spacing devices are ava
ilable to use with
pressurised (aerosol) inhalers, providing metered doses. The space introduced be
tween the inhaler and the
mouth reduces the velocity of the aerosol and thus the impact it has on the orop
harynx. More time is
therefore allowed for evaporation of the propellant, with a greater concentratio
n of drug particles being
inhaled. Inhalers with larger spacing devices and a oneway valve are very effect
ive and particularly useful
for children and patients needing higher doses of the drug. (See INHALANTS; NEBU
LISERS.)
Inheritance The transfer of characteristics, traits and disorders from p
arents to children by means of
Insecticides GENES carried in the germ cells. (See GERM GENETIC DISORDERS.)
CHROMOSOMES of the CELL; GENETIC CODE;
Inhibition Inhibition means arrest or restraint of some process effected
by nervous influence. The term
is applied to the action of certain inhibitory nerves: for example, the vagus ne
rve which contains fibres
that inhibit or control the action of the heart. The term is also applied genera
lly to the mental processes
by which instinctive but undesirable actions are checked by a process of self-co
ntrol.
Injections An injection is the introduction of a substance into the body
using a syringe and an
attached needle. Injections may be given under the skin (subcutaneous), via a ve
in (intravenous), deep into
a muscle (intramuscular), or into the fluid surrounding the spinal cord (intrath
ecal).
Inner Ear This comprises three fluid-filled chambers, or labyrinths, sit
uated in the bony temporal area
that are concerned with identifying a persons position in space. Each chamber lie
s in a different plane,
and movement of fluid within it is picked up by sensory cells that transmit the
information to the brain.
Disease or damage to the inner ear upsets the sense of balance and causes vertig
o. MOTION TRAVEL SICKNESS
is caused by the inner ear being unable to accommodate the changes in position r
esulting from motion. (See
EAR.)
Innervation The nerve supply to a tissue, organ or part of the body. It
carries motor impulses to and
sensory impulses away from the part.
Inoculation The process by which infective material is brought into the
system through a small wound in
the skin or in a mucous membrane. Many infectious diseases are contracted by acc
idental inoculation of
microbes as is bloodpoisoning (see SEPTICAEMIA). Inoculation is now used as a pr
eventive measure against
many infectious diseases. (See also VACCINE.)
Inositol A sugar compound that is one constituent of some phospholipids
(see LIPID) found in cells. It
is found in many foods but, although sometimes classified as a VITAMIN, it is no
t a vital part of the human
diet.
369
Inotropic Adjective describing anything that affects the force of muscle
contraction. It is usually
applied to the heart muscle; an inotrope such as DIGOXIN is a drug that improves
its contraction.
Beta-blocker drugs such as PROPRANOLOL HYDROCHLORIDE have negative inotropic pro
perties.
Inpatient A person who requires a hospital bed for investigation or trea
tment.
Inquest An official inquiry conducted by a CORONER into the cause of an
individuals death. The coroner
is a judicial officer who, when a death is sudden, unexpected or occurs in suspi
cious circumstances,
considers the results of medical and legal investigation and, sitting with a jur
y or on his or her own,
makes the conclusions public. He/she has wide powers, and, in deaths of uncertai
n cause, no official death
certificate can be issued without his or her approval. A coroner may be legally
or medically qualified (or
both). In Scotland the comparable officer is the procurator fiscal.
Insanity See MENTAL ILLNESS.
Insecticides Substances which kill insects. Since the discovery of the i
nsecticidal properties of DDT
(see DICHLORODIPHENYL TRICHLOROETHANE) in 1940, a steady stream of new ones has
been introduced. Their
combined use has played an outstanding part in international public health campa
igns, such as that of the
World Health Organisation for the eradication of MALARIA. Unfortunately, insects
are liable to become
resistant to insecticides, just as bacteria are liable to become resistant to an
tibiotics, and it is for
this reason that so much research work is being devoted to the discovery of new
ones. Researchers are also
exploring new methods, such as releasing sexually sterile insects into the natur
al population. The useful
effects of insecticides must be set against increasing evidence that the indiscr
iminate use of some of
these potent preparations is having an adverse effect not only upon human beings
, but also upon the
ecosystems. Some, such as DDT the use of which is now banned in the UK are very
stable compounds that
enter the food chain and may ultimately be lethal to many animals, including bir
ds and fishes.
I
370 Insemination
Insemination The ejaculation of SEMEN in the VAGINA in the act of sexual
intercourse. In ARTIFICIAL
INSEMINATION the semen is placed there by the use of an instrument. (See also AS
SISTED CONCEPTION.)
Insight A persons knowledge of him or herself. The description is especia
lly relevant to a persons
realisation that he or she has psychological difficulties. Thus, someone with a
psychosis (see MENTAL
ILLNESS) lacks insight. Insight also refers to an individuals concept of his or h
er personality and
problems.
Insomnia See SLEEP, DISORDERS OF; HYPNOTICS.
I
Inspissation The process of the drying or thickening of fluids or excret
ions by evaporation.
Institutionalisation A condition brought about by a prolonged stay in an
impersonal institution. The
individual becomes apathetic and listless as a result of inadequate stimulation
in an uninteresting
environment. The condition can occur in mental institutions or long-stay nursing
homes; the affected person
loses the ability to make any decisions and becomes pathetic and increasingly de
pendent on others.
Insufflation Insufflation means the blowing of powder or vapour into a c
avity, especially through the
air passages, for the treatment of disease.
Insulin A POLYPEPTIDE hormone (see HORMONES) produced in the PANCREAS by
the beta cells of the ISLETS
OF LANGERHANS. It plays a key role in the bodys regulation of CARBOHYDRATE, FAT,
and PROTEIN, and its
deficiency leads to DIABETES MELLITUS. Diabetic patients are described as type 1
(insulin dependent), or
type 2 (non-insulin dependent), although many of the latter may need insulin lat
er on, in order to maintain
good control. Insulin is extracted mainly from pork pancreas and purified by cry
stallisation; it may be
made biosynthetically by recombinant DNA technology using Escherichia coli, or s
emisynthetically by
enzymatic modification of porcine insulin to produce human insulin. The latter i
s the form now generally
used, although some patients find it unsuitable and have to return to porcine in
sulin.
The hormone acts by enabling the muscles and other tissues requiring sug
ar for their activity to take
up this substance from the blood. All insulin preparations are to a greater or l
esser extent immunogenic in
humans, but immunological resistance to insulin action is uncommon. Previously a
vailable in three
strengths, of 20, 40, and 80 units per millilitre (U/ml), these have now largely
been replaced by a
372 Intercostal
patients undergoing intensive care in the UK are usually more seriously
ill than those in the US. This
is reflected in the shortage of available ITU beds in Britain, especially in the
winter. (See CORONARY CARE
UNIT (CCU); HIGH DEPENDENCY UNIT.)
Intercostal The term applied to the nerves, vessels and muscles that lie
between the ribs, as well as
to diseases affecting these structures.
Interferon
I
It has been known for many years that one VIRUS will interfere with the
growth of another. In 1957, UK
research workers isolated the factor that was responsible for the phenomenon, gi
ving it the name of
interferon. There are now known to be three human interferons. They are glycopro
teins and are released from
cells infected with virus or exposed to stimuli which mimic virus infection. The
y not only inhibit the
growth of viruses; they also inhibit the growth and reduplication of cells, and
this is the basis for their
investigation as a means of treating cancer. Hitherto the major difficulty has b
een obtaining sufficient
supplies of interferon, but methods have now been evolved which promise to provi
de adequate amounts of it.
The most promising of these is by means of what is known as genetic engineering,
or manipulation, whereby a
portion of DNA from interferon is inserted into the micro-organism known as Esch
erichia coli (see
ESCHERICHIA) which thus becomes a source of almost unlimited amounts of interfer
on as it can be grown so
easily. Interferon alfa previously termed leucocyte interferon or lymphoblastoid
interferon has some
antitumour effect in some solid tumours and lymphomas. It is also used to treat
HEPATITIS B and C (chronic
variety). Various sideeffects include suppression of MYELOBLAST production. Inte
rferon beta previously
termed fibroblast interferon is used (under restricted conditions in the UK) to
treat patients with
relapsing, remitting MULTIPLE SCLEROSIS (MS), and interferon beta-16 is licensed
for use in patients with
the secondary progressive type of this disorder. The use of interferon, which ha
s a range of side-effects,
should be recommended by a neurologist.
Interleukins Interleukins are lymphokines that is, polypeptides produced
by activated lymphocytes.
They are involved in signalling between cells of the immune system (see IMMUNITY
) and are released by
several cell types, including lymphocytes. They interact to control the immune response of cells and also pa
rticipate in HAEMOPOIESIS.
There are seven varieties, interleukins 1 to 7. For example, interleukin 1 is pr
oduced as a result of
Intersexuality 373
going through Parliament as this text was going to press, so modificatio
ns to them are possible.)
Intermittent A term applied to fevers which continue for a time, subside
completely and then return
again. The name is also used in connection with a pulse in which occasional hear
tbeats are not felt, in
consequence of irregular action of the heart.
Intermittent Claudication A condition occurring in middle-aged and elder
ly people, which is
characterised by pain in the legs after walking a certain distance. The pain is
relieved by resting for a
short time. It is due to arteriosclerosis (see ARTERIES, DISEASES OF) of the art
eries to the leg, which
results in inadequate blood supply to the muscles. Drugs usually have little eff
ect in easing the pain, but
useful preventive measures are to stop smoking, reduce weight (if overweight), a
nd to take as much exercise
as possible within the limits imposed by the pain.
Internet Access to medical information via the Internet is widespread in
some populations, often
serving more patients than doctors. In addition to the huge variety of informati
on available, patients can
share experiences via electronic discussion groups, or obtain e-mail advice on a
fee-for-service basis.
Some professional organisations and journals provide free access to information,
and the Internet can be a
useful resource for medical practitioners and researchers. Concerns have arisen
about the growth in
electronic medical information: some believe that patients who have unlimited ac
cess to information via the
Internet will be less likely to tolerate health-care rationing or will demand tr
eatments that may be
inappropriate in their individual circumstances. Other criticisms relate to the
quality and accuracy of the
information provided, potential breaches of patient CONFIDENTIALITY, and the ris
k of increased accusations
of medical negligence (see also ETHICS).
Intermittent SelfCatheterisation
Internode
A technique in which a patient (of either sex) inserts a disposable cath
eter (see CATHETERS) through
the URETHRA into the bladder to empty it of urine. It is increasingly used to ma
nage patients with chronic
retention of urine, or whose bladders do not empty properly usually the result o
f neurological disorder
affecting the bladder (neuropathic bladder). (See URINARY BLADDER, DISEASES OF.)
Intersexuality
Intern An American term for a doctor-in-training who carries out his or
her duties and learns in
hospital, usually spending some of his/her time living there. The terms preferre
374 Interstitial
the sex that he or she is to be brought up as. Surgical or hormonal mean
s should then be employed, when
appropriate, to develop the attributes of that sex and diminish those of the oth
er, together with
psychological counselling.
Interstitial Interstitial is a term applied to indifferent tissue set am
ong the proper active tissue of
an organ. It is generally of a supporting character and formed of fibrous tissue
. The term is also applied
to the fluid always present in this in a small amount, and to diseases which spe
cially affect this tissue,
such as interstitial keratitis.
I
Lateral view of prolapsed intervertebral disc.
Interstitial Cells Also called Leydig cells, these cells are scattered b
etween the SEMINIFEROUS TUBULES
of the testis (see TESTICLE). LUTEINISING HORMONE from the anterior PITUITARY GL
AND stimulates the
interstitial cells to produce androgens, or male hormones.
Intertrigo Inflammation between two skin surfaces in contact, typically
in the toe clefts, axillae,
under the breasts or in the anogenital folds. Heat, friction and obesity are agg
ravating factors. Secondary
fungal or bacterial infection with CANDIDA or bacteria is common.
Intestine
Interventional Radiology The use of radiology (see X-RAYS) to enable doc
tors to carry out diagnostic or
treatment procedures under direct radiological vision. This X-ray procedure is u
sed in MINIMALLY INVASIVE
SURGERY (MIS) for example, ANGIOPLASTY, the removal of stones from the kidney (s
ee KIDNEYS, DISEASES OF),
and the observation of obstructions in the bile ducts (percutaneous CHOLANGIOGRA
PHY). (See also magnetic
resonance imaging MRI.)
Intervention Study Comparison of outcomes between two or more groups of
patients who have been
intentionally given different treatments or preventative measures, for example,
diets. The subjects in the
trial should be randomly allocated to the groups, with patients in one group cal
led controls receiving
no active treatment. If possible, neither patients nor doctors participating in
a study should know which
patients are receiving what treatment (double blind study/trial). Furthermore, g
roups should exchange
treatments after a prearranged time (crossover study/trial). (See CLINICAL TRIAL
S; RANDOMISED CONTROLLED
TRIAL.)
Intervertebral Disc The fibrous disc that acts as
bony vertebrae (see SPINAL
COLUMN), enabling them to rotate and bend one on another.
nerate with age and may get
ruptured and displaced prolapsed or slipped disc as a
action. Prolapsed disc
occurs mainly in the lower back; it is more common in men
the 3040 age group.
Intestine All the alimentary canal beyond below the stomach. In it, most
DIGESTION is carried on, and
through its walls all the food material is absorbed into the blood and lymph str
eams. The length of the
intestine in humans is about 859 metres (2830 feet), and it takes the form of one c
ontinuous tube
suspended in loops in the abdominal cavity.
Divisions The intestine is divided into small intestine and large intest
ine. The former extends from
the stomach onwards for 65 metres (22 feet) or thereabouts. The large intestine i
s the second part of the
tube, and though shorter (about 18 metres [6 feet] long) is much wider than the s
mall intestine. The
latter is divided rather arbitrarily into three parts: the duodenum, consisting
of the first 2530 cm
375
(1012 inches), into which the ducts of the liver and pancreas open; the j
ejunum, comprising the next
2427 metres (89 feet); and finally the ileum, which at its lower end opens into the
large intestine.
The large intestine begins in the lower part of the abdomen on the right side. T
he first part is known as
the caecum, and into this opens the appendix vermiformis. The appendix is a smal
l tube, closed at one end
and about the thickness of a pencil, anything from 2 to 20 cm (average 9 cm) in
length, which has much the
same structure as the rest of the intestine. (See APPENDICITIS.) The caecum cont
inues into the colon. This
is subdivided into: the ascending colon which ascends through the right flank to
beneath the liver; the
transverse colon which crosses the upper part of the abdomen to the left side; a
nd the descending colon
which bends downwards through the left flank into the pelvis where it becomes th
e sigmoid colon. The last
part of the large intestine is known as the rectum, which passes straight down t
hrough the back part of the
pelvis, to open to the exterior through the anus.
Structure The intestine, both small and large, consists of four coats, w
hich vary slightly in structure
and arrangement at different points but are broadly the same throughout the enti
re length of the bowel. On
the inner surface there is a mucous membrane; outside this is a loose submucous
coat, in which blood
vessels run; next comes a muscular coat in two layers; and finally a tough, thin
peritoneal membrane.
MUCOUS COAT The interior of the bowel is completely lined by a single layer of p
illar-like cells placed
side by side. The surface is increased by countless ridges with deep furrows thi
ckly studded with short
hair-like processes called villi. As blood and lymph vessels run up to the end o
f these villi, the digested
food passing slowly down the intestine is brought into close relation with the b
lood circulation. Between
the bases of the villi are little openings, each of which leads into a simple, t
ubular gland which produces
a digestive fluid. In the small and large intestines, many cells are devoted to
the production of mucus for
lubricating the passage of the food. A large number of minute masses, called lym
ph follicles, similar in
structure to the tonsils are scattered over the inner surface of the intestine.
The large intestine is bare
both of ridges and of villi. SUBMUCOUS COAT Loose connective tissue which allows
the mucous membrane to
play freely over the muscular coat. The blood vessels
I
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 gen
etic defects in the Y
chromosome to sons born after ICSI.
Intrathecal Intrathecal means within the membranes or meninges which env
elop the SPINAL CORD. The
intrathecal space, between the arachnoid and the pia mater, contains the CEREBRO
SPINAL FLUID (see
INTRACRANIAL PRESSURE).
Intrauterine Contraceptive Device (IUCD) I
A mechanical device, commonly a coil, inserted into the UTERUS to preven
t CONCEPTION, probably by
interfering with the implantation of the EMBRYO. For many women, IUCDs are an ef
fective and acceptable form
of contraception, although only about 10 per cent of women in the UK use them. T
he devices are of various
shapes and made of plastic or copper; most have a string that passes through the
cervix and rests in the
vagina. About one-third of women have adverse effects as the result of IUCD use:
common ones are backache
and heavy menstrual bleeding (see MENSTRUATION). The frequency of unwanted pregn
ancies is about 2 per 100
women-years of use. (See CONTRACEPTION.)
Position of intravenous needle inserted into vein on back of hand for ad
ministration of intravenous
fluid or blood transfusion.
Intrinsic Factor Secreted in the lining of the stomach, this factor is o
ne of the GLYCOPROTEINS, and is
essential for the absorption into the bloodstream of vitamin B12 (see APPENDIX 5
: VITAMINS). Absence of
intrinsic factor causes a deficiency of this essential vitamin, which in turn ca
uses PERNICIOUS ANAEMIA.
Intrauterine Insemination
Intromission
A method of helping CONCEPTION to occur when a man is infertile (see INF
ERTILITY) because his sperm
(see SPERMATOZOON) cannot penetrate either the cervical mucus at the entrance of
the UTERUS or the barriers
that surround the OVUM. The sperm, often treated chemically beforehand to increa
se motility, are injected
directly into the uterus via the VAGINA.
Introspection
Intravenous A term which means inside a vein. An intravenous injection i
s one that is given into a
vein. Blood transfusions are given intravenously, as are other infusions of flui
d.
Iodides
379
and to have reactions that are reserved and defensive.
spread of cancer into normal, nearby tissues or organs.
Introvert
In Vitro
Physically it means turning inside out. Psychologically, the term refers
to an individual whose
character looks inwards on him or herself and who may also be obsessive and have
few friends. (See
INTROVERSION.)
A term commonly used in medical research and experimental biology. Liter
ally in a glass, it refers to
observations made outside the body: for example, on the action of drugs on bacte
ria. The opposite term is
IN VIVO, which refers to observations of processes in the body.
Intubation A procedure consisting in the introduction, through the mouth
or nose into the larynx, of a
tube designed to keep the air passage open at this point.
Intuition The immediate understanding of a situation by someone without
the customary mental process of
reasoning.
Intussusception A form of obstruction of the bowels in which part of the
INTESTINE enters within that
part immediately beneath it. This can best be understood by observing what takes
place in the fingers of a
tightly fitting glove as they turn outside-in when the glove is pulled off the h
and. Mostly, the condition
affects infants. Often it occurs during the course of a viral infection or a mil
d attack of
gastroenteritis, or it may be that swelling of lymphoid tissue in the gut provok
es the event. The point at
which it most often occurs is the junction between the small and the large intes
tines, the former passing
within the latter. The symptoms are those of intestinal obstruction in general (
see INTESTINE, DISEASES OF
Obstruction), and in addition there is often a discharge of blood-stained mucus
from the bowel. Unless
the symptoms rapidly subside, when it may be assumed that the bowel has righted
itself, treatment consists
of either hydrostatic reduction by means of a barium or air ENEMA, or an operati
on. At operation the
intussusception is either reduced or, if this not possible, the obstructed part
is cut out and the ends of
the intestine then stitched together. If treated adequately and in time, the mor
tality is now reduced to
around 1 per cent. The condition may recur in about 5 per cent of patients.
In Vitro Fertilisation (IVF) Fertilisation of the egg (ovum) outside the
body. The fertilised ovum is
then incubated until the blastocyst stage develops, when it is implanted into th
e UTERUS. The procedure was
developed in Britain and the first successful in vitro baby, a girl, was born in
1978. IVF is used when a
woman has blocked FALLOPIAN TUBES or when the sperm and ovum are unable to fuse
in the reproductive tract.
Hormone treatment results in the potential mothers producing several mature ova,
some of which are removed
from the ovary using a LAPAROSCOPE and fertilised with her partners semen. (See A
SSISTED CONCEPTION.)
In Vivo A Latin term to describe biological events that take place insid
e the bodies of living
organisms.
Involucrum The sheath of new bone which is formed round a piece of dead
bone in, for example,
OSTEOMYELITIS.
Involuntary Muscle Muscle that does not operate under a persons conscious
control. Involuntary muscle
also called smooth muscle, because the cells do not contain the striations that
occur in VOLUNTARY MUSCLE
is found in blood vessels, the heart, stomach, and intestines. (See PARASYMPATHE
TIC NERVOUS SYSTEM.)
Involution The process of change whereby the UTERUS returns to its resti
ng size after parturition
(birth). The term is also applied to any retrograde biological change, as in sen
ility (see AGEING).
In Utero
Iodides
Literally in the UTERUS and used to refer to events occurring to a baby be
fore birth.
Salts of iodine, those which are especially used in medicine being the i
odide of potassium and iodide
of sodium. Iodides are excreted in the mucus secretions, as well as in the urine
, saliva and sweat, and
have an action in liquefying the
Invasion The entry of bacteria into the body; the
I
380 Iodine
I
mucus secretion of the bronchial tree. They are therefore used in EXPECT
ORANTS. They are also used to
assist in providing a supply of iodine in patients with goitre, or in individual
s who live in an area where
goitre is liable to occur because of a deficiency of IODINE in the drinking wate
r. They may be given in the
form of iodised salt. (See THYROID GLAND, DISEASES OF Goitre.)
(see EXPECTORANTS) given in BRONCHITIS. (See POISONS.)
Iodine
See INTELLIGENCE QUOTIENT (IQ).
A non-metallic element which is found largely in seaweed. The body conta
ins about 30 mg, largely
concentrated in the THYROID GLAND where it is used to synthesise thyroid hormone
s. Iodine has a highly
irritating action and, when applied to the skin, stains the latter dark brown an
d causes it to peel off in
flakes, while internally it is a violent irritant poison in large doses. Externa
lly iodine is used as an
antiseptic. Its drawback is that it is fixed by protein, which reduces its antis
eptic efficiency in open
wounds. Its main use in this sphere therefore is for sterilising the unbroken sk
in, as before an operation.
Radioactive iodine is used for diagnosing and treating disease of the thyroid gl
and.
Ion Atom An atom (or a collection of atoms) that has an electrical charg
e. Positive atoms are cations,
negative ones are anions. Calcium, hydrogen, potassium and sodium are positive i
ons. Negative ones include
bicarbonate chloride and phosphate. All the substances are critical to the bodys
physiological activities.
Ion Exchange Resins Synthetic organic substances, capable of exchanging
ions cationic or anionic
from the contents of the intestine. Originally used in the prevention of OEDEMA,
they have been superseded
in this role by the modern DIURETICS, and are now used chiefly in the treatment
of HYPERKALAEMIA. They are
usually taken by mouth or as an ENEMA.
Ionisation Ionisation means the breaking up of a substance in solution i
nto its constituent.
Ipecacuanha The root of Cephalis ipecacuanha, a Brazilian shrub. It conta
ins an alkaloid, emetine,
which acts as an irritant when brought into contact with the interior of the sto
mach, producing vomiting.
Formerly used to induce vomiting among young children after poisoning and if sti
ll alert, but now of
uncertain value, it was used in many traditional expectorant mixtures
the treatment of
large amounts of anti-Rh antibodies which can enter the fetal circulation and ca
use its blood cells to
break up. (See HAEMOLYTIC DISEASE OF THE NEWBORN; BLOOD GROUPS.)
Isolation This is important when treating patients with serious infectio
n or whose immune systems (see
IMMUNITY) are severely compromised by illness or radio- or chemotherapy. The pro
cedure also protects staff
caring for infectious patients. (See INCUBATION; INFECTION; QUARANTINE.)
Isoleucine One of the essential AMINO ACIDS, which are fundamental compo
nents of all proteins. It
cannot be synthesised by the body and so must be obtained from the diet.
Isometric Of similar measurement. Isometric exercises are based on the i
sometric contraction of the
muscles. Fibres are provoked into working by pushing or pulling an immovable obj
ect, but this technique
prevents them from shortening in length. These exercises improve a persons fitnes
s and builds up his or
her muscle strength.
Isoniazid One of the anti-tuberculous drugs. It has the advantages of be
ing relatively non-toxic and of
being active when taken by mouth. Unfortunately, like streptomycin, it may rende
r the Mycobacterium
tuberculosis resistant to its action. This tendency to produce resistance is con
siderably reduced if it is
given in conjunction with RIFAMPICIN and PYRAZINAMIDE.
SYPHILIS.
Islets of Langerhans Groups of specialised cells distributed throughout
the PANCREAS, that produce
three hormones: INSULIN, GLUCAGON, and SOMATOSTATIN.
Isoprenaline An INOTROPIC sympathomimetic drug which is used as a shortterm emergency treatment of
heart block or severe BRADYCARDIA. (See HEART, DISEASES OF.)
Isotope
Isotonic A term applied to solutions which have the same power of diffus
ion as one another. An isotonic
solution used in medicine is one which can be mixed with body fluids without cau
sing any disturbance. An
isotonic saline solution for injection into the blood, so that it may possess th
e same osmotic pressure
(see OSMOSIS) as the blood SERUM, is one of 09 per cent strength that is, contain
ing 9 grams of sodium
chloride to 1 litre of water. This is also known as normal or physiological salt
solution. An isotonic
solution of bicarbonate of soda for injection into the blood is one of 135 per ce
nt strength in water. An
isotonic solution of glucose for injection into the blood is one of 5 per cent s
trength in water. Solutions
which are weaker, or stronger, than the fluids of the body with which they are i
ntended to be mixed are
known as hypotonic and hypertonic, respectively.
Isotope This is a form of a chemical element with the same chemical prop
erties as other forms, but
which has a different atomic mass. It contains an identical number of positively
charged particles called
protons, in the nucleus, giving it the same atomic number, but the numbers of ne
utrons differ. A
radioactive isotope, or radionuclide, is one that decays into other isotopes, an
d in doing so emits alpha,
beta or gamma radiation.
Applications of radionuclides to diagnosis The use of radionuclides in d
iagnosis is based on the fact
that it is possible to tag many of the substances normally present in the body w
ith a radioactive label.
Certain synthetic radioactive elements, such as technetium, can also be used. Be
cause it is possible to
detect minute quantities of radioactive material, only very small doses are need
ed, making the procedure a
safe one. Furthermore the body pool of the material is therefore not appreciably
altered, and metabolism is
not disturbed. Thus in studies of iodine metabolism the ratio of radioactive ato
ms administered to stable
atoms in the body pool is of the order of 1:1,000 million. By measuring radioact
ivity in the body, in blood
samples, or in the excreta it is possible to gain information about the fate of
the labelled substance, and
hence of the chemically identical inactive material. Therefore it is theoretical
ly possible to trace the
absorption, distribution and excretion of any substance normally present in the
body, provided that it can
be tagged with a suitable radioactive label.
383
If the investigation necessitates tracing the path of the material throu
gh the body by means of
external counting over the body surface, it is obviously essential to use an iso
tope that emits gamma
radiation or positrons. If, however, only measurements on blood sample or excret
a are required, it is
possible to use pure beta emitters. Whole-body counters measure the total radioa
ctivity in the body, and
these are of great value in absorption studies. Moving images can provide inform
ation on body functions
such as the movements of the heart, blood flow, bile flow in the liver, and urin
e in the kidneys. The
development of COMPUTED TOMOGRAPHY or CT scanning has replaced radionuclide scan
ning for some imaging
procedures. Five main groups of diagnostic uses may be defined: (1) METABOLIC ST
UDIES The use of
radioactive materials in metabolic studies is based on the fundamental property
that all isotopes of an
element are chemically identical. The radioactive isotope is used as a true isot
ope tracer that is, when
introduced into the body (in whatever form) it behaves in the same way as the in
active element. For
example, isotopes of iodine are used to measure thyroid function (see THYROID GL
AND), and isotopes of
calcium enable kinetic studies of bone formation and destruction to be performed
. (2) ABSORPTION AND
DISTRIBUTION STUDIES
The fate of labelled substances given by mouth can be followed to assess
their absorption, utilisation
and excretion. In most of these studies the isotope is a true isotope tracer. Fo
r example, iron absorption
can be measured with radioactive iron; vitamin B12 absorption may be investigate
d with vitamin B12 tagged
with radioactive cobalt. (3) BODY COMPOSITION BY DILUTION STUDIES
By introducing an isotope into a compartment, such as the blood or extra
cellular space, it is possible
to measure the volume of that compartment by determining the dilution of radioac
tivity when equilibrium has
been reached. (4) PHYSICAL TRACING STUDIES In this type of study the isotope is
not necessarily used as a
true isotopic tracer. In other words, it does not trace the path of the correspo
nding inactive isotope. For
example, xenon-133 is used in measurements of blood flow in muscles, and in lung
function studies;
krypton-85 is used to detect intracardiac shunts (abnormal blood flows in the he
art). Neither of these
elements is normally present in the body. The survival of ERYTHROCYTES may be fo
llowed and the organ
I
384 Itch
I
of sequestration revealed by labelling them with radioactive chromium. (
5) SCANNING OF ORGANS AND
TISSUES Scanning is a technique which is used to determine the distribution of r
adioactive isotopes within
the body or within one particular organ. In the conventional scanner, the radiat
ion detector which is a
scintillation counter sees only a small cross-sectional area of the body at a time
. The activity seen
at each point is registered, and a map of the activity seen over the scanned area
is recorded. Various
methods of presentation have been used, and the recently improved display system
s present the information
gathered by the scanner more effectively. More recent developments are stationar
y detectors such as the
gamma camera, auto-fluoroscope, and other devices which can view the whole of th
e area simultaneously. Thus
when selective concentration of an isotope in a tissue occurs, it is possible to
examine the distribution
of that isotope by means of scanning. A toxic nodule in the thyroid may be ident
ified by its selective
concentration of iodine-131. Areas of absent function on the radioactive scan (co
ld areas) suggest the
presence of tumours, abscesses, and similar lesions. Iodine-131 may be used to l
ocalise tumours of the
thyroid, and chlormerodrin labelled with mercury-197 to delineate tumours of the
kidneys. Of even greater
practical application is the localising of brain tumours with human serum albumi
n labelled with iodine-131
or with radioactive technetium.
Treatment Radioactive isotopes are also used in medical treatment. The o
veractivity of the thyroid
gland in thyrotoxicosis can be treated by the ingestion of radioactive iodine. T
he ingested iodine is taken
up by the thyroid gland where local irradiation of the gland takes place, reduci
ng its activity.
Radioactive phosphorus is used in the treatment of polycythemia rubra vera. It i
s largely taken up in bone
as this is the main source of body phosphate, and irradiation of the bone marrow
results, controlling the
overactivity that is characteristic of polycythaemia rubra vera (see under POLYC
YTHAEMIA). In cobalt
teletherapy the isotope cobalt 60 is used to deliver 1213 million volt radiation wh
ich is equivalent to
X-rays generated at a
peak voltage of 34 million volts. (See RADIOTHERAPY.)
Itch Itch is a popular name for SCABIES.
Itching See PRURITUS.
-Itis A suffix added to the name of an organ to signify any INFLAMMATION
of that organ.
ITP See IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP).
386 Joints
J
Diagram of synovial joints. (Left) A right shoulder-joint (simple synovi
al) from the front. (Right)
Right kneejoint (synovial with articular disc) from the front.
Joints A joint is the articulation point between different parts of the
skeleton, whether bone or
cartilage. Joints are divided into those which are fixed or relatively fixed (fi
brous and cartilaginous
joints), and those which allow free movement (synovial joints). In the former, e
xemplified by the sutures
between the bones of the skull, a layer of cartilage or fibrous tissue lies betw
een the bones, binding them
firmly together. Amphiarthrodial joints, exemplified by the joints between the v
ertebral bodies (see SPINAL
COLUMN), have a thick disc of fibrocartilage between the bones. Although the ind
ividual joint is capable of
very little movement, a series of these gives to the spinal column, as a whole,
a flexible character. All
movable joints involve four structures: the bones whose junction forms the joint
; a layer of cartilage
covering the ends of these, making them smooth; a fibrous sheath, the capsule, t
hickened at various points
into bands or ligaments, which hold the bones together; and, finally, the synovi
al membrane, which lines
the capsule and produces a synovial fluid, lubricating the movements of the join
t. In addition, the bones
are kept in position at the joints by the various muscles passing over them and
by
atmospheric pressure. Where the ends of the bones do not quite correspon
d, a subsidiary disc of
fibro-cartilage may help to adapt the ends of the bones more perfectly to each o
ther. Larger cavities may
be filled by movable pads of fat under the synovial membrane, giving additional
protection to the joint.
Varieties After this main division of joints into those which are fixed
and those movable, the movable
joints may be further subdivided. In gliding joints, such as the wrist and ankle
, the bones have flat
surfaces capable of only a limited amount of movement. In hinge joints, such as
the elbow and knee,
movement takes place around one axis. Ball-and-socket joints, exemplified by the
shoulder and hip, allow
free movement in any direction. Subsidiary varieties are named according to the
shape of the bones which
enter the joint.
Joints, Diseases of Rheumatism is the colloquial term for nonspecific musc
uloskeletal symptoms
arising in the joints, ligaments, tendons and muscles. Arthritis describes a patho
logical musculoskeletal
disorder. Most common are sprains of ligaments, strains of tendons and muscles,
Joints, Diseases of BURSITIS, TENDINITIS and non-specific back pain (see BACKACH
E).
387
Systemic autoimmune rheumatic diseases (see AUTOIMMUNE DISORDERS). see a
lso main entry. The most
common of these diseases. Acute inflammation causes lymphoid synovitis, leading
to erosion of the
cartilage, associated joints and soft tissues. Fibrosis follows, causing deformi
ty. Autoantibodies are
common, particularly Rheumatoid Factor. A common complication of RA is Sjgrens syn
drome, when
inflammation of the mucosal glands may result in a dry mouth and eyes. SYSTEMIC
LUPUS ERYTHEMATOSUS (SLE)
and various overlap syndromes occur, such as systemic sclerosis and dermatomyosi
tis. Autoantibodies against
nuclear proteins such as DNA lead to deposits of immune complexes and VASCULITIS
in various tissues, such
as kidney, brain, skin and lungs. This may lead to various symptoms, and sometim
es even to organ failure.
RHEUMATOID ARTHRITIS (RA)
Osteoarthritis (OA) rarely starts before 40, but by the age of 80 affect
s 80 per cent of the
population. There are structural and functional changes in the articular cartila
ge, as well as changes in
the collagenous matrix of tendons and ligaments. OA is not purely wear and tear; v
arious sub-groups have
a genetic component. Early OA may be precipitated by localised alteration in ana
tomy, such as a fracture or
infection of a joint. Reactive new bone growth typically occurs, causing scleros
is (hardening) beneath the
joint, and osteophytes outgrowths of bone are characteristic at the margins of t
he joint. The most
common sites are the first metatarsal (great toe), spinal facet joints, the knee
, the base of the thumb and
the terminal finger joints (Heberdens nodes). OA has a slow but variable course,
with periods of pain and
low-grade inflammation. Acute inflammation, common in the knee, may result from
release of pyrophosphate
crystals, causing pseudo-gout.
Urate gout results from crystallisation of in joints, against a backgrou
nd of hyperuricaemia. This high
concentration of uric acid in the blood may result from genetic and environmenta
l factors, such as excess
dietary purines, alcohol or diuretic drugs. URIC ACID
Inflammatory arthritis is less common than OA, but potentially much more
serious. Several types exist,
including: SPONDYLARTHRITIS This affects younger men, chiefly involving spinal a
nd leg joints. This may
lead to inflammation and eventual ossification of the enthesis that is, where th
e ligaments and tendons
are inserted into the bone around joints. This may be associated with disorders
in other parts of the body:
skin inflammation (PSORIASIS), bowel and genito-urinary inflammation, sometimes
resulting in infection of
the organs (such as dysentery). The syndromes most clearly delineated are ankylo
388 Joule
azathioprine or cyclophosphamide. Recent research promises more specific
and less toxic
anti-inflammatory drugs, such as the monoclonal antibodies like infliximab. An i
mportant treatment for some
osteoarthritic joints is surgical replacement of the joints.
Joule The unit of energy in the International System of Units. The offic
ial abbreviation is J. 4,1868
J = 1 CALORIE (or kilocalorie). (See also BRITISH WEIGHTS AND THERMAL UNIT (BTU)
; MEASURES.)
Jugular Jugular is a general name for any structure in the neck, but is
especially applied to three
large veins, the anterior, external and internal jugular veins, which convey blo
od from the head and neck
regions to the interior of the chest.
J
Jumpers Knee See PATELLAR TENDINITIS.
Jungian Analysis A school of analytical psychology, first described by Car
l Gustav Jung in 1913. It
introduced the concepts of introvert and extrovert personalities, and developed the
theory of the
collective unconscious with its archetypes of mans basic psychic nature. In contras
t with Freudian
analysis (see FREUDIAN THEORY), in Jungian analysis the relationship between the
rapist and patient is less
one-sided because the therapist is more willing to be active and to reveal infor
mation about him or
herself. (See also PSYCHOANALYSIS.)
Juvenile Idiopathic Arthritis (JIA) Previously called juvenile rheumatoi
d arthritis and juvenile
chronic arthritis, this is a set of related conditions of unknown cause affectin
g
children. Characteristically, the synovial membrane of a joint or joints
becomes inflamed and swollen
for at leat six weeks (and often very much longer even years). About 1 in 10,000
children develop it each
year, many of whom have certain HLA genetic markers, thought to be important in
determining who gets the
illness. Inflammatory CYTOKINES play a big part.
Clinical features There are various types. The oligoarthritic type invol
ves 14 joints (usually knee or
ankle) which become hot, swollen and painful. One complication is an inflammatio
n of the eyes UVEITIS.
The condition often burns out, but may reappear at any time, even years later. The
polyarthritic type is
more like RHEUMATOID ARTHRITIS in adults, and the child may have persistent symp
toms leading to major joint
deformity and crippling. The systemic type, previously called Stills disease, pre
sents with a high fever
and rash, enlarged liver, spleen and lymph nodes, and arthritis although the lat
ter may be mild. In some
children the illness becomes recurrent; in others it dies down only to return as
polyarthritis.
Complications These include uveitis, which can lead to loss of vision; a
failure to thrive;
osteoporosis (see under BONE, DISORDERS OF); joint deformity; and psychosocial d
ifficulties.
Treatment This includes
ANTIPYRETICS and ANALGESICS, including NON-STEROIDAL ANTIINFLAMMATORY DR
UGS (NSAIDS), intra-articular
steroid injections, anti-tumour necrosis factor drugs and steroids. Phys
iotherapy is vital, and
children may need to wear splints or other orthotic devices to alleviate deformi
ty and pain. Orthopaedic
operative procedures may be necessary.
K
and toes may peel. The disease may last for several weeks before spontan
eously resolving. It is
possible that it is caused by an unusual immune response to INFECTION (see IMMUN
ITY).
Arteritis is a common complication and can
Kala-Azar
Another name for visceral LEISHMANIASIS.
Kanamycin An antibiotic derived from Streptomyces kanamyceticus. It is a
ctive against a wide range of
organisms, including Staphylococcus aureus and Mycobacterium tuberculosis.
Kaolin Kaolin, or china clay, is a smooth white powder consisting of nat
ural white aluminium silicate
resulting from the decomposition of minerals containing felspar. It is used as a
dusting powder for eczema
(see DERMATITIS) and other forms of irritation in the skin. It is also used inte
rnally in cases of
diarrhoea. Talc, French chalk and Fullers earth are similar silicates. Kaolin pou
ltice contains kaolin,
boric acid, glycerin and various aromatic substances.
Kaolinosis Kaolinosis is a form of PNEUMOCONIOSIS caused by the inhaling
of clay dust.
Kaposis Sarcoma Once a very rare disease in western countries, although m
ore common in Africa,
Kaposis sarcoma is now a feature of AIDS (see AIDS/HIV) indeed, its increasing oc
currence was one of the
first pointers to the development of AIDS. It is a condition in which malignant
skin tumours develop,
originating from the blood vessels. The tumours form purple lumps which customar
ily start on the feet and
ankles, then spread up the legs and develop on the arm and hands. In AIDS the sa
rcoma appears in the
respiratory tract and gut, causing serious bleeding. Radiotherapy normally cures
mild cases of Kaposis
sarcoma, but severely affected patients will need anti-cancer drugs to check the
tumours growth.
Kawasaki Disease Also called mucocutaneous lymph node syndrome, this dis
order of unknown origin occurs
mainly in children under five and was first described in Japan. It is characteri
sed by high fever,
conjunctivitis (see under EYE, DISORDERS OF), skin rashes and swelling of the ne
ck glands. After about two
weeks the skin from fingertips
result in the development of coronary artery aneurysms (see ANEURYSM) in
up to 60 per cent of those
affected. These aneurysms and even myocardial infarction (see HEART, DISEASES OF
Coronary thrombosis) are
often detected after the second week of illness. The disease can be hard to diag
nose as it mimics many
childhood viral illnesses, especially in its early stages. The incidence in the
390 Kerion
damage from exposure to sun. The face and backs of the hands are most co
mmonly affected. (See also
MELANOMA; PHOTODERMATOSES.) CRYOTHERAPY is effective, but prevention by appropri
ate clothing and
sun-blocking creams is a better strategy.
EPILEPSY
Kerion
Another name for acetone or dimethyl ketone. The term, ketone bodies, is
applied to a group of
substances closely allied to acetone, especially beta-hydroxybutyric acid and ac
etoacetic acid. These are
produced in the body from imperfect oxidation of fats and protein foods, and are
found in especially large
amount in severe cases of DIABETES MELLITUS. Ketonuria is the term applied to th
e presence of these bodies
in the urine.
A suppurating form of RINGWORM.
Kernicterus The staining with BILE of the basal nuclei of the BRAIN, wit
h toxic degeneration of the
nerve cells, which sometimes occurs in severe HAEMOLYTIC DISEASE OF THE NEWBORN
especially if prompt
treatment by exchange TRANSFUSION has not been carried out. Rare nowadays, the r
esult is a form of CEREBRAL
K
and chronic infections of the urinary tract by Escherichia coli; butter,
cream, eggs and fat meat are
allowed, whilst sugar, bread and other carbohydrates are cut out as far as possi
ble.
Ketone
PALSY.
Ketoprofen
Kernigs Sign
See NON-STEROIDAL DRUGS (NSAIDS).
This is found in MENINGITIS. A healthy persons thigh can be bent to a rig
ht-angle with the body when
the knee is straight; in cases of meningitis the knee cannot be straightened whe
n the thigh is bent this
way not without causing the patient intense pain.
Ketamine An anaesthetic drug, administered by intravenous or intramuscul
ar injection and used mainly in
children. The drug has good analgesic properties when used in subanaesthetic dos
es. One disadvantage is
that when used as an anaesthetic, a high incidence of hallucinations occur. Keta
mine is contraindicated in
Tender leaves of a shrub that grows in the Middle East called Catha
leaves are wrapped
nuts and chewed: the result is a feeling of EUPHORIA and an ability
harsh living
Kidneys, Diseases of
Kidneys These are a pair of glands located in the upper abdomen close to
the spine and embedded in fat
and loose connective tissue.
Structure Each kidney is about 10 cm long, 6.5 cm wide, 5 cm thick, and
weighs around 140 grams. Adult
kidneys have a smooth exterior, enveloped by a tough fibrous coat that is bound
to the kidney only by loose
fibrous tissue and by a few blood vessels that pass between it and the kidney. T
he outer margin of the
kidney is convex; the inner is concave with a deep depression, known as the hilu
m, where the vessels enter.
The URETER, which conveys URINE to the URINARY BLADDER, is also joined at this p
oint. The ureter is spread
out into an expanded, funnel-like end, known as the pelvis, which further divide
s up into little funnels
known as the calyces. A vertical section through a kidney (see diagram) shows tw
o distinct layers: an outer
one, about 4 mm thick, known as the cortex; and an inner one, the medulla, lying
closer to the hilum. The
medulla consists of around a dozen pyramids arranged side by side, with their ba
se on the cortex and their
apex projecting into the calyces of the ureter. The apex of each pyramid is stud
ded with tiny holes, which
are the openings of the microscopic uriniferous tubes. In effect, each pyramid,
taken together with the
portion of cortex lying along its base, is an independent mini-kidney. About 20
small tubes are on the
surface of each pyramid; these, if traced up into its substance, repeatedly subd
ivide so as to form bundles
of convoluted tubules, known as medullary rays, passing up towards the cortex. O
ne of these may be traced
further back, ending, after a tortuous course, in a small rounded body: the Malp
ighian corpuscle or
glomerulus (see diagram). Each glomerulus and its convoluted tubule is known as
a nephron, which
constitutes the functional unit of the kidney. Each kidney contains around a mil
lion nephrons. After
entering the kidney, the renal artery divides into branches, forming arches wher
e the cortex and medulla
join. Small vessels come off these arches and run up through the cortex, giving
off small branches in each
direction. These end in a tuft of capillaries, enclosed in Bowmans capsule, which
forms the end of the
uriniferous tubules just described; capillaries with capsule constitute a glomer
ulus. After circulating in
the glomerulus, the blood leaves by a small vein, which again divides into capil
laries on the walls of the
urinifer391
ous tubules. From these it is finally collected into the renal veins and
then leaves the kidney. This
double circulation (first through the glomerulus and then around the tubule) all
ows a large volume of fluid
to be removed from the blood in the glomerulus, the concentrated blood passing o
n to the uriniferous tubule
for removal of parts of its solid contents. Other arteries come straight from th
e arches and supply the
medulla direct; the blood from these passes through another set of capillaries a
nd finally into the renal
veins. This circulation is confined purely to the kidney, although small connect
ions by both arteries and
veins exist which pass through the capsule and, joining the lumbar vessels, comm
unicate directly with the
aorta.
Function The kidneys work to separate fluid and certain solids from the
blood. The glomeruli filter
from the blood the non-protein portion of the plasma around 150200 litres in 24 h
ours, 99 per cent of
which is reabsorbed on passing through the convoluted tubules. Three main groups
of substances are
classified according to their extent of uptake by the tubules: (1) SUBSTANCES AC
TIVELY REABSORBED These
include amino acids, glucose, sodium, potassium, calcium, magnesium and chlorine
(for more information, see
under separate entries). (2) SUBSTANCES DIFFUSING THROUGH THE TUBULAR EPITHELIUM
when their concentration
in the filtrate exceeds that in the PLASMA, such as UREA, URIC ACID and phosphat
es. (3) SUBSTANCES NOT
RETURNED TO THE BLOOD from the tubular fluid, such as CREATINE, accumulate in ki
dney failure, resulting in
general poisoning known as URAEMIA.
Kidneys, Diseases of Diseases affecting the kidneys can be broadly class
ified into congenital and
genetic disorders; autoimmune disorders; malfunctions caused by impaired blood s
upply; infections;
metabolic disorders; and tumours of the kidney. Outside factors may cause functi
onal disturbances for
example, obstruction in the urinary tract preventing normal urinary flow may res
ult in hydronephrosis (see
below), and the CRUSH SYNDROME, which releases proteins into the blood as a resu
lt of seriously damaged
muscles (rhabdomyolosis), can result in impaired kidney function. Another outsid
e factor, medicinal drugs,
can also be hazardous to the kidney. Large quantities of ANALGESICS taken over a
long time damage the
kidneys and acute tubular NECROSIS can result from certain antibiotics.
K
Kidneys, Diseases of
reflexes, reduced sensation, and a coarse flapping tremor (asterixis) du
e to severe disturbance of the
bodys normal metabolism.
Renal failure Serious kidney disease may lead to impairment or failure o
f the kidneys ability to
filter waste products from the blood and excrete them in the urine a process tha
t controls the bodys
water and salt balance and helps to maintain a stable blood pressure. Failure of
this process causes
URAEMIA an increase in urea and other metabolic waste products as well as other
metabolic upsets in the
blood and tissues, all of which produce varying symptoms. Failure can be sudden
or develop more slowly
(chronic). In the former, function usually returns to normal once the underlying
cause has been treated.
Chronic failure, however, usually irreparably reduces or stops normal function.
Acute failure commonly
results from physiological shock following a bad injury or major illness. Seriou
s bleeding or burns can
reduce blood volume and pressure to the point where blood-supply to the kidney i
s greatly reduced. Acute
myocardial infarction (see HEART, DISEASES OF) or pancreatitis (see PANCREAS, DI
SORDERS OF) may produce a
similar result. A mismatched blood transfusion can produce acute failure. Obstru
ction to the urine-flow by
a stone (calculus) in the urinary tract, a bladder tumour or an enlarged prostat
e can also cause acute
renal failure, as can glomerulonephritis (see below) and the haemolytic-uraemia
syndrome. HYPERTENSION,
DIABETES MELLITUS, polycystic kidney disease (see below) or AMYLOIDOSIS are amon
g conditions that cause
chronic renal failure. Others include stone, tumour, prostatic enlargement and o
veruse of analgesic drugs.
Chronic failure may eventually lead to end-stage renal failure, a life-threateni
ng situation that will need
DIALYSIS or a renal transplant (see TRANSPLANTATION).
Familial renal disorders include autosomal dominant inherited polycystic
kidney disease and sex-linked
familial nephropathy. Polycystic kidney disease is an important cause of renal f
ailure in the UK. Patients,
usually aged 3050, present with HAEMATURIA, loin or abdominal discomfort or, rare
ly, urinary-tract
infection, hypertension and enlarged kidneys. Diagnosis is based on ultrasound e
xamination of the abdomen.
Complications include renal failure, hepatic cysts and, rarely, SUBARACHNOID HAE
MORRHAGE. No specific
treatment is available. Familial nephropathy occurs more
393
often in boys than in girls and commonly presents as Alports syndrome (fa
milial nephritis with nerve
DEAFNESS) with PROTEINURIA, haematuria, progressing to renal failure and deafnes
s. The cause of the disease
lies in an absence of a specific ANTIGEN in a part of the glomerulus. The treatm
ent is conservative, with
Koilonychia
patients with Klinefelters syndrome have 47 chromosomes instead of the no
rmal 46. The extra chromosome
is an X chromosome, so that the sex chromosome constitution is XXY instead of XY
. Klinefelters syndrome is
one of the most common chromosome abnormalities and occurs in 1 in 300 of the ma
le population. Patients
with this syndrome show that the Y chromosome is strongly sex-determining: thus,
a patient who has an XXY
chromosome constitution may have the appearance of a normal male, with infertili
ty the only incapacity,
while the loss of a Y chromosome leads to the development of a bodily form which
is essentially feminine
(see TURNERS SYNDROME).
Klumpkes Paralysis Injury as a result of the stretching of a babys brachia
l plexus during its birth
may cause partial paralysis of the arm with atrophy of the muscles of the forear
m and hand.
395
slip beyond the edges of the bones, or it may become folded on itself. I
n either case, it tends to
cause locking of the joint when sudden movements are made. This causes temporary
inability to use the joint
until the cartilage is replaced by forcible straightening, and the accident is a
pt to be followed by an
attack of synovitis, which may last some weeks, causing lameness with pain and t
enderness especially felt
at a point on the inner side of the knee. This condition can be relieved by an o
peration sometimes by
keyhole surgery (see MINIMALLY INVASIVE SURGERY (MIS)) to remove the loose porti
on of the cartilage.
Patients whose knees are severely affected by osteoarthritis or rheumatoid arthr
itis which cause pain and
stiffness can now have the joint replaced with an artificial one. (See also ARTH
ROPLASTY; JOINTS, DISEASES
OF.)
Knee Jerk See REFLEX ACTION.
Knee The joint formed by the FEMUR, TIBIA and patella (knee-cap). It bel
ongs to the class of
hinge-joints, although movements are much more complex than the simple motion of
a hinge, the condyles of
the femur partly rolling, partly sliding over the flat surfaces on the upper end
of the tibia, and the acts
of straightening and of bending the limb being finished and begun, respectively,
by a certain amount of
rotation. The cavity of the joint is very intricate: it consists really of three
joints fused into one, but
separated in part by ligaments and folds of the synovial membrane. The ligaments
which bind the bones
together are extremely strong, and include the popliteal and the collateral liga
ments, a very strong
patellar ligament uniting the patella to the front of the tibia, two CRUCIATE LI
GAMENTS in the interior of
the joint, and two fibrocartilages which are interposed between the surfaces of
L Labetalol
Labetalol is an alpha- and beta-adrenoceptor blocker (see ADRENERGIC REC
EPTORS) used to treat
HYPERTENSION. Beta blockers block the beta-adrenoceptors in the heart, periphera
l blood vessels and
bronchi. Many drugs belonging to this group are now available, and all are equal
ly effective but with
differences that may make them suitable for a particular patient. Labetalol has
the added property of
dilating arterioles (small arteries), thus lowering resistance in the small peri
pheral blood vessels and
helping to reduce blood pressure.
Labia Lips. The labia majora and labia minora are the outer and inner li
p-like folds of skin
surrounding the entrance to the VAGINA.
Labium Labium is the Latin word for a lip or lip-shaped organ.
Labour See PREGNANCY AND LABOUR.
Labyrinth A convoluted system of structures forming the inner EAR and in
volved in hearing and balance.
Labyrinthitis Inflammation of the LABYRINTH of the EAR. Usually caused b
y bacterial or viral infection,
the former often the result of inadequately treated otitis media (see EAR, DISEA
SES OF Diseases of the
middle ear), or MEASLES. Symptoms are VERTIGO, nausea, vomiting, nystagmus (see
EYE, DISORDERS OF),
TINNITUS and loss of hearing. Bacterial infection needs treatment with ANTIBIOTI
CS; viral infection is
usually selflimiting. ANTIHISTAMINE DRUGS will help reduce the vertigo. Rarely,
surgery may be required to
drain the infection in bacteria-based labyrinthitis.
Laceration A wound to the skin or surface of an organ which results in a
cut with irregular edges (cf.
an incision produced with a knife, which has smooth, regular edges).
Lacrimal See EYE
Lacrimal apparatus.
Lacrimal Bones The smallest bones of the face, one forming part of the b
ony structure of each orbit
containing an EYE.
Lacrimal Nerve A branch of the ophthalmic nerve supplying the lacrimal g
land and conjunctiva of the
EYE.
Lacrimation Crying, or the secretion of an excess quantity of tears.
Lactase An
ENZYME produced by INTESTINE which changes
glands in the small lactose (milk sugar) into glucose and galactose duri
398 Lactose
development of dental caries (see ORDERS OF).
TEETH, DISLactose The official name for sugar of milk.
Lactose Intolerance
L
is due to lack in the INTESTINE of the ENZYME known as LACTASE which is
responsible for the digestion
of lactose, the sugar in milk. The result is that drinking milk or eating milkco
ntaining products is
followed by nausea, a sensation of bloating, or distension, in the gut, abdomina
l pain and diarrhoea.
(Similar disturbances after taking milk may also occur in those who do not lack
lactase but have an allergy
to milk protein). Treatment is by means of a low-lactose diet avoiding fresh or
powdered milk and milk
puddings. Many can tolerate fermented milk products, as well as the small amount
s of milk used in baking
and added to margarine and sausages. However, infamts may have to be fed exclusi
vely on a lactose-free
formula as even breast milk may produce symptoms.
Lactulose An osmotic laxative (see OSMOSIS; LAXATIVES), lactulose is a s
emisynthetic disaccharide a
type of carbohydrate which is not absorbed from the GASTROINTESTINAL TRACT. It r
educes the acidity of
FAECES.
Lacuna
Lanolin Derived from wool fat, it is an ingredient of many ointments and
creams but may cause allergic
contact DERMATITIS.
Lansoprazole One of the PROTON-PUMP INHIBITORS, it blocks the proton pump
ENZYME system of the
STOMACHs acid-producing PARIETAL cells. It is used in short-term treatment of PEP
TIC ULCER and in
combination with antibacterial drugs to eliminate infection with the bacteria HE
LICOBACTER PYLORI.
Lanugo Soft fine hair covering the FETUS. It disappears by the ninth mon
th of gestation and is
therefore only seen on premature babies.
Laparoscope An instrument consisting, essentially, of a rigid or flexibl
e cylinder, an eyepiece and a
light source, which is inserted through a small incision into the abdominal cavi
ty (which has already been
distended with carbon dioxode gas). The laparoscope allows the contents of the a
bdominal cavity to be
examined without performing a LAPAROTOMY. Some operations may be performed using
the laparoscope to guide
the manipulation of instruments inserted through another small incision for exam
ple, STERILISATION;
CHOLECYSTECTOMY. (See also ENDOSCOPE; MINIMALLY INVASIVE SURGERY (MIS).)
A small pit or depression.
Laparoscopy
Lamblia
Also called peritoneoscopy, this is a technique using an instrument call
ed an ENDOSCOPE for viewing the
contents of the ABDOMEN. The instrument is inserted via an incision just below t
he UMBILICUS and air is
then pumped into the peritoneal (abdominal) cavity. Visual inspection may help i
n the diagnosis of cancer,
APPENDICITIS, SALPINGITIS, and abnormalities of the LIVER, GALL-BLADDER, OVARIES
or GASTROINTESTINAL TRACT.
A BIOPSY can be taken of tissue suspected of being abnormal, and operations such
as removal of the
gall-bladder or appendix may be carried out. (See also MINIMALLY INVASIVE SURGER
Y (MIS).)
See GIARDIASIS.
Lamella A small disc of glycerin jelly, 3 mm (1/8 inch) in diameter, con
taining an active drug for
application to the eye. It is applied by insertion behind the lower lid.
Laminectomy An operation in which the arches of one or more vertebrae in
the SPINAL COLUMN are removed
so as to expose a portion of the SPINAL CORD for removal of a tumour, relief of
pressure due to a fracture
(see under BONE, DISORDERS OF), or disc protrusion.
Lamotrigine An antiepileptic drug for the treatment of patients with EPI
LEPSY, whose condition is
characterised by partial seizures.
Laparotomy A general term applied to any operation in which the abdomina
l cavity is opened (see
ABDOMEN). A laparotomy may be exploratory to establish a diagnosis, or carried o
ut as a preliminary to
major surgery. Viewing of the peritoneal cavity (see PERITONEUM) through an
Larynx, Disorders of
is called a peritoneoscopy. ENDOSCOPE
LAPAROSCOPY
or
399
Larynx, Disorders of Obstruction of the larynx is potentially
Larva The pre-adult stage in insects and nematodes occurring between the
egg and the sexually mature
adult.
Larva Migrans A self-limiting, intensely itching skin eruption caused by
nematode (roundworm) larvae,
usually of the dog and cat hookworm (see ANCYLOSTOMIASIS). The migrating larvae
leave red, raised,
irregular tracks in the skin, often on the foot and less frequently elsewhere. T
he disease is usually
acquired by people who take their holidays on tropical beaches. It can be cured
by a three-day course of
oral ALBENDAZOLE.
Laryngeal Reflex A protective cough occurring as a result of irritation of
the LARYNX for example,
a small particle of food may be accidentally inhaled into the larynx, which reacts
with an expulsive
cough to prevent the food from entering the lungs.
Laryngectomy Operation for removal of the LARYNX.
See LARYNX, DISORDERS OF.
Laryngology See OTOLARYNGOLOGY.
Laryngoscope Examination of the LARYNX may be performed indirectly with
use of a laryngeal mirror, or
directly by use of a laryngoscope a type of endoscope. The direct examination is
usually performed under
general anaesthetic.
Laryngo-Tracheo-Bronchitis see under LARYNX, DISORDERS OF.
Larynx The organ of voice which also forms one of the higher parts of th
e AIR PASSAGES. It is placed
high up in the front of the neck and there forms a considerable prominence on th
e surface (Adams apple).
The vocal cords vibrating in different notes, according to their tenseness and t
he like, produce the sounds
of VOICE AND SPEECH.
Laryngitis Inflammation of the mucous membrane of the larynx and vocal c
hords may be acute or chronic.
The cause is usually an infection, most commonly viral, although it may be the r
esult of secondary
Lasik
A laryngoscopic view of the interior of the larynx.
throughout the country to support patients following laryngectomy. Speec
h therapists provide speech
rehabilitation.
Laryngo-tracheo-bronchitis Also known as croup. An acute infection of th
e respiratory tract in infants
and young children, usually caused by parainfluenza virus. The onset is variable
but the croupy cough and
stridulous breathing usually occur a few days after the onset of a viral upper-r
espiratory-tract infection.
A harsh barking cough is typical of the condition. The majority of affected chil
dren can be treated with
HUMIDIFICATION and a single dose of inhaled corticosteroid (budesonide see CORTI
COSTEROIDS) or a single
days treatment with oral prednisolone. Severe croup can cause serious breathing p
roblems when the child
should be referred for urgent specialist assessment, and hospitalisation is pref
erable in all cases.
Rarely, some form of intervention is necessary and this will either be in the fo
rm of endotracheal
intubation or of a tracheostomy.
Laser Laser stands for Light Amplification by Stimulated Emission of Rad
iation. The light produced by a
laser is of a single wavelength and all the waves are in phase with each other,
allowing a very high level
of energy to be projected as a parallel beam or focused on to a small spot. Vari
ous gases, liquids and
solids will emit light when they are suitably stimulated. A gassed laser is pump
ed by the ionising effect
of a high-voltage current. This is the same process as that used in a fluorescen
t tube. Each type of laser
has a different effect on biological tissues and this is related to the waveleng
th of the light
401
produced. The wavelength determines the degree of energy absorption by d
ifferent tissues, and because
of this, different lasers are needed for different tasks. The argon laser produc
es light in the visible
green wavelength which is selectively absorbed by HAEMOGLOBIN. It heats and coag
ulates (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 bea
m 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 endo
scopic (see ENDOSCOPE)
photocoagulation of bleeding vessels, and the incision of tissue. Lasers have im
portant applications in
OPHTHALMOLOGY in the treatment of such disorders as detachment of the retina and
the diabetic complications
of proliferative retinopathy and of the cornea (see EYE, DISORDERS OF). The dest
Learning Disability
lic lead, if ingested, is absorbed if it remains in the gut. The absorpt
ion is greater in children, who
may ingest lead from the paint on old cots although lead-containing paints are n
o longer used for items
that children may be in contact with. Acute poisonings are rare. Clinical featur
es include metallic taste,
abdominal pain, vomiting, diarrhoea, ANOREXIA, fatigue, muscle weakness and SHOC
K. Neurological effects may
include headache, drowsiness, CONVULSIONS and COMA. Inhalation results in severe
respiratory-tract
irritation and systemic symptoms as above. Chronic poisonings cause gastrointest
inal disturbances and
constipation. Other effects are ANAEMIA, weakness, pallor, anorexia, insomnia, r
enal HYPERTENSION and
mental fatigue. There may be a bluish lead line on the gums, although this is rare
ly seen. Neuromuscular
dysfunction may result in motor weakness and paralysis of the extensor muscles o
f the wrist and ankles.
ENCEPHALOPATHY and nephropathy are severe effects. Chronic lowlevel exposures in
children are linked with
reduced intelligence and behavioural and learning disorders.
403
Treatment Management of patients who have been poisoned is supportive, w
ith removal from source,
gastric decontamination if required, and X-RAYS to monitor the passage of metall
ic lead through the gut if
ingested. It is essential to ensure adequate hydration and renal function. Conce
ntrations of lead in the
blood should be monitored; where these are found to be toxic, chelation therapy
should be started. Several
CHELATING AGENTS are now available, such as DMSA (Meso-2,3dimercaptosuccinic aci
d), sodium calcium edetate
(see EDTA) and PENICILLAMINE. (See also POISONS.)
need more intensive inpatient treatment, and a very small minority with
disturbed behaviour need secure
(i.e. locked) settings. In the United Kingdom, the 1993 Education Act refers to l
earning difficulties:
generalised (severe or moderate), or specific (e.g. DYSLEXIA, dyspraxia [or APRA
XIA], language disorder).
The 1991 Social Security (Disability Living Allowance) Regulations use the term s
everely mentally
impaired if a person suffers from a state of arrested development or incomplete p
hysical development of
the brain which results in severe impairment of intelligence and social function
ing. This is distinct from
the consequences of DEMENTIA. Though mental handicap is widely used, learning disab
ility is preferred
by the Department of Health. There is a distinction between impairment (a biolog
ical deficit), disability
(the functional consequence) and handicap (the social consequence). People with
profound learning
disability are usually unable to communicate adequately and may be seriously mov
ement-impaired. They are
totally dependent on others for care and mobility. Those with moderate disabilit
y may achieve basic
functional literacy (recognition of name, common signs) and numeracy (some under
standing of money) but most
have a life-long dependency for aspects of self-care (some fastenings for clothe
s, preparation of meals,
menstrual hygiene, shaving) and need supervision for outdoor mobility. Children
with moderate learning
disability develop at between half and three-quarters of the normal rate, and re
ach the standard of an
average child of 811 years. They become independent for self-care and public tran
sport unless they have
associated disabilities. Most are capable of supervised or sheltered employment.
Living independently and
raising a family may be possible.
Learning Disability
Occurrence Profound learning disability
Learning disability, previously called mental handicap, is a problem of
markedly low intellectual
functioning. In general, people with learning disability want to be seen as them
selves, to learn new
skills, to choose where to live, to have good health care, to have girlfriends o
r boyfriends, to make
decisions about their lives, and to have enough money to live on. They may live
at home with their
families, or in small residential units with access to work and leisure and to o
ther people in ordinary
communities. Some people with learning disabilities, however, also have a MENTAL
ILLNESS. Most can be
treated as outpatients, but a few
affects about 1 in 1,000; severe learning disability 3 in 1,000; and mod
erate learning disability
requiring special service, 1 per cent. With improved health care, survival of pe
ople with profound or
severe learning disability is increasing.
Causation Many children with profound or severe learning disability have
a diagnosable biological brain
disorder. Forty per cent have a chromosome disorder see CHROMOSOMES (three quart
ers of whom have DOWNS
(DOWN) SYNDROME); a further 15 per cent have other genetic causes, brain malform
ations or
L
special day
or boarding school. Other children can be provided for in mainstream sch
ools with extra classroom
support. The 1993 Education Act lays down stages of assessment and support up to
a written statement of
special educational needs with annual reviews. Pupils with learning disability a
re entitled to remain at
school until the age of 19, and most with severe or profound learning disability
do so. Usually those with
moderate learning disability move to further education after the age of 16. Advi
ce is available from the
Mental Health Foundation, the British Institute of Learning Disabilities, MENCAP
(Royal Society for
Mentally Handicapped Children and Adults), and ENABLE (Scottish Society for the
Mentally Handicapped).
Lecithin A very complex fat found in various tissues of the body, but pa
rticularly in the brain and
nerves, of which it forms a large part. It is also found in large quantities in
the yolk of an egg.
Leeches Animals provided with suckers surrounding the mouth, and living
a semi-parasitic life, their
food being mainly derived from the blood of other animals. They abstract blood b
y means of the sucker,
which has several large, sharp teeth. Land leeches live in tropical forests and
can attach themselves to a
persons ankles and lower legs. Aquatic leeches are found in warm water and may at
tach themselves to
swimmers. Their bites are painless, their saliva reducing the clotting propertie
s of blood with hirudin;
the result is that the wound continues to bleed after the leech has detached its
elf or been gently removed
(lighted match, alcohol, salt and vinegar are effective removal agents). The med
icinal leech, Hirudo
medicinalis, was formerly employed for the abstraction of small quantities of bl
ood in inflammatory and
other conditions. Nowadays it is occasionally used to drain haematomas and to ma
nage healing in certain
types of plastic surgery.
Left to Right Shunt A term used when a hole in the septum (internal wall
) of the HEART allows blood to
flow from the systemic circulation properly confined to the left side of the hea
rt to the pulmonary
circulation, confined to the right. The
Leproma
shunt is usually detected by hearing a murmur, and the diagnosis confirm
ed by ECHOCARDIOGRAPHY (see
also SEPTAL DEFECT).
Legionnaires Disease A form of PNEUMONIA due to a bacterium known as Legi
onella pneumophila, so-called
because the first identified outbreak was in a group of US ex-servicemen (member
s of the American Legion).
Inhalation of water aerosols seems the most likely way that people acquire the d
isease, for example from
air-conditioning outlets. Some rubber outlets in showers and taps are able to su
pport the growth of
legionnellae so that high concentrations of the organism are released when the t
ap is first used in the
morning. In the presence of the disease, the treatment of infected water systems
is essential by cleaning,
chlorination, heating or a combination of all three. The pneumonia caused by leg
ionnellae has no
distinctive clinical or radiological features, so that the diagnosis is based on
an antibody test performed
on a blood sample. There is no evidence that the disease is transmitted directly
from person to person. The
incubation period is 210 days; the disease starts with aches and pains followed r
apidly by a rise in
temperature, shivering attacks, cough and shortness of breath. The X-ray tends t
o show patchy areas of
consolidation in the lungs. Erythromycin and rifampicin are the most useful anti
biotics, although
rifampicin should never be given alone because of the rapid development of drug
resistance.
405
Untreated, the infection is fatal within two years, in approximately 70
per cent of patients. Treatment
traditionally involved sodium stibogluconate, but other chemotherapeutic agents
(including allupurinol,
ketoconazole, and immunotherapy) are now in use, the most recently used being li
posomal amphotericin B.
Although immunointact persons usually respond satisfactorily, they are likely to
relapse if they have HIV
infection (see AIDS/HIV).
Cutaneous leishmaniasis This form is caused by infection with L. tropica
, L. major, L. aethiopica, and
other species. The disease is widely distributed in the Mediterranean region, Mi
ddle East, Asia, Africa,
Central and South America, and the former Soviet Union. It is characterised by l
ocalised cutaneous ulcers
usually situated on exposed areas of the body. Diagnosis is by demonstration of
the causative organism in a
skin biopsy-specimen; the leishmanin skin test is of value. Most patients respon
d to sodium stibogluconate
(see above); local heat therapy is also used. Paromomycin cream has been success
fully applied locally.
Mucocutaneous leishmaniasis
Leishmaniasis
This form is caused by L. braziliensis and rarely L. mexicana. It is pre
sent in Central and South
America, particularly the Amazon basin, and characterised by highly destructive,
ulcerative, granulomatous
lesions of the skin and mucous membranes, especially involving the mucocutaneous
junctions of the mouth,
nasopharynx, genitalia, and rectum. Infection is usually via a superficial skin
lesion at the site of a
sandfly bite. However, spread is by haematogenous routes (usually after several
years) to a mucocutaneous
location. Diagnosis and treatment are the same as for cutaneous leishmaniasis.
A group of infections caused by parasites transmitted to humans by sandf
lies.
Lens of the Eye
Leiomyoma A benign tumour made up of unstriped or involuntary muscle fib
res.
See EYE.
Visceral leishmaniasis (kala-azar) A systemic infection caused by Leishm
ania donovani which occurs in
tropical and subtropical Africa, Asia, the Mediterranean littoral (and some isla
nds), and in tropical South
America. Onset is frequently insidious; incubation period is 26 months. Enlargeme
nt of spleen and liver
may be gross; fever, anaemia, and generalised lymphadenopathy are usually presen
t. Diagnosis is usually
made from a bone-marrow specimen, splenic-aspirate, or liver-biopsy specimen; am
astigotes (Leishman-Donovan
bodies) of L. donovani can be visualised. Several serological tests are of value
in diagnosis.
Lentigo Lentigines (freckles) are brown MACULES varying in diameter from
110 mm or more. Simple
lentigines arise in childhood, not necessarily on exposed areas. They may also o
ccur on the lips and are
harmless and usually very small. Solar or actinic lentigines are common on the f
ace, neck and backs of the
hands in older people and reflect the total cumulative lifetimes exposure to sunl
ight.
Leproma A nodule in the skin occurring in LEPROSY.
L
406 Leprosy
Leprosy
L
Also known as Hansens disease, this is a chronic bacterial infection caus
ed by Mycobacterium leprae
affecting the skin, mucous membranes, and nerves. Infection is now almost confin
ed to tropical and
subtropical countries mostly in Africa and India. There are two distinct (polari
sed) clinical forms:
tuberculoid and lepromatous. The former usually takes a benign course and freque
ntly burns out, whereas the
latter is relentlessly progressive; between these two polar forms lies an interm
ediate/dimorphous group.
Susceptibility may be increased by malnutrition. Nasal secretions (especially in
lepromatous disease) are
teeming with M. leprae and constitute the main source of infection; however, liv
ing in close proximity to
an infected individual seems necessary for someone to contract the disease. M. l
eprae can also be
transmitted in breast milk from an infected mother. Only a small minority of tho
se exposed to M. leprae
develop the disease. The incubation period is 35 years or longer. The major clini
cal manifestations
involve skin and nerves: the former range from depigmented, often anaesthetic ar
eas, to massive nodules;
nerve involvement ranges from localised nerve swelling(s) to extensive areas of
anaesthesia. Advanced nerve
destruction gives rise to severe deformities: foot-drop, wrist-drop, claw-foot,
extensive ulceration of the
extremities with loss of fingers and toes, and bone changes. Eye involvement can
produce blindness.
Laryngeal lesions produce hoarseness and more serious sequelae. The diagnosis is
essentially a clinical
one; however, skin-smears, histological features and the lepromin skin-test help
to confirm the diagnosis
and enable the form of disease to be graded. Although the World Health Organisat
ion had originally hoped to
eliminate leprosy worldwide by 2000, that has proved an unrealistic target. The
reason is an absence of
basic information. Doctors are unable to diagnose the disorder before a patient
starts to show symptoms;
meanwhile he or she may have already passed on the infection. Doctors do not kno
w exactly how transmission
occurs or how it infects humans nor do they know at what point a carrier of the
bacterium may infect
others. The incidence of new infections is still more than 650,000 cases a year
or about 4.5 cases per
10,000 people in those countries worst affected by the disease.
Treatment Introduction of the sulphone compound, dapsone, revolutionised
management of the disease. More recently, rifampicin and clofazimine have been
added as first-line drugs for
treatment. Second-line drugs include minocycline, ofloxacin and clarithromycin;
a number of regimens
incorporating several of these compounds (multi-drug regimens introduced in 1982
Leucocytes 407
by rats these animals excreting the organism in their urine, hence the l
iability of sewage workers to
the disease. The condition is characterised by fever, jaundice, enlarged liver,
nephritis, and bleeding
from mucous membranes.
hypothyroidism (see THYROID GLAND, DISEASES OF). Some of these patients
have a true depressive illness
and their presentation and response to treatment is little different from that o
f sufferers of any other
depressive illness, URAEMIA, alcoholism and DIABETES MELLITUS.
Lesbian
Leucine
A female homosexual (see HOMOSEXUALITY); lesbians form about 2 per cent
of the female population in the
UK. Some engage in active sexual behaviour with another woman, with MASTURBATION
, mutual stimulation of the
CLITORIS and oral sex being the usual techniques for achieving ORGASM.
Lesion Lesion meant originally an injury, but is now applied generally t
o all disease changes in organs
and tissues.
Lethal Gene A gene that produces a GENOTYPE which causes the death of an
organism before that organism
has reproduced or which prevents it from reproducing. Lethal genes are usually R
ECESSIVE, so the organism
will die only if both its parents carry the gene. Should only one parent have the
lethal gene, its
consequences will be masked by the dominant ALLELE passed on by the normal paren
t.
Lethargy Lethargy, or lassitude, means a loss of energy. It is a common
presenting complaint both to
general practitioners and to hospital consultants. It may have a physical cause
or a psychological cause;
it may be the result of inadequate rest, environmental noise, boredom, insomnia
or recent illness. Certain
medicinal drugs can cause lethargy, the most common being beta blockers (see BET
A-ADRENOCEPTOR-BLOCKING
DRUGS) and DIURETICS, and drugs of abuse may also be a cause (see DEPENDENCE). T
he common psychosocial
problems producing lethargy are DEPRESSION and anxiety. If the patient with leth
argy runs a fever, the
differential diagnosis is that of a PUO (pyrexia of unknown origin). Many patien
ts with fatigue can
establish the onset of the symptom to a febrile illness even though they no long
er run a fever. The
lethargy that follows some viral infecions, such as HEPATITIS A and glandular fe
ver (see MONONUCLEOSIS) is
well recognised; MYALGIC ENCEPHALOMYELITIS (ME) or chronic fatigue syndrome is a
nother disorder associated
with lethargy and tiredness. Organic causes of lethargy include ANAEMIA, malnutr
ition and
408 Leucocytosis
formed predominantly in LYMPHOID TISSUE. There is some controversy as to
the site of origin of
monocytes: some say they arise from lymphocytes, whilst others contend that they
are derived from
histiocytes i.e. the RETICULO-ENDOTHELIAL SYSTEM.
Function The leucocytes constitute one of the most important of the defe
nce mechanisms against
infection. This applies particularly to the neutrophil leucocytes (see LEUCOCYTO
SIS). (See also ABSCESS;
BLOOD Composition; INFLAMMATION; PHAGOCYTOSIS; WOUNDS.)
Leucocytosis
L
A condition in which the polymorphonuclear LEUCOCYTES in the blood are i
ncreased in number. It occurs
in many different circumstances, and forms a valuable means of diagnosis in cert
ain diseases; however, the
condition may occur as a normal reaction in certain conditions (e.g. pregnancy,
menstruation, and during
muscular exercise). It is usually due to the presence of inflammatory processes
(see INFLAMMATION) the
increased number of leucocytes helping to destroy the invading bacteria. Thus, d
uring many acute infective
diseases, such as pneumonia, the number is greatly increased. In all suppurative
conditions (where PUS is
formed) there is also a leucocytosis, and if it seems that an ABSCESS is forming
deep in the abdomen, or in
some other site where it cannot be readily examined as, for example, an abscess
resulting from
APPENDICITIS the examination of a drop of blood gives a valuable aid in the diag
nosis, and may be
sufficient, in the absence of other signs, to point out the urgent need of an op
eration.
discharges with an offensive smell and yellow or green colouring: these
may be caused by
micro-organisms or by fungal infection such as Candida albicans. Another causati
ve agent is the protozoan
parasite, Trichomonas vaginalis (see TRICHOMONIASIS). A pessary or tampon that a
woman has forgotten to
remove will cause a substantial and offensive discharge. Children rarely have va
ginal discharge; if they
do, it is usually due to an infection or foreign body in the vagina. (See also U
TERUS, DISEASES OF.)
Leucotomy See PSYCHOSURGERY.
Leukaemia
Leucoderma, or leucodermia, is a condition of the skin in which areas of
it become white, as the result
of various skin diseases.
Leukaemia is an umbrella term for several malignant disorders of white b
lood cells in which they
Levodopa
to lack of platelets, and may have enlarged lymphatic glands and spleen.
The temperature is raised, and
the condition may be mistaken for an acute infection (or may first become appare
nt because the patient
develops a severe infection due to a lack of normal white blood cells). In the c
hronic type of the disease
the onset is gradual, and the first symptoms which occasion discomfort are eithe
r swelling of the abdomen
and shortness of breath, due to painless enlargement of the spleen; or the enlar
gement of glands in the
neck, armpits and elsewhere; or the pallor, palpitation, and other symptoms of a
naemia which often
accompany leukaemia. Occasional bleeding from the nose, stomach, gums or bowels
may occur, and may be
severe. Generally, there is a slight fever. When the blood is examined microscop
ically, not only is there
an enormous increase in the number of white cells, which may be multiplied 30- o
r 60-fold, but various
immature forms are also found. In the lymphatic form of the disease, most white
cells resemble lymphocytes,
which, in healthy blood, are present only in small numbers. In the myeloid form,
myelocytes, or large
immature cells from the bone marrow, which are never present in healthy blood, a
ppear in large numbers, and
there may also be large numbers of immature, nucleated erythrocytes.
Treatment This varies according to the type of leukaemia and to the part
icular condition of the
patient. Excellent results are being obtained in the control of ALL using blood
transfusions, CHEMOTHERAPY,
RADIOTHERAPY and bone-marrow TRANSPLANTATION. In the case of acute leukaemia, th
e drugs now being used
include MERCAPTOPURINE, METHOTREXATE and CYCLOPHOSPHAMIDE. Blood transfusion and
CORTICOSTEROIDS play an
important part in controlling the condition during the period before a response
to chemotherapy can be
expected. Chemotherapy has almost completely replaced radiotherapy in the treatm
ent of chronic leukaemia.
For the myeloid form, BUSULFAN is the most widely used drug, replaced by hydroxy
urea, mercaptopurine, or
one of the nitrogen mustard (see NITROGEN MUSTARDS) derivatives in the later sta
ges of the disease. For the
lymphatic form, the drugs used are CHLORAMBUCIL, CYCLOPHOSPHAMIDE, and the nitro
gen mustard derivatives.
Prognosis Although there is still no guaranteed cure, the outlook in bot
h acute and chronic leukaemia
has greatly improved par409
ticularly for the acute form of the disease. Between 70 and 80 per cent
of children with acute
lymphoblastic leukaemia may be cured; between 20 and 50 per cent of those with a
cute myeloid leukaemia now
have much-improved survival rates. Prognosis of patients with chronic lymphocyti
c leukaemia is often good,
depending on early diagnosis.
LeukoSee LEUCO-.
Leukoplakia A white plaque on mucous membranes caused by overgrowth of t
he tissues. It is occasionally
a pre-cancerous condition.
Leukotrienes A group of naturally occurring, slow-reacting substances (S
RSS) which have powerful
smooth-muscle stimulating properties, particularly on bronchial smooth muscle. L
eukotrienes are a metabolic
derivative of PROSTAGLANDINS. Leukotriene receptor antagonists, such as monteluk
ast and zafirlukast, are
drugs useful in asthma.
Levallorphan Tartrate An antidote to intravenously.
MORPHINE.
It is usually given
Levamisole A drug used to treat ASCARIASIS. Its main advantage seems to
be in mass treatment, as one
dose may prove effective. It is also being used in the treatment of a group of d
iseases of obscure origin,
including CROHNS DISEASE and RHEUMATOID ARTHRITIS. The drug is available in the U
K with certain
restrictions.
Levator (1) Any muscle that raises the organ or structure into which it
is inserted. (2) A surgical
instrument for raising depressed fragments of bone in a fracture, particularly a
fracture of the skull.
Levodopa A drug used in the treatment of PARKINSONISM. It is converted t
o DOPAMINE in the brain,
correcting the deficiency which causes the disorder. Levodopa is often given wit
h carbidopa or benserazide,
both dopamine decarboxylase inhibitors, to prevent its conversion to dopamine in
the body before it reaches
the brain. It may cause nausea, HYPOTENSION or cardiac DYSRHYTHMIA.
L
410 Levorphanol
Levorphanol A synthetic derivative of MORPHINE. It is an effective analg
esic but, like morphine, is a
drug of addiction.
LHRH Abbreviation for LUTEINISING HORMONERELEASING HORMONE (LHRH), which
is released by the PITUITARY
GLAND.
LHRH Analogue A synthetically produced agent with the same properties as
LUTEINISING HORMONERELEASING
HORMONE (LHRH).
Libido
L
The natural desire for sexual intercourse. Lack of desire or diminished
libido may occur in any general
medical illness as well as in endocrine diseases when there is a lack of product
ion of the sex hormones.
The strength or weakness of the sexual drive may be associated with psychiatric
diseases; it may also be
the result of certain drugs. It must be distinguished from IMPOTENCE, where the
desire for intercourse is
normal but the performance is defective due to the inability to achieve or maint
ain an erection.
CHLOROQUINE. Severe cases CORTICOSTEROIDS to control
may require oral the eruption.
Lidocaine A local anaesthetic given by injection, previously called lign
ocaine. It is also used in the
treatment of certain disorders of cardiac rhythm known as ventricular arrhythmia
s which may be particularly
dangerous following a coronary thrombosis (see HEART, DISEASES OF).
Life Expectancy The number of years an individual can expect to live. Li
fe expectancy at birth in most
western countries is over 75 years for women (nearly 80 in the UK in 1998) and o
ver 70 for men (over 74 in
the UK in 1998) a figure that has been steadily rising as living standards have
improved. The longer a
person lives, the greater is his or her life expectancy.
Lifestyle Medicines
See CHLORDIAZEPOXIDE.
Drugs used for non-health problems or for disorders that are in the grey
area between a genuine health
need and a desire to change a lifestyle failing by the use of medication. Examples
are: SILDENAFIL
CITRATE, which is prescribed for men unable to achieve penile erection (erectile
dysfunction); and
ORLISTAT, a drug used to combat OBESITY.
Lice
Ligaments
See PEDICULOSIS.
Strong bands of fibrous tissue which serve to bind together the bones en
tering into a joint. In some
cases they are cord-like; in others, flattened bands whilst most joints are surr
ounded by a fibrous
capsule or capsular ligament. (See JOINTS.)
Librium
Lichen Lichen, or lichenification, is a term used to describe a thickeni
ng of chronically inflamed skin
to give a tree-bark-like appearance.
Lichen simplex (neurodermatitis) is a form of eczema (see DERMATITIS) pe
rpetuated by constant rubbing
of the affected skin. Typically, well-defined plaques occur on one or both sides
of the nape of the neck,
on the ulnar forearm near the elbow, or on the sides of the calves. It is often
associated with emotional
stress. Lichen planus is a less common inflammation of the skin characterised by
small, shiny, flat-topped
violaceous papules which may coalesce to form large plaques. Itching can be inte
nse. Typically seen on the
flexor aspects of the wrists, the lower back and on the legs below the knees, it
may also affect the mucous
membranes of the mouth and lips. The cause is unknown. While in some patients th
e disorder appears to be
nervous or emotional in origin, it can be caused by certain drugs such as
Ligation Tying-off for example, of a blood vessel by completely encircli
ng it with a tight band,
usually of catgut or some other suture material.
Ligature A cord or thread used to tie around arteries in order to stop t
he circulation through them, or
to prevent escape of blood from their cut ends. Ligatures are generally made of
catgut or silk, and are
tied with a reef-knot.
Light Reflex Pupillary constriction in the EYE in response to light. The
direct light reflex involves
pupillary constriction in the eye into which a light is shone; the consensual li
ght reflex is the pupillary
constriction that occurs in the other eye. The afferent or inward pathway of the
reflex is
Liothyronine Acid
via the optic nerve, and the efferent or outward pathway is via the occu
lomotor nerve.
Limbic System A circular, complex system of NERVE pathways in the middle
of the BRAIN. This connected
cluster of neuronal nuclei is involved in the working of the AUTONOMIC NERVOUS S
YSTEM, helping to control
the expression of instinct and mood in activities of the motor systems and the E
NDOCRINE GLANDS of the
body. The brain regions involved include the amygdala (an almond-shaped basal ga
nglion deep in each
cerebral hemisphere), and the HYPOTHALAMUS. If the limbic system is impaired by
injury or disease, the
person may suffer abnormal emotional responses such as unprovoked rage, unreason
able fear and anxiety,
depression, greater-than-normal sexual interest, and crying or laughing for no g
ood reason.
Limb Lengthening An orthopaedic procedure in which the length of a limb,
usually a leg, is increased.
The bone is surgically divided and slowly stretched in a special frame. The oper
ation is usually done on
people with unequal leg lengths as a result of injury or from PARALYSIS in child
hood. Exceptionally, it may
be done in both legs to help people of short stature.
Limbs, Artificial See PROSTHESIS.
Lime-Juice A yellow liquid obtained by squeezing limefruit, Citrus limet
ta. In common with lemonjuice,
it is a rich source of vitamin C (168625 mg per 100 ml) and contains a large quanti
ty of citric acid. It
is used as a refreshing drink and as a preventive of, and remedy for, SCURVY. Li
mejuice which has been
boiled, or preserved for a prolonged period, loses its anti-scorbutic properties
.
411
Linea Alba The line of fibrous tissue stretching down the mid line of th
e belly from the lower end of
the sternum to the pubic bone (see PUBIS). The linea alba gives attachment to th
e muscles of the wall of
the stomach.
Linea Nigra During pregnancy, the LINEA ALBA becomes pigmented and appea
rs as a dark line down the
middle of the belly, and is called the linea nigra.
Linear Accelerator See RADIOTHERAPY.
Lingual Referring or related to the TONGUE: for example, the lingual ner
ve supplies sensation to the
tongue.
Liniments Liniments, or EMBROCATIONS, are oily mixtures intended for ext
ernal application by rubbing.
Their chief use is in the production of pain relief, particularly in rheumatic c
412 Lipaemia
thyroid gland. (See
THYROID GLAND, DISEASES
OF.)
Lipaemia The presence of an excessive amount of the blood.
FAT
in
Lipase An ENZYME widely distributed in plants, and present also in the l
iver and gastric and pancreatic
juices, which breaks down fats to the constituent fatty acids and glycerol.
Lipid
L
A substance which is insoluble in water, but soluble in fat solvents suc
h as alcohol and ether. The
main lipid groups are the triglycerides, phospholipids, and glycolipids. They pl
ay an important role in
nutrition, health (particularly in the functioning of the cell membranes, and th
e immune response), and
disease (notably cardiovascular disease). There is a strong correlation between
the concentration of
CHOLESTEROL in the blood (transported as lipoproteins) and the risk of developin
g ATHEROMA and coronary
heart disease (see HEART, DISEASES OF). Lipoproteins are classified by their den
sity and mobility, the
chief groups being low-density (LDL) and high-density (HDL). High SERUM concentr
ations of LDL increase the
risk of cardiovascular disease, while HDL is thought to protect the vessel wall
by removing cholesterol,
and has an inverse relationship to risk. The various serum lipid abnormalities h
ave been classified into
five groups, according to the cause and particular lipoprotein raised. Most impo
rtant are type II
(increased LDL, genetically determined) and type IV (increased VLDL, associated
with obesity, diabetes, and
excess alcohol). Various lipidlowering drugs are available, but any drug treatme
nt must be combined with a
strict diet, reduction of blood pressure, and cessation of smoking.
Lipidosis Any disorder of LIPID metabolism in body cells. Some hereditar
y disorders cause deposition of
lipids within the brain.
Lipid-Regulating Drugs These drugs reduce the amount of low-density LIPO
PROTEINS, which transport
CHOLESTEROL and triglycerides (see TRIGLYCERIDE) in the blood, or raise the conc
entration of highdensity
lipoproteins. The aim is to reduce the progression of ATHEROSCLEROSIS and theref
ore help prevent coronary
heart disease (see HEART,
DISEASES OF). These drugs should be combined with reducing other risk fa
ctors for raised lipid
concentrations, such as a high-fat diet, smoking and obesity. Lipid-regulating d
rugs include STATINS,
fibrates, anion-exchange resins, and NICOTINIC ACID, which may be used singly or
in combination under
careful medical supervision (see HYPERLIPIDAEMIA).
Lipodystrophy A congenital maldistribution of FAT tissue. Subcutaneous f
at is totally absent from a
portion of the body and hypertrophied in the remainder. Another form of lipodyst
rophy occurs at the site of
INSULIN injections, but is much less frequently seen nowadays; the new, syntheti
c preparations of insulin
are pure and unlikely to cause this reaction, which was not uncommon with the ol
der preparations.
Occasionally the converse occurs at the site of insulin injections, where the li
pogenic action of insulin
stimulates the fat cells to hypertrophy. This can also be disfiguring and usuall
y results from using the
same site for injections too frequently.
Lipoid Factor An agent involved in the clotting mechanism of the blood.
It helps in the activation of
THROMBOPLASTIN in the blood PLASMA (see COAGULATION).
Lipolysis The enzymatic breaking-down of FAT.
Lipoma A TUMOUR mainly composed of FAT. Such tumours arise in almost any
part of the body, developing
in fibrous tissues particularly in that beneath the skin. They are benign in nat
ure, and seldom give any
trouble beyond that connected with their size and position. If large, they can b
e excised.
Lipoproteins Compounds containing lipids and proteins (see LIPID; PROTEI
N). Most lipids in blood PLASMA
are present in this form and are characterised according to their densities: ver
y low (VLDL), intermediate
(IDL), low (LD), high (HDL) and very high (VHDL). Concentrations of lipoproteins
are key factors in
assessing the risk of cardiovascular disease (see HEART, DISEASES OF).
Liposarcoma A rare malignant TUMOUR of adipose or fatty tissue. It occur
s most frequently in the
thighs, buttocks or retro-peritoneum. The four main
Lithium Carbonate
types are: well differentiated; myxoid; round cell; and pleomorphic (var
iety of forms).
Liposomes These are essentially tiny oil droplets consisting of layers o
f fatty material, known as
phospholipid, separated by aqueous compartments. Drugs can be incorporated into
the liposomes, which are
then injected into the bloodstream or into the muscles, or given by mouth. Using
this method of giving
drugs, it is possible to protect them from being broken down in the body before
they reach the part of the
body where their curative effect is required: for example, in the liver or in a
tumour.
Liposuction A surgical procedure, also called suction lipectomy, for ext
racting unwanted accumulations
of subcutaneous FAT with the use of a powerful suction tube passed through the s
kin at different sites.
Widely used in cosmetic surgery to improve the contour of the body, particularly
that of women, the
technique can have unwanted side-effects.
Lips These form a pair of curtains before the mouth, each composed of a la
yer of skin and of mucous
membrane, between which lies a considerable amount of fat and of muscle fibres.
Fissures coming on in cold weather are often difficult to get rid of. Pe
eling and cracking of the
vermilion of the lips is common in those exposed for long periods to wind and su
nlight. Treatment consists
of the application of aqueous cream. If the main cause is excessive exposure to
sunlight in which case
the lower lip is mainly affected a protective cream should be applied.
Herpes in the form of cold sores often develops on the lip as a result of
a cold or other feverish
condition, but quickly passes off (see HERPES SIMPLEX). Ulcers may form on the i
nner surface of the lip,
usually in consequence of bad teeth or of DYSPEPSIA.
Small cysts sometimes form on the inner surface of the lip, and are seen
as little bluish swellings
filled with mucus; they are of no importance.
Hare-lip is a deformity sometimes present at birth (see PALATE, MALFORMA
TIONS OF).
413
Cancer of the lip sometimes occurs almost always in men, and usually on
the lower lip. (See also
MOUTH, DISEASES OF.)
Liquor See SOLUTION.
Liquorice The root of Glycyrrhiza glabra, a plant of southern Europe and
Asia. It is a mild expectorant
(see EXPECTORANTS), but is mainly used to cover the taste of disagreeable and mo
414 Litholapaxy
with monitoring of the blood levels, as the gap between therapeutic and
toxic concentrations is narrow.
Due to the risk of its damaging the unborn child, it should not be prescribed, u
nless absolutely necessary,
during pregnancy particularly not in the first three months. Mothers should not
take it while breast
feeding, as it is excreted in the milk in high concentrations. The drug should n
ot be taken with DIURETICS.
Litholapaxy Litholapaxy is the term applied to the operation in which a
stone in the URINARY BLADDER is
crushed by an instrument introduced along the URETHRA, and the fragments washed
out through a catheter (see
CATHETERS).
Lithotomy
L
The operation of cutting for stone in the bladder. The operation is of g
reat historic interest, because
more has probably been written about it in early times than about any other type
of surgery and because,
for a long time, it formed almost the only operation in which the surgeon dared
to attack diseases of the
internal organs.
Lithotripsy Extracorporeal shock-wave lithotripsy (ESWL) causes disinteg
ration of renal and biliary
stones (see CALCULI) without physical contact, and is therefore an attractive pr
ocedure for patients and
surgeons alike. Shock waves generated outside the body can be accurately focused
with a reflector whilst
the patient is suspended in water, to facilitate transmission of the waves. Thes
e are focused on the
calculus. The resultant fine fragments are passed spontaneously in the urine wit
h minimal, if any,
discomfort. The procedure has been shown to be safe, short and effective, and is
most acceptable to
patients.
Litigation See MEDICAL LITIGATION.
Litmus Litmus, which is prepared from several lichens, is a vegetable dy
e-substance, which on contact
with alkaline fluids becomes blue, and on contact with acid fluids, red. Slips o
f paper, impregnated with
litmus, form a valuable test for the acidity of the secretions and discharges.
Litre A unit measurement of volume. One litre (l) is equivalent to the v
olume occupied by one kilogram of pure water at 4 C and 760 mm Hg pressure. For day-to-day measurem
ent, 1 litre is taken as
being equal to 1,000 cubic centimetres (cm3).
Littles Disease A form of CEREBRAL PALSY.
Liver The liver is the largest gland in the body, serving numerous funct
ions, chiefly involving various
aspects of METABOLISM.
Form The liver is divided into four lobes, the greatest part being the r
ight lobe, with a small left
lobe, while the quadrate and caudate lobes are two small divisions on the back a
nd undersurface. Around the
middle of the undersurface, towards the back, a transverse fissure (the porta he
patis) is placed, by which
the hepatic artery and portal vein carry blood into the liver, and the right and
left hepatic ducts emerge,
carrying off the BILE formed in the liver to the GALL-BLADDER attached under the
right lobe, where it is
stored.
Position Occupying the right-hand upper part of the abdominal cavity, th
e liver is separated from the
right lung by the DIAPHRAGM and the pleural membrane (see PLEURA). It rests on v
arious abdominal organs,
chiefly the right of the two KIDNEYS, the suprarenal gland (see ADRENAL GLANDS),
the large INTESTINE, the
DUODENUM and the STOMACH.
Vessels The blood supply differs from that of the rest of the body, in t
hat the blood collected from
the stomach and bowels into the PORTAL VEIN does not pass directly to the heart,
but is first distributed
to the liver, where it breaks up into capillary vessels. As a result, some harmf
ul substances are filtered
from the bloodstream and destroyed, while various constituents of the food are s
tored in the liver for use
in the bodys metabolic processes. The liver also receives the large hepatic arter
y from the coeliac axis.
After circulating through capillaries, the blood from both sources is collected
into the hepatic veins,
which pass directly from the back surface of the liver into the inferior vena ca
va. Minute structure The
liver is enveloped in a capsule of fibrous tissue Glissons capsule from which str
ands run along the
vessels and penetrate deep into the organ, binding it together. Subdivisions of
the hepatic artery, portal
vein, and bile duct lie alongside each other, finally forming the interlobular v
essels,
Liver, Diseases of The LIVER may be extensively diseased without any obv
iously serious symptoms, unless
the circulation through it is impeded, the outflow of BILE checked, or neighbour
ing organs implicated.
JAUNDICE is a symptom of several liver disorders, and is discussed under its sep
arate heading. ASCITES,
which may be caused by interference with the circulation through the portal vein
of the liver, as well as
by other reasons, is also considered separately. The presence of gallstones is a
complication of some
diseases connected with the liver, and is treated under GALLBLADDER, DISEASES OF
. For hydatid cyst of the
liver, see TAENIASIS. Liver diseases in a tropical environment are dealt with la
ter in this section.
Inflammation of the liver, or HEPATITIS, may occur as part of a generali
sed infection or may be a
localised condition. Infectious hepatitis, which is the result of infection with
a virus, is one of the
most common forms. Many different viruses can cause hepatitis, including
L
Lobe
considered. Ascaris lumbricoides (the roundworm) can produce obstruction
to the biliary system. CHRONIC
LIVER DISEASE Long-term disease is dominated by sequelae of HBV and HCV infectio
ns (often acquired during
the neonatal period), both of which can cause chronic active hepatitis, cirrhosi
s, and hepatocellular
carcinoma (hepatoma) one of the worlds most common malignancies. Chronic liver dise
ase is also caused
by SCHISTOSOMIASIS (usually Schistosoma mansoni and S. japonicum), and acute and
chronic alcohol ingestion.
Furthermore, many local herbal remedies and also orthodox chemotherapeutic compo
unds (e.g. those used in
tuberculosis and leprosy) can result in chronic liver disease. HAEMOSIDEROSIS is
a major problem in
southern Africa. Hepatocytes contain excessive iron derived primarily from an ex
cessive intake, often
present in locally brewed beer; however, a genetic predisposition seems likely.
Indian childhood cirrhosis
associated with an excess of copper is a major problem in India and surrounding
countries.
Epidemiological evidence shows that much of the copper is derived from copper ve
ssels used to store milk
after weaning. Veno-occlusive disease was first described in Jamaica and is caus
ed by pyrrolyzidine
alkaloids (present in bush-tea). Several HIV-associated opportunistic infections c
an give rise to hepatic
disease (see AIDS/HIV). A localised (focal) form of liver disease in all tropica
l/subtropical countries
results from invasive Entamoeba histolytica infection (amoebic liver abscess); ser
ology and imaging
techniques assist in diagnosis. Hydatidosis also causes localised liver disease;
one or more cysts usually
involve the right lobe of the liver. Serological tests and imaging techniques ar
e of value in diagnosis.
Whilst surgery formerly constituted the sole method of management, prolonged cou
rses of albendazole and/or
praziquantel have now been shown to be effective; however, surgical intervention
is still required in some
cases. Hepato-biliary disease is also a problem in many tropical/subtropical cou
ntries. In southeast Asia,
Clonorchis sinensis and Opisthorchis viverini infections cause chronic biliary-t
ract infection, complicated
by adenocarcinoma of the biliary system. Praziquantel is effective chemotherapy
before advanced disease
ensues. Fasciola hepatica (the liver fluke) is a further hepato-biliary helminth
ic infection; treatment is
with bithionol or triclabendazole, praziquantel being relatively ineffective.
417
Liver Fluke Fasciola hepatica is a parasite infesting sheep and occasion
ally invading the bile ducts
and liver of humans (see FASCIOLIASIS).
Liver Spots A misnomer applied to the brown MACULES often seen on the ba
cks of the hands of those
chronically exposed to sunlight (see LENTIGO). They have no connection with any
liver disorder.
418 Lobectomy
various organs, such as to the four lobes of the LIVER, the three lobes
of the right and the two lobes
of the left lung, which are separated by fissures from one another (see LUNGS),
and to the lobes or
superficial areas into which the BRAIN is divided. The term lobar is applied to
structures which are
connected with lobes of organs, or to diseases which have a tendency to be limit
ed by the boundaries of
lobes, such as lobar PNEUMONIA.
Lobectomy The operation of cutting out a lobe of the lung in such diseas
es as abscess of the lung and
bronchiectasis and carcinoma (see LUNGS, DISEASES OF).
Lobotomy Lobotomy is the cutting of a lobe of the BRAIN. (See also PSYCH
OSURGERY.)
Lobule
L
The term applied to a division of an organ smaller than a lobe: for exam
ple, the lobules of the lung
are of the size of millet seeds (see LUNGS); those of the LIVER, slightly larger
. Lobules form the smallest
subdivisions or units of an organ, each lobule being similar to the others, of w
hich there may be perhaps
several hundred thousand in the organ.
Local Anaesthesia Loss of sensation produced in a part of the body to st
op pain while a person is
examined, investigated or treated (see also ANAESTHESIA). The anaesthesia is eff
ected by giving drugs in a
local area temporarily to stop the action of pain-carrying nerve fibres. To anae
sthetise a large area, a
nerve block is done. Various drugs are used, depending on the depth and length o
f local anaesthesia
required.
Lochia Lochia is the discharge which takes place during the first week o
r two after childbirth. During
the first four days it consists chiefly of blood; after the fifth day the colour
should become paler, and
after the first week the quantity should diminish. If the discharge becomes smel
ly, it may indicate an
infection and immediate investigation and treament are necessary. (See also PUER
PERIUM.)
Locked-In Syndrome This describes a condition in which a patient is awak
e and retains the power of
sense perception, but is unable to communicate except by limited eye movements b
ecause the motor nervous system is paralysed. Several diseases can cause this syndrome, whic
h results from interruption of
some of the nerve tracts between the mid brain and the pons (see BRAIN). Sometim
es the syndrome is caused
by severe damage to muscles or the nerves enervating them. Lockedin syndrome may
Lumbago
Long-Sight Also known as hypermetropia: see DISORDERS OF Errors of refra
ction.
under EYE,
Loop Diuretics Drugs used in pulmonary oedema (excess fluid in the lungs
) caused by failure of the left
VENTRICLE of the HEART. DIURETICS cause an increase in excretion of URINE, thus
reducing the amount of
fluid in the body. Intravenous administration of loop diuretics relieves patient
s breathlessness. They
work by inhibiting resorption of fluid in the renal tubule loops of the KIDNEYS.
Frusemide and bumetanide
are commonly used loop diuretic drugs that act quickly and last for six hours so
that they can be given
twice in 24 hours without disturbing the patients sleep.
Loperamide A drug that reduces the motility of the GASTROINTESTINAL TRAC
T. It is of limited use as an
adjunct to fluid replacement in diarrhoea in adults, and is sometimes used in ch
ronic noninfective
diarrhoea in children.
Lorazepam
419
with sugar, gum, glycerin-jelly or fruit-paste. They are used in various
affections of the mouth and
throat, being sucked and slowly dissolved by the saliva, which brings the drugs
they contain into contact
with the affected surface. Some of the substances used in lozenges are benzalkon
ium (disinfectant),
benzocaine (analgesic), betamethasone (corticosteroid), bismuth (disinfectant),
formaldehyde
(disinfectant), hydrocortisone (corticosteroid), liquorice, and penicillin (anti
biotic).
LSD See LYSERGIC ACID DIETHYLAMIDE (LSD).
Lucid Interval A temporary restoration of consciousness after a person h
as been rendered unconscious
from a blow to the head. The victim subsequently relapses into COMA. This is a s
ign of raised INTRACRANIAL
PRESSURE from arterial bleeding and indicates that surgery may be required to co
ntrol the intracranial
haemorrhage. (See also GLASGOW COMA SCALE.)
Ludwigs Angina
A benzodiazepine tranquilliser (see BENZODIAZEPINES), shown to be of lim
ited use in the short-term
treatment of anxiety or insomnia, in STATUS EPILEPTICUS, or for perioperative us
e. Its use is not
recommended for children. As with other benzodiazepines, the smallest possible d
ose should be given for the
shortest possible time, as DEPENDENCE is a well-recognised danger.
420 Lumbar
Moderate activity rather than bed rest is recommended for most patients.
Lumbar A term used to denote structures in, or diseases affecting, the r
egion of the loins (see LOIN)
as, for example, the lumbar vertebrae, lumbar abscess.
Lumbar Puncture A procedure for removing CEREBROSPINAL FLUID (CSF) from
the spinal canal in the LUMBAR
region in order: (1) to diagnose disease of the nervous system; (2) to introduce
medicaments spinal
anaesthetics or drugs. A hollow needle is inserted into the lower section of the
space around the SPINAL
CORD (see diagram) and the cerebrospinal fluid withdrawn. The
procedure should not be done too rapidly or the subject may develop a se
vere headache. Examination of
the cerebrospinal fluid helps in the diagnosis and investigation of disorders of
the brain and spinal cord
for example, MENINGITIS and SUBARACHNOID HAEMORRHAGE. When using the procedure t
o inject drugs into the
CSF, the operator must take care to inject only those agents specifically produc
ed for CSF injection.
Deaths have occurred because the wrong drug has been injected, and there have be
en demands for specialised
equipment and strict procedures that will prevent such tragedies.
Lumbar Sympathectomy Destruction of the LUMBAR chain of sympathetic nerv
es (see NERVOUS SYSTEM) by
means of surgery, DIATHERMY or injection of chemicals (phenol or alcohol). The t
echnique is used to improve
the blood flow to the leg in patients with peripheral vascular disease, and to t
reat some types of chronic
leg pain. It has only limited success.
Lumbar Vertebra There are five lumbar vertebrae in the lower SPINAL COLU
MN between the thoracic
vertebrae and the sacrum.
L
Lumbricus Lumbricus is a name sometimes applied to the roundworm, or Asc
aris 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, DISEAS
ES OF), in which the tumour is
removed from the breast rather than with it (see MASTECTOMY).
Lunatic The patient lies on his/her left side with the back on the edge
of the bed and the hips and
knees flexed as shown in this diagram. The needle is inserted through the skin b
etween the processes of the
third and fourth lumbar vertebrae. The needle is then passed through the spinal
ligaments and the dura into
the subarachnoid space which contains the spinal fluid. A sample of fluid is slo
wly withdrawn.
An out-of-date and now derogatory term applied to people of disordered m
ind, because lunacy was
supposed at one time to be largely influenced by the moon. (See MENTAL ILLNESS.)
Lung Volumes The volume of air within the LUNGS changes with the respira
tory cycle (see RESPIRATION).
The volumes defined in the following table can
or pneumonia. Air beyond the blockage is absorbed into the circulation, causing
the affected area of lung
to collapse. Collapse may also occur when air is allowed into the pleural space
the space between the
lining of the lung and the lining of the inside of the chest wall. This is calle
d a pneumothorax and may
occur following trauma, or spontaneously for example, when there is a rupture of
a subpleural air pocket
(such as a cyst) allowing a communication between the airways and the pleural sp
ace. Lung collapse by
compression may occur when fluid collects in the pleural space (pleural effusion
): when this fluid is
blood, it is known as a haemothorax; if it is due to pus it is known as an empye
ma. Collections of air,
blood, pus or other fluid can be removed from the pleural space by insertion of
a chest drain, thus
allowing the lung to re-expand.
Tumours of the lung are the most common cause of cancer in men and, alon
g with breast cancer, are a
major cause of cancer in women. Several types of lung cancer occur, the most com
mon being squamous cell
carcinoma, small- (or oat-) cell carcinoma, adenocarcinoma, and large-cell carci
noma. All but the
adenocarcinoma have a strong link with smoking. Each type has a different patter
n of growth and responds
differently to treatment. More than 30,000 men and women die of cancer of the tr
achea, bronchus and lung
annually in England and Wales. The most common presenting symptom is cough; othe
rs include haemoptisis
(coughing up blood), breathlessness, chest pain, wheezing and weight loss. As we
ll as spreading locally in
the lung the rate of spread varies lung cancer commonly spawns secondary growths
in the liver, bones or
brain. Diagnosis is confirmed by X-rays and bronchoscopy with biopsy.
Treatment Treatment for the two main categories of lung cancer small-cel
l and nonsmall-cell cancer
is different. Surgery is the only curative treatment for the latter and should b
e considered in all cases,
even though fewer than half undergoing surgery will survive five years. In those
patients unsuitable for
surgery, radical RADIOTHERAPY should be considered. For other patients the aim s
hould be the control of
symptoms and the maintenance
Lymph
of quality of life, with palliative radiotherapy one of the options. Sma
ll-cell lung cancer progresses
rapidly, and untreated patients survive for only a few months. Because the disea
se is often widespread by
the time of diagnosis, surgery is rarely an option. All patients should be consi
dered for CHEMOTHERAPY
which improves symptoms and prolongs survival.
Wounds of the lung may cause damage to the lung and, by admitting air in
to the pleural cavity, cause
the lung to collapse with air in the pleural space (pneumothorax). This may requ
ire the insertion of a
chest drain to remove the air from the pleural space and allow the lung to re-ex
pand. The lung may be
wounded by the end of a fractured rib or by some sharp object such as a knife pu
shed between the ribs.
which stimulates OVULATION, maturation of the CORPUS LUTEUM, and the syn
thesis of progesterone by the
ovary (see OVARIES) and testosterone by the testis (see TESTICLE).
GLAND
Luteinising Hormone-Releasing Hormone (LHRH) A natural hormone released
by the HYPOTHALAMUS gland in
the BRAIN. It stimulates the release of GONADOTROPHINS from the PITUITARY GLAND;
these control the
production of the sex hormones (see ANDROGEN; OESTROGENS).
Lux The unit of illumination. The abbreviation is lx.
Luxation Another
word
for
This is the Latin word for wolf, and a term applied to certain chronic s
kin diseases which can destroy
skin, underlying cartilage and even bone to cause serious deformity if uncontrol
led.
Lycanthropy
Lupus vulgaris is a form of TUBERCULOSIS
See PREGNANCY AND LABOUR.
of the skin. It typically begins in childhood and may spread slowly for
decades if untreated. The face
and neck are the usual sites. In untreated disease, large, well-demarcated areas
may be affected with
redness, scaling and thickening. If the affected skin is blanched by pressure, y
ellow-brown foci may be
observed the socalled apple-jelly nodules. The disease causes extensive scarring
as it spreads and may
destroy cartilage in its path for example, on the nose or ear causing gross defo
rmity. The disease was
common in the UK up to 50 years ago, but is now rare. It is treated with a combi
nation of tuberculostatic
drugs.
Lyme Disease
Lupus erythematosus is an autoimmune disease which can affect skin or in
ternal organs.
Discoid lupus erythematosus (DLE) In this disease, only the skin is affe
cted. Sharply defined red,
scaly and eventually atrophic patches appear on the face, especially on the nose
and cheeks. ALOPECIA with
scarring is seen if the scalp is affected. The condition is aggravated by sunlig
ht. Topical CORTICOSTEROIDS
are helpful.
Systemic lupus erythematosus (SLE) separate dictionary entry.
Luteinising Hormone A hormone secreted by the anterior
dislocation
(see
DISLOCATIONS).
Lupus
See
423
PITUITARY
Morbid delusion that one is a wolf.
Lying-In
This comprises ARTHRITIS associated with skin rashes, fever and sometime
s ENCEPHALITIS or carditis
(inflammation of the heart). It is caused by a SPIROCHAETE which is transmitted
by tick bite. Treatment is
with antibiotics.
Lymph Lymph is the fluid which circulates in the lymphatic vessels of th
e body. It is a colourless
fluid, like blood PLASMA in composition, only rather more watery. It contains sa
lts similar to those of
blood plasma, and the same proteins, although in smaller amount: FIBRINOGEN, ser
um albumin (see ALBUMINS),
and serum GLOBULIN. It also contains lymphocytes (white blood cells), derived fr
om the glands. In some
lymphatic vessels, the lymph contains, after meals, a great amount of FAT in the
form of a fine milky
emulsion. These are the vessels which absorb fat from the food passing down the
INTESTINE, and convey it to
the thoracic duct; they are called lacteals because their contents look milky (s
ee CHYLE). The lymph is
derived, initially, from the blood, the watery constituents of which exude throu
424 Lymphadenectomy
L
to that of the capillaries of the blood-vessel system, being composed of
delicate flat cells joined
edge to edge. These unite to form fine vessels, resembling minute veins in struc
ture, called lymphatics,
which ramify throughout the body, passing through lymphatic glands and ultimatel
y discharging their
contents into the jugular veins in the root of the neck. Other lymph vessels com
mence in great numbers as
minute openings on the surface of the PLEURA and PERITONEUM, and act as drains f
or these otherwise closed
cavities. When fluid is effused into these cavities as in a pleural effusion, fo
r example its
absorption takes place through the lymphatic vessels. The course of these vessel
s is described under the
entry on GLAND. Lymph circulates partly by reason of the pressure at which it is
driven through the walls
of the blood capillaries, but mainly in consequence of incidental forces. The ly
mph capillaries and vessels
are copiously provided with valves, which prevent any back flow of lymph, and ev
ery time these vessels are
squeezed (as by the contraction of a muscle, or movement of a limb) the lymph is
pumped along. The term
lymph is also applied to the serous fluid contained in the vesicles which develo
p as the result of
vaccination, and used for the purpose of vaccinating other individuals.
Lymphadenectomy Surgical removal of the LYMPH NODES. The procedure is us
ually carried out when cancer
has infiltrated the nodes in the lymphatic drainage zone of an organ or tissue i
nvaded by a malignant
growth. RADIOTHERAPY or CHEMOTHERAPY may be given if laboratory tests show that
the type or extent of
spread of the cancer cells merits this.
Lymphadenitis Inflammation of lymphatic glands (see
LYMPHATICS; GLAND).
Lymphadenoma Another name for Hodgkins disease. (See LYMPHOMA.)
Lymphadenopathy Medical description of swollen lymph glands (see GLAND).
One cause is HIV infection
(see AIDS/HIV); another is spread of malignant cells from a tumour in the catchm
ent area of lymphatic
drainage.
Lymphangiectasis Lymphangiectasis means an abnormal dilatation of the ly
mph vessels, as in FILARIASIS.
Lymphangiography A procedure whereby the LYMPHATICS and lymphatic glands
can be rendered visible on
X-ray films by means of the injection of radio-opaque substances. It has now bee
n replaced largely by
magnetic resonance imaging (MRI).
Lymphoma
Lymphocytosis An increase in the number of lymphocytes in the blood (see
LYMPHOCYTE) for example, in
response to viral infection or in chronic lymphocytic LEUKAEMIA.
Lymphoedema Swelling of a part or organ due to obstruction to the LYMPH
vessels draining it.
Lymphogranuloma Inguinale A venereal disease in which the chief characte
ristic is enlargement of glands
in the groin the infecting agent being a virus.
Lymphoid Tissue Tissue involved in the formation of LYMPH, lymphocytes (
see LYMPHOCYTE), and
ANTIBODIES. It consists of the LYMPH NODES, THYMUS GLAND, TONSILS and SPLEEN.
Lymphokines Lymphokines are polypeptides that are produced by lymphocyte
s (see LYMPHOCYTE) as part of
their immune response to an ANTIGEN; their function is to communicate with other
cells of the immune system
(see IMMUNITY). Some lymphokines stimulate B-cells to differentiate into antibod
y-producing plasma cells;
others stimulate T-lymphocytes to proliferate; other lymphokines become interfer
ons (see INTERFERON).
Lymphoma A malignant tumour of the LYMPH NODES divided histologically an
d clinically into two types:
Hodgkins disease, and non-Hodgkins lymphoma. Hodgkins disease or lymphadenoma was n
amed after Thomas
Hodgkin (17981866), a Guys Hospital pathologist, who first described the condition
.
Hodgkins
disease The incidence is around four new cases per 100,000 population an
nually, with slightly more men
than women contracting it. The first incidence peak is in age group 2035 and the
second in age group 50
70. The cause of Hodgkins is not known, although it is more common in patients fr
om small families and
well-educated backgrounds. The disease is three times more likely to occur in pe
ople who have had glandular
fever (see MONONUCLEOSIS) but no link with the EPSTEIN BARR VIRUS has been estab
lished (see Burkitts
lymphoma, below) The disease is characterised histologically by the presence of
large malignant lymphoid
cells (Reed-Sternberg cells) in the lymph glands.
425
Clinically the lymph glands are enlarged, rubbery but painless; usually
those in the neck or just above
the CLAVICLE are affected. Spread is to adjacent lymph glands and in young peopl
e a mass of enlarged glands
may develop in the MEDIASTINUM. The SPLEEN is affected in about one-third of pat
ients with the disorder.
Treatment is either with RADIOTHERAPY, CHEMOTHERAPY or both, depending on when t
he disease is diagnosed and
the nature of the abnormal lymph cells. Cure rates are good, especially if the l
426 Lymphosarcoma
Lymphosarcoma A traditional term for non-Hodgkins lymphoma (see LYMPHOMA)
.
Lysergic Acid Diethylamide (LSD)
Lysol
Lysergic acid diethylamide belongs to the ergot group of ALKALOIDS. It h
as various effects on the
brain, notably analgesic and hallucinogenic, thought to be due to its antagonism
of 5hydroxytryptamine
(5-HT). In small doses it induces psychic states, in which the individual may be
come aware of repressed
memories. For this reason it may help in the treatment of certain anxiety states
, if used under skilled
supervision. LSD rapidly induces TOLERANCE, however, and psychological DEPENDENC
E may occur, although not
physical dependence. Serious side-effects include psychotic reactions, with an i
ncreased risk of suicide.
Lysine
L
dissolution of a blood clot, or the destruction of CELLS as a result of
damage to or rupture of the
PLASMA membrane, thus allowing the cell conAn essential amino acid (see AMINO ACIDS; INDISPENSABLE AMINO ACIDS), ly
sine was first isolated in 1889
from casein, the principal protein of milk. Like other essential amino acids, it
ensures optimum growth in
infants and balanced nitrogen metabolism in adults.
Lysis The gradual ending of a fever, and the opposite of CRISIS, which s
ignifies the sudden ending of a
fever. It is also used to describe the process of
tents to escape. A brown, clear, oily fluid with antiseptic properties,
made from coal-tar and
containing 50 per cent CRESOL. When mixed with water it forms a clear soapy flui
d.
Lysol Poisoning When LYSOL is swallowed it burns the mouth and throat. B
rown discoloration of the
affected tissues, accompanied by the characteristic smell of lysol on the breath
, is typical.
Treatment This is urgent. If the skin has been contaminated with the lys
ol, it must be washed with
water, and any lysol-contaminated clothing must be taken off. Do not make the vi
ctim vomit if he or she has
swallowed a corrosive substance such as lysol or phenol. Call an ambulance and s
ay what the victim has
taken. See APPENDIX 1: BASIC FIRST AID.
Lysozyme An ENZYME present in tears and egg white, lysozyme catalyses th
e destruction of some bacteria
M Maceration
and central nervous system. Free macrophages move between cells and, usi
ng their scavenger properties,
collect at infection sites to remove foreign bodies, including bacteria. Fixed m
acrophages are found in
connective tissue.
Macropsia
Maceration is the softening of a solid by soaking in fluid.
Condition in which objects appear larger than normal. It can be due to d
isease of the MACULA see also
EYE.
Macr-/MacroMacula
Prefix denoting large-sized cell for example, a MACROPHAGE is a large PH
AGOCYTE.
Macrocyte Macrocyte is an unusually large red blood cell (see ERYTHROCYT
ES) especially characteristic
of the blood in PERNICIOUS ANAEMIA.
Macrocytosis This condition is particularly associated with PERNICIOUS A
NAEMIA but can also be caused
by a number of other things, such as alcohol, pregnancy, myxoedema (see THYROID
GLAND, DISEASES OF
Hypothyroidism) and MYELOMATOSIS, and also by vitamin B12 deficiency: this occur
s sometimes in vegans (see
VEGANISM) as well as in patients with CROHNS DISEASE.
Macroglossia An abnormally large TONGUE.
Macrolides A group of ANTIBIOTICS. The original macrolide, ERYTHROMYCIN,
was discovered in the early
1950s and used successfully as an alternative to PENICILLIN. The name macrolide de
rives from the
molecular structure of this group, three others of which are clarithromycin, azi
thromycin and spiramycin.
Macrolides check PROTEIN synthesis in BACTERIA and the latest ones are, like ery
thromycin, active against
several bacterial species including gram-positive COCCI and rods. In addition, t
hey act against Haemophilus
influenzae. Clarithromycin is potent against Helicobacter pylori; azithromycin i
s effective against
infections caused by Legionella spp. (see LEGIONNAIRES DISEASE) and GONOCOCCI. Sp
iramycin is a
restricted-use macrolide prescribed for pregnant patients with TOXOPLASMOSIS.
Macrophage A large
PHAGOCYTE that forms part of the RETICULO-ENDOTHELIAL SYSTEM. It is foun
d in
many organs and tissues, including connective tissue, bone marrow, lymph
nodes, spleen, liver
esistance to various
preventative and treatment drugs. The disease constitutes a significant problem
for travellers, who must
obtain sound advice on chemoprophylaxis before embarking on tropical trips espec
ially to a rural area
where intense transmission can occur. Transmission has also been recorded at air
ports, and following blood
transfusion. The World Health Organisation (WHO) has listed malaria as one of Eu
ropes top ten infectious
diseases. In 1992, 20,000 cases were reported: this had risen to more than 200,0
00 by the late 1990s. The
resurgence of malaria has been worldwide, in part the result of the development
of resistant strains of the
disease, and in part because many countries have failed (or been unable) to impl
ement environmental
measures to eliminate mosquitoes. Nearly 40 years ago the WHO forecast that by 1
980 only four million
people would be affected worldwide; now, at the beginning of the 21st century, a
round 500 million people a
year are contracting malaria with about 3,000 people a day dying from the infect
ion as many as 70 per
cent of them children under the age of five, according to WHO figures. The appar
ently steady advance of
global warming means that countries with temperate climates may well warm up suf
ficiently to enable malaria
to become established as an ENDEMIC disease. In any case, the great increase in
international air travel
has exposed many more people to the risk of malaria, and infected individuals ma
y not exhibit symptoms
until they are back home. Doctors seeing a recent traveller with unexplained pyr
exia and illness should
consider the possibility of malarial infection. Diagnosis is by demonstration of
trophozoites a stage in
the parasites life-cycle that takes place in red blood cells in thick/thin bloodfilms of peripheral
blood. Serological tests are of value in deciding whether an
Maldescended Testis
individual has had a past infection, but are of no value in acute diseas
e.
P. vivax and P. ovale infections cause less severe disease than P. falci
parum (see below), although
overall there are many clinical similarities; acute complications are unusual, b
ut chronic ANAEMIA is often
present. Primaquine is necessary to eliminate the exoerythrocytic cycle in the h
epatocyte (liver cell).
P. falciparum Complications of P. falciparum infection include cerebral
involvement (see BRAIN
Cerebrum), due to adhesion of immature trophozoites on to the cerebral vascular
endothelium; these lead to
a high death rate when inadequately treated. Renal involvement (frequently resul
ting from HAEMOGLOBINURIA),
PULMONARY OEDEMA, HYPOTENSION, HYPOGLYCAEMIA, and complications in pregnancy are
also important. In
complicated disease, HAEMODIALYSIS and exchange TRANSFUSION have been used. No a
dequate controlled trial
using the latter regimen has been carried out, however, and possible benefits mu
st be weighed against
numerous potential sideeffects for instance, the introduction of a wide range of
infections, overload of
the circulatory system with infused fluids, and other complications.
P. malariae usually produces a chronic infection, and chronic renal dise
ase (nephrotic syndrome) is an
occasional sequel, especially in tropical Africa. Gross SPLENOMEGALY (hyper-reac
tive malarious
splenomegaly, or tropical splenomegaly syndrome) can complicate all four human P
lasmodium spp. infections.
The syndrome responds to long-term malarial chemoprophylaxis. BURKITTS LYMPHOMA i
s found in geographical
areas where malaria infection is endemic; the EPSTEIN BARR VIRUS is aetiological
ly involved.
Prophylaxis Malaria specialists in the United Kingdom have produced guid
ance for residents travelling
to endemic areas for short stays. Drug choice takes account of: risk of exposure
to malaria; extent of drug
resistance; efficacy of recommended drugs and their side-effects; criteria relev
ant to the individual (e.g.
age, pregnancy, kidney or liver impairment). Personal protection against being b
itten by mosquitoes is
essential. Permethrinimpregnated nets are an effective barrier, while
429
skin barrier protection and vaporised insecticides are helpful. Lotions,
sprays or roll-on applicators
all containing diethyltoluamide (DEET) are safe and work when put on the skin. T
heir effect, however, lasts
only for a few hours. Long sleeves and trousers should be worn after dark. Drug
prophylaxis should be
started at least a week before travelling into countries where malaria is endemi
430 Malformation
Malformation
Malleolus
See DEFORMITIES.
Name of either of the two bony prominences at the ANKLE.
Malignant
Deformation of a finger due to sudden forced flexion of the terminal joi
nt, leading to rupture of the
tendon. As a result the individual is unable to extend the terminal part of the
finger, which remains bent
forwards. The middle, ring and little fingers are most commonly involved. Treatm
ent is by splinting the
finger. The end result is satisfactory provided that the patient has sufficient
patience.
Malignant Hyperpyrexia
Mallet Toe
See MALIGNANT HYPERTHERMIA.
Malignant Hypertension Malignant hypertension has nothing to do with can
cer; it derives its name from
the fact that, if untreated, it runs a rapidly fatal course. (See HYPERTENSION.)
Malignant Hyperthermia M
Mallet Finger
A term applied in several ways to serious disorders. A TUMOUR is called
malignant when it grows
rapidly, tending to infiltrate surrounding healthy tissues and to spread to dist
ant parts of the body,
leading eventually to death (see CANCER). The term is also applied to types of d
isease which are much more
serious than the usual form for example, MALIGNANT HYPERTENSION. Malignant pustu
le is another name for
ANTHRAX.
This disorder is a rare complication of general ANAESTHESIA caused, it i
s believed, by a combination of
an inhalation anaesthetic (usually HALOTHANE) and a muscle-relaxant drug (usuall
y succinycholine). A
life-endangering rise in temperature occurs, with muscular rigidity the first si
gn. TACHYCARDIA, ACIDOSIS
and SHOCK usually ensue. About 1:20,000 patients having general anaesthesia suff
er from this disorder,
which progresses rapidly and is often fatal. Surgery and anaesthesia must be sto
pped immediately and
appropriate corrective measures taken, including the intravenous administration
of DANTROLENE. It is a
dominantly inherited genetic condition; therefore, when a case is identified it
is most important that
relatives are screened.
Mania
431
number of cases has been rising sharply in the United Kingdom, where the
more usual term is clinical
negligence. The increase is assumed to be partly because of failings in the NHS,
and partly because
patients have more understanding of health care, accompanied by higher expectati
ons of treatment outcomes.
Patients concerned that they or their relatives might have been subject to negli
gence which has caused harm
should consult a solicitor experienced in the field of clinical negligence. www.
avma.org.uk
to treat breast cancer; to enlarge small breasts; or to reduce the size
of overlarge breasts. The
routine method for breast enlargement used to be the insertion of silicone (see
SILICONES) implants under
the skin; controversy about the long-term safety of silicone, however, has restr
icted their use mainly to
women needing reconstruction of their breasts after cancer surgery. Side-effects
have included hardening of
breast tissue, leaking of implants and development of scar tissue. (See also MAS
TECTOMY.)
Malpresentation
This process aims to reduce the costs of health care while maintaining i
ts quality. The concept
originated in the United States but has attracted interest in the United Kingdom
and Europe, where the
spiralling costs of health care have been causing widespread concern. Managed ca
re works through changing
clinical practice, but it is not a discrete entity: the American I. J. Iglehart
has defined it as a
variety of methods of financing and organising the delivery of comprehensive hea
lth care in which an
attempt is made to control costs by controlling the provision of services. Manage
d care has three facets:
health policy; how that policy is managed; and how individuals needing health ca
re are dealt with. The
process and its applications are still evolving and it is likely that different
health-care systems will
adapt it to suit their own particular circumstances.
A situation during childbirth in which a baby is not in the customary he
ad-first position before
delivery. The result is usually a complicated labour in which a caesarean operat
ion may be necessary to
effect the birth. (See PREGNANCY AND LABOUR.)
Malta Fever See BRUCELLOSIS.
Mammary Gland See BREASTS.
Mammography The special technique whereby X-rays are used to show the st
ructure of the breast or any
abnormalities in it (see BREASTS; BREASTS, DISEASES OF). It is an effective way
of distinguishing benign
from malignant tumours, and can detect tumours that are not palpable. In a multi
-centre study in the USA,
called the Breast Cancer Detection Demonstration Project and involving nearly 30
0,000 women in the 4049
age group, 35 per cent of the tumours found were detected by mammography alone,
13 per cent by physical
examination, and 50 per cent by both methods combined. The optimum frequency of
screening is debatable: the
American College of Radiologists recommends a baseline mammogram at the age of 4
0 years, with subsequent
mammography at one- to two-year intervals up to the age of 50; thereafter, annua
l mammography is
recommended. In the United Kingdom a less intensive screening programme is in pl
ace, with women over 50
being screened every three years. As breast cancer is the commonest malignancy i
n western women and is
increasing in frequency, the importance of screening for this form of cancer is
obvious.
Mammoplasty A surgical operation to reconstruct a breast (see BREASTS) a
fter part or all of it has been
removed
Managed Health Care
Mandelic Acid Also known as mandelamine, a non-toxic ketoacid used in th
e treatment of infections of
the urinary tract, especially those due to the Escherichia coli and the Streptoc
occus faecalis or
Enterococcus. It is administered in doses of 3 grams several times daily. As it
is only effective in an
acid urine, ammonium chloride must be taken at the same time.
Mandible The bone of the lower JAW.
Manganese A metal, oxides of which are found abundantly in nature. Perma
nganate of potassium is a
wellknown disinfectant. The body requires small amounts of the metal for normal
growth and development.
(See also TRACE ELEMENTS.)
Mania A form of mental disorder characterised by great excitement. (See
MENTAL ILLNESS.)
M
or
Marasmus Progressive wasting, especially in young children, when there i
s no ascertainable cause. It is
generally associated with defective feeding. (See also ATROPHY; INFANT FEEDING.)
Marburg Disease This is also known as green monkey disease, or vervet mo
nkey disease, because the first
recorded human cases acquired their infection from monkeys of this genus. It is
a highly dangerous viral
infection with a high mortality rate. The incubation period is 49 days. The onset
is sudden with marked
nausea and severe headache; this is followed by rising temperature, diarrhoea, a
nd vomiting. Towards the
end of the first week a rash appears which persists for a week and is accompanie
d by internal bleeding. In
those who recover, convalescence is slow and prolonged. Apart from laboratory in
fections acquired through
working with vervet monkeys, all the cases so far reported have occurred in Afri
ca.
March Fracture A curious condition in which a fracture occurs of the sec
ond (rarely, the third)
metatarsal bone in the foot without any obvious cause. The usual story is that a
pain suddenly developed in
the foot while walking or marching (hence the name), and that it has persisted e
ver since. The only
treatment needed is immobilisation of the foot and rest, and the fracture heals
satisfactorily. (For more
information on fractures, see BONE, DISORDERS OF Bone fractures.)
March Haemoglobinuria A complication of walking and running over long di
stances. It is due to damage to
red blood cells in the blood vessels of the soles of the feet. This results in H
AEMOGLOBIN being released
into the bloodstream, which is then voided in the URINE the condition known as H
AEMOGLOBINURIA. No
treatment is required.
Marfans Syndrome An inherited disorder affecting about one person in 50,0
00 in which the CONNECTIVE
TISSUE is abnormal. The result is defects of the heart valves, the arteries aris
ing from the heart, the
skeleton and the eyes. The victims are unusually tall and thin with a particular
facial appearance (the US
President Abraham Lincoln was said to have Marfans) and deformities of the chest
and spine. They have
spider-like
Mastectomy
fingers and toes and their joints and ligaments are weak. Orthopaedic in
tervention may help, as will
drugs to control the heart problems. As affected individuals have a 50 per cent
chance of passing on the
disease to their children, they should receive genetic counselling.
433
by trained practitioners. A complete list of members of the Chartered So
ciety of Physiotherapy can be
obtained on application to the Secretary of the Society.
Masseter
Another term for CANNABIS, hemp, or hashish. (See also DEPENDENCE.)
An important muscle of MASTICATION that extends from the zygomatic arch
in the cheek to the mandible or
jawbone. It acts by closing the 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 o
f people. It has been used on a
large scale as a means of screening the population for pulmonary TUBERCULOSIS. I
t is no longer used in the
United Kingdom.
Marijuana
Marsh Fever See MALARIA.
Mask A device that covers the nose and mouth
hetics (see ANAESTHESIA) or
other gases such as oxygen to be administered. It is
e and mouth to ensure that
antiseptic conditions are maintained during surgery,
rsing a patient in
conditions of isolation. The term is also applied to
ce that occurs in certain
disorders for example, in PARKINSONISM.
434 Mastication
quadrantectomy or subcutaneous mastectomy (which preserves the nipple an
d much of the skin, so
producing a better cosmetic effect). Lumps bigger than 5 cm and fixed to the und
erlying tissues require
total mastectomy in which the breast tissue, skin and some fat are dissected dow
n to the chest muscles and
removed. In addition, the tail of the breast tissue and regional lymph glands ar
e removed. In all types of
mastectomy, surgeons endeavour to produce as good a cosmetic result as possible,
subject to the adequate
removal of suspect tissue and glands. Breast reconstructive surgery (MAMMOPLASTY
) may be done at the same
time as the mastectomy the preferred option or, if that is not feasible, at a la
ter date. Where the
whole breast has been excised, some form of artificial breast (prosthesis) will
be provided. This may be an
external prosthesis fitted into a specially made brassiere, or an internal impla
nt perhaps a silicone
bag, though there has been controversy over the safety of this device. Reconstru
ctive techniques involving
the transfer of skin and muscle from nearby areas are also being developed. Post
-operatively, patients can
obtain advice from Breast Cancer Care.
M Mastication The act whereby, as a result of movements of the lower jaw
, lips, tongue, and cheek, food
is reduced to a condition in which it is ready to be acted on by the gastric jui
ces in the process of
DIGESTION. Adequate mastication before swallowing is an essential part of the di
gestive process.
Mastitis The term applied to inflammation of the breast (see BREASTS, DI
SEASES OF).
Mastocytosis A rare condition in which the primary abnormality is of MAS
T CELLS a type of cell
responsible for the storage and release of agents such as HISTAMINE, important i
n allergic states. Patients
may present with an urticarial rash (urticaria pigmentosa) but may have symptoms
referable to any part of
the body, related to collections of active mast cells in these areas.
Mastoid Process The large process of the temporal bone of the SKULL whic
h can be felt immediately
behind the ear. It contains numerous cavities, one of which the mastoid antrum c
ommunicates with the
middle ear, and is liable to suppurate
when the middle ear is diseased. (See
under EAR,
DISEASES OF.)
Masturbation The production of an ORGASM by selfmanipulation of the PENI
S or CLITORIS.
Mat Burn A combination of a burn and an abrasion which occurs in wrestle
Median
doubt due to the fact that this viral infection is most potent in the ea
rlier stages. Hence the
difficulty of timely isolation, and the readiness with which the disease is spre
ad, which is mostly by
infected droplets. In developing countries measles results in the death of more
than a million children
annually.
Symptoms The incubation period, during which the child is well, lasts 721
days. Initial symptoms are
CATARRH, conjunctivitis (see EYE, DISORDERS OF), fever and a feeling of wretched
ness. Then Koplik spots a
classic sign of measles appear on the roof of the mouth and lining of the cheeks
. The macular body rash,
typical of measles, appears 35 days later. Common complications include otitis me
dia (see under EAR,
DISEASES OF) and PNEUMONIA. Measles ENCEPHALITIS can cause permanent brain damag
e. A rare event is a
gradual dementing disease (see DEMENTIA) called subacute sclerosing panenecephal
itis (SSPE).
Treatment Isolation of the patient and treatment of any secondary bacter
ial infection, such as
pneumonia or otitis, with antibiotics. Children usually run a high temperature w
hich can be relieved with
cool sponging and antipyretic drugs. Calamine lotion may alleviate any itching.
Measures
435
Meckels Diverticulum A hollow pouch sometimes found attached to the small
INTESTINE. It is placed on
the small intestine about 90120 cm (34 feet) from its junction with the large inte
stine, is several
centimetres long, and ends blindly. It is lined with cells similar to those whic
h line the stomach, and so
may produce acid. This leads to occasional illness Meckels diverticulitis with ul
ceration, which causes
abdominal pain and fever (sometimes referred to as left-sided appendicitis). Perfo
ration may result in
PERITONITIS and, rarely, may be the lead point of an INTUSSUSCEPTION.
Meconium The brown, semi-fluid material which collects in the bowels of
a FETUS before birth, and which
should be discharged either at the time of birth or shortly afterwards. It consi
sts partly of BILE secreted
by the liver before birth; partly of debris from the mucous membrane of the inte
stines.
Media The middle layer of an organ or tissue, but more usually applied t
o the wall of an artery or
vein, where the media comprises layers of elastic and smooth muscle fibres.
Medial Near the middle of tissue, organ or body.
See APPENDIX 6: MEASUREMENTS IN MEDICINE.
Meat See PROTEIN.
436 Mediastinum
Mediastinum Mediastinum is the space in the chest which lies between the
two lungs. It contains the
heart and great vessels, the gullet, the lower part of the windpipe, the thoraci
c duct and the phrenic
nerves, as well as numerous structures of less importance.
Medicaid A joint state and federal health insurance scheme in the United
States that provides cover for
poorer people in the population.
Medical Audit A systematic review of the procedures involved in the diag
nosis, care and treatment of
patients. Such a review includes the input of associated resources for example,
social-services care and
funding and an assessment of the outcome and quality of life for the patient(s).
If the review is
undertaken by health-care professionals, the process is called CLINICAL AUDIT.
Medical Defence Organisations
M
These are UK bodies that provide doctors with advice and, where appropri
ate, financial support in
defending claims for medical negligence in their clinical practice. They also ad
vise doctors on all legal
aspects of their work, including patients complaints, and provide representation
for members called to
account by the GENERAL MEDICAL COUNCIL (GMC) or other regulatory body. The sharp
rise in claims for medical
negligence in the NHS in the 1980s persuaded the UK Health Departments to introd
uce a risk-pooling system
called the Clinical Negligence Scheme for Trusts, and the defence societies liai
se with this scheme when
advising their doctor members on responding to claims of negligence (see MEDICAL
LITIGATION; MEDICAL
NEGLIGENCE).
Medical Devices Agency An executive agency of the Department of Health i
n the UK. Set up in 1994, it is
responsible for regulating and advising on the sale or use of any product, other
than a medicine, used in
the health-care environment for the diagnosis, prevention, monitoring or treatme
nt of illness or disease.
Equipment ranges from pacemakers (see CARDIAC PACEMAKER) to prostheses (see PROS
THESIS), and from syringes
to magnetic resonance imaging (see (MRI).
Medical Education This term is used to define the process of learning an
d knowledge-acquisition in the
study of medicine. It also encompasses the expertise
required to develop education and training for students and learners in
all aspects of medical health
care. Studies for undergraduate students, postgraduate students and individual h
ealthcare practitioners,
from the initial stages to the ongoing development of a career in medicine or as
sociated health fields, are
also included in medical education. The word pedagogy is sometimes applied to this
process. A range of
research investigations has developed within medical education. These apply to c
ourse monitoring, audit,
development and validation, assessment methodologies and the application of educ
ationally appropriate
principles at undergraduate and postgraduate levels. Research is undertaken by m
edical educationalists
whose backgrounds include teaching, social sciences and medicine and related hea
lth-care specialties, and
who will hold a medical or general educational diploma, degree or other appropri
ate postgraduate
qualification. Development and validation for all courses are an important part
of continuing accreditation
processes. The relatively conservative courses at both undergraduate and postgra
duate levels, including
diplomas and postgraduate qualifications awarded by the specialist medical royal
colleges (responsible for
standards of specialist education) and universities, have undergone a range of r
eassessment and
redefinition driven by the changing needs of the individual practitioner in the
last decade. The stimuli to
change aspects of medical training have come from the government through the for
mer Chief Medical Officer,
Sir Kenneth Calman, and the introduction of new approaches to specialist trainin
g (the Calman programme),
from the GENERAL MEDICAL COUNCIL (GMC) and its document Tomorrows Doctors, as wel
l as from the profession
itself through the activities of the British Medical Association and the medical
royal colleges. The
evolving expectations of the public in their perception of the requirements of a
doctor, and changes in
education of other groups of health professionals, have also led to pressures fo
r changes. Consequently,
many new departments and units devoted to medical education within university me
dical schools, royal
colleges and elsewhere within higher education have been established. These deve
lopments have built upon
practice developed elsewhere in the world, particularly in North America, Austra
lia and some European
countries. Undergraduate education has seen application of new educational metho
ds, including Problem-Based
Learning (PBL) in Liverpool, Glasgow and Manchester; clinical and communications
skills
Medical Litigation
teaching; early patient contact; and the extensive adoption of Internet
(World Wide Web) support and
Computer-Aided Learning (CAL). In postgraduate education driven by European dire
ctives and practices,
changes in specialist training and the needs of community medicine new courses h
ave developed around the
membership and fellowship examinations for the royal colleges. Examples of these
changes driven by medical
education expertise include the STEP course for the Royal College of Surgeons of
England, and
distance-learning courses for diplomas in primary care and rheumatology, as well
as examples of good
practice as adopted by the Royal College of General Practitioners. Continuing Pr
ofessional Development
(CPD) and Continuing Medical Education (CME) are also important aspects of medic
al education now being
developed in the United Kingdom, and are evolving to meet the needs of individua
ls at all stages of their
careers. Bodies closely involved in medical educational developments and their r
eview include the General
Medical Council, SCOPME (the Standing Committee on Postgraduate Medical Educatio
n), all the medical royal
colleges and medical schools, and the British Medical Association through its Bo
ard of Medical Education.
The National Health Service (NHS) is also involved in education and is a key to
facilitation of CPD/CME as
the major employer of doctors within the United Kingdom. Several learned societi
es embrace medical
education at all levels. These include ASME (the Association for the Study of Me
dical Education), MADEN
(the Medical and Dental Education Network) and AMEE (the Association for Medical
Education in Europe).
Specialist journals are devoted to research reports relating to medical educatio
nal developments (e.g.
Academic Medicine, Health Care Education, Medical Education). The more general m
edical journals (e.g.
British Medical Journal, New England Journal of Medicine, The Lancet, Annals of
the Royal College of
Surgeons) also carry articles on educational matters. Finally, the World Wide We
b (WWW) is a valuable
source of information relating to courses and course development and other aspec
ts of modern medical
education. The UK government, which controls the number of students entering med
ical training, has recently
increased the quota to take account of increasing demands for trained staff from
the NHS. More than 5,700
students 3,300 women and 2,400 men are now entering UK medical schools annually
with nearly 28,600 at
medical school in any one year, and an attrition
437
rate of about 810 per cent. This loss may in part be due to the changes i
n universityfunding
arrangements. Students now pay all or part of their tuition fees, and this can r
esult in medical graduates
owing several thousand pounds when they qualify at the end of their five-year ba
sic qualification course.
Medicines
Ageing process This is associated with the in women and, in both sexes,
with a reduction in the bodys
tissue elasticity and often a deterioration in mental and physical capabilities.
When compared with
illnesses described in much younger people, similar illnesses in old age present
in an atypical manner
for example, confusion and changed behaviour due to otherwise asymptomatic heart
failure, causing a reduced
supply of oxygen to the brain. Social adversity in old age may result from the c
ombined effects of reduced
body reserve, atypical presentation of illness, multiple disorders and POLYPHARM
ACY. MENOPAUSE
Age-related change in the presentation of illnesses This was first recog
nised by the specialty of
geriatric medicine (also called the medicine of ageing) which is concerned with
the medical and social
management of advanced age. The aim is to assess, treat and rehabilitate such pa
tients. The number of
institutional beds has been steadily cut, while availability of day-treatment ce
ntres and respite
facilities has been boosted although still inadequate to cope with the growing n
umber of people over 65.
These developments, along with day social centres, provide relatives and carers
with a break from the often
demanding task of looking after the frail or ill elderly. As the proportion of e
lderly people in the
population rises, along with the cost of hospital inpatient care, close cooperat
ion between hospitals,
COMMUNITY CARE services and primary care trusts (see under GENERAL PRACTITIONER
(GP)) becomes increasingly
important if senior citizens are not to suffer from the consequences of the tigh
t operating budgets of the
various medical and social agencies with responsibilities for the care of the el
derly. Private or voluntary
nursing and residential homes have expanded in the past 15 years and now care fo
r many elderly people who
previously would have been occupying NHS facilities. This trend has been acceler
ated by a tightening of the
benefit rules for funding such care. Local authorities are now responsible for a
ssessing the needs of
elderly people in the community and deciding whether they are eligible for finan
cial support (in full or in
part) for nursing-home care. With a substantial proportion of hospital inpatient
s in the United Kingdom
being over 60, it is sometimes argued that all health professionals should be sk
illed in the care of the
elderly; thus the need for doctors and nurses trained in the specialty of geriat
rics is diminishing. Even
so, as more people are reaching their
439
80s, there seems to be a reasonable case for training staff in the type
of care these individuals need
and to facilitate research into illness at this stage of life.
Medicines Medicines are drugs made stable, palatable and acceptable for
BENZODIAZEPINES.
Naming of drugs A European Community Directive (92/27/EEC) requires the
use of the Recommended
International Non-proprietary Name (rINN) for medicinal substances. For most of
these the British Approved
Name (BAN) and rINN were identical; where the two were different, the BAN has be
en modified in line with
the rINN. Doctors and other authorised subscribers are advised to write titles o
f drugs and preparations in
full because unofficial abbreviations may be misinterpreted. Where a drug or pre
paration has a
non-proprietary (generic) title, this should be used in prescribing unless there
is a genuine problem over
the bioavailability properties of a proprietary drug and its generic equivalent.
Where proprietary
commercially registered names exist, they may in general be used only for produc
ts supplied by the
trademark owners. Countries outside the European Union have their own regulation
s for the naming of
medicines.
Methods of administration The ways in
M which drugs are given are increasingly ingenious. Most are still given
by mouth; some oral
preparations (slow release or controlled release preparations) are designed to relea
se their contents
slowly into the gut, to maintain the action of the drug. Buccal preparations are
allowed to dissolve in the
mouth, and sublingual ones are dissolved under the tongue. The other end of the
gastrointestinal tract can
also absorb drugs: suppositories inserted in the rectum can be used for their lo
cal actions for example,
as laxatives or to allow absorption when taking the drug by mouth is difficult o
r impossible for
example, during a convulsion, or when vomiting. Small amounts of drug can be abs
orbed through the intact
skin, and for very potent drugs like OESTROGENS (female sex hormones) or the ant
i-anginal drug GLYCERYL
TRINITRATE, a drug-releasing patch can be used. Drugs can be inhaled into the lung
s as a fine powder to
treat or prevent ASTHMA attacks. They can also be dispersed (nebulised) as a fine
mist which can be
administered with compressed air or oxygen. Spraying a drug into the nostril, so
that it can be absorbed
through the lining of the nose into the bloodstream, can avoid destruction of th
e drug in the stomach. This
route is used for a small number of drugs like antidiuretic hormone (see VASOPRE
SSIN).
Injection remains an important route of administering drugs both locally
(for example, into joints or
into the eyeball), and into the bloodstream. For this latter purpose, drugs can
be given under the skin
that is, subcutaneously (s.c. also called hypodermic injection); into muscle int
ramuscularly (i.m.); or
into a vein intravenously (i.v.). Oily or crystalline preparations of drugs inje
cted subcutaneously form
a depot from which they are absorbed only slowly into the blood. The action of dru
gs such as TESTOSTERONE
and INSULIN can be prolonged by using such preparations, which also allow contra
ceptive implants that
work for some months (see CONTRACEPTION).
Safe disposal of unwanted medicines Unwanted medicines are a form of cont
rolled waste under the
Environmental Protection Act 1990 and must be disposed of in an appropriate way.
The best thing is to take
any extra or unwanted medicines to a registered pharmacy. Syringes and needles (
used by diabetic patients,
for example) pose problems: devices exist to cut off and retain the needle, and
some local authorities in
the United Kingdom arrange for collection and safe disposal. There are also loca
l needle exchange schemes
for intravenous drug abusers.
Safe use of medicines All medicines can have unwanted effects (side-effec
ts or, more strictly,
adverse effects) that are unpleasant and sometimes harmful. It is best not to ta
ke any medicine, prescribed
or otherwise, unless there is a clear reason for doing so; the possible adverse
effects of treatment, and
the risk of their occurring, have to be set against any likely benefit. Remember
too that one treatment can
affect another already being taken. Many adverse events depend upon the recommen
ded dose being exceeded.
Some people for example, those with allergies (see ALLERGY) to a particular grou
p of drugs, or those with
kidney or liver disease are more likely to suffer adverse effects than otherwise
healthy people. When an
individual begins a course of treatment, he or she should take it as instructed.
With ANTIBIOTICS
treatments especially, it is important to take the whole course of tablets presc
ribed, because brief
exposure of bacteria to an antibiotic can make them resistant to treatment. Most
drugs can be stopped at
once, but some treatments can cause unpleasant, and occasionally dangerous, symp
toms if stopped abruptly.
Sleeping tablets, anti-EPILEPSY treatment, and medicines used to treat ANGINA PE
CTORIS are among the agents
which can cause
Meiosis
441
such
Medulla Oblongata
STEROIDS
The hindmost part of the BRAIN, continuing into the SPINAL CORD. In it a
re situated several of the
nerve centres which are most essential to life, such as those governing breathin
g, the action of the heart
and swallowing.
withdrawal symptoms. CORTICOare a particularly important group of medicine
s in this respect, because
prolonged courses of treatment with high doses can suppress the ability of the b
ody to respond to severe
stresses (such as surgical operations) for many months or even years.
Medicines Commission A government-appointed expert advisory body on the
use of MEDICINES in the UK.
Medicines Control Agency An executive agency of the Department of Health
with the prime function of
safeguarding the public health. It ensures that branded and non-branded MEDICINE
S on the UK market meet
appropriate standards of safety, quality and efficacy. The agency applies the st
rict standards set by the
UK Medicines Act (1968) and relevant European Community legislation.
Medicolegal A term that relates to the practice of medicine and law (see
FORENSIC MEDICINE; MEDICAL
LITIGATION; MEDICAL NEGLIGENCE).
Medlars Medical Literature Analysis and Retrieval System a computerised
index system produced by the
US National Library of Medicine.
Medline A computer-based telephone line linkage to MEDLARS for rapid tra
nsmission of medical
information held by that library. Information can be accessed worldwide. Informa
tion is also available via
the web.
Mefenamic Acid One
of the NON-STEROIDAL ANTIINFLAMMATORY DRUGS (NSAIDS) that is an analgesi
c (see ANALGESICS) for mild to
moderate pain in RHEUMATOID ARTHRITIS, OSTEOARTHRITIS and other musculoskeletal
disorders. Also used for
DYSMENNORRHOEA and MENORRHAGIA. It must be used with care as it has several side
-effects, in particular
diarrhoea and occasional haemolytic ANAEMIA. It must not be used in patients wit
h INFLAMMATORY BOWEL
DISEASE (IBD).
Megacolon A greatly enlarged colon that may be present at birth or devel
442 Meiosis
M
The formation of gametes. Top, normal meiosis. Centre, non-disjunction a
t first meiotic division.
Bottom, non-disjunction at second meiotic division.
Two divisions of the NUCLEUS occur (see also and only one division of th
e chromosomes, so that the
number of chromosomes in the ova and sperms is half that of the somatic cells. E
ach chromosome pair divides
so that the gametes receive only one member of each pair. The number of chromoso
mes is restored to full
complement at fertilisation so that the zygote has a complete set, each chromoso
me from the nucleus of the
sperm pairing up with its corresponding partner from the ovum. The first stage o
f meiosis involves the
pairing of homologous chromosomes which join together and synapse lengthwise. Th
e chromosomes then become
doubled by splitting along their length and the chromatids so formed are held to
gether by centromeres. As
the homologous chromosomes one of which has come from the mother, and the other
from the father are
lying together, genetic interCELLS)
change can take place between the chromatids and in this way new combina
tions of GENES arise. All four
chromatids are closely interwoven and recombination may take place between any m
aternal or any paternal
chromatids. This process is known as crossing over or recombination. After this
period of interchange,
homologous chromosomes move apart, one to each pole of the nucleus. The cell the
n divides and the nucleus
of each new cell now contains 23 and not 46 chromosomes. The second meiotic divi
sion then occurs, the
centromeres divide and the chromatids move apart to opposite poles of the nucleu
s so there are still 23
chromosomes in each of the daughter nuclei so formed. The cell divides again so
that there are four
gametes, each containing a half number (haploid) set of chromosomes. However, ow
ing to the recombination or
crossing over, the genetic
Memory
material is not identical with either parent or with other spermatozoa.
Melaena Blood in the FAECES in which dark, tarry masses are passed from
the bowel. It is due to
bleeding from the stomach or from the higher part of the bowel, the blood underg
oing chemical changes under
the action of the secretions, and being finally converted in large part into sul
phide of iron. It is a
serious symptom meriting medical investigation. It can indicate peptic ulcer or
carcinoma of the stomach.
Melancholia A term used in the past for illness characterised by great m
ental and physical DEPRESSION.
(See MENTAL ILLNESS.)
Melanin Pigment which confers colour on the SKIN, hair and EYE. It is pr
oduced by cells called
melanocytes interspersed along the basal layer of the EPIDERMIS. The maturation
of the epidermis into
stratum corneum cells packed with melanin granules confers an ultraviolet light
barrier which protects the
skin against the harmful effects resulting from continued solar exposure. The ra
ces do not differ in the
number of melanocytes in their skin, only in the rate and quantity of melanin pr
oduction. Exposure to
bright sunlight stimulates melanin production and distribution causing suntan. A h
ormone from the
PITUITARY GLAND may stimulate melanin production on the face in pregnancy (see C
HLOASMA).
Melanocyte Clear branching cell in the epidermis of the SKIN that produc
es tyrosinase (an ENZYME) and
MELANIN.
Melanoma A malignant tumour arising from melanocytes (see MELANOCYTE). I
t may start in an existing MOLE
or arise de novo. Increasing exposure to sunlight of white populations in the 20
th century has resulted in
an alarming increase in the incidence of this cancer. It is mainly seen in those
over 40 years, especially
on the legs in women and on the back in men. An enlarging pigmented macule or no
dule with irregular
contour, profile or colour distribution is always suspect.
Treatment is excision with a margin of normal tissue. The specimen must
be examined histologically, and
prognosis depends on the
443
depth of invasion. Very superficial melanomas carry an excellent outlook
once removed, but deeper
tumours may spread to regional lymph glands and beyond with fatal results. Publi
cawareness campaigns have
led to the earlier presentation of melanomas in recent years, with corresponding
benefit. (See also
SUNBURN.)
Melatonin A hormone that plays a key role in the bodys diurnal (night and
day) rhythms. Produced by
the PINEAL GLAND and derived from SEROTONIN, it acts on receptors in an area of
the brain above the OPTIC
CHIASMA, synchronising them to the diurnal rhythm. Melatonin is under investigat
ion as a possible agent to
treat insomnia in the elderly, in shift workers and in those with severe learnin
g disability (mental
handicap). It may also help people with SEASONAL
AFFECTIVE
DISORDER
SYNDROME
(SADS) and those who suffer from jet lag.
Melphalan One of the ALKYLATING AGENTS, melphalan is used to treat certa
in forms of malignant disease
including breast tumours (see BREASTS, DISEASES OF), MELANOMA and Hodgkins LYMPHO
MA. It can be given
orally or by injection. (See CYTOTOXIC.)
Membranes See BRAIN; CROUP; DIPHTHERIA; PREGNANCY AND LABOUR).
labour (under
Memory The capacity to remember. It is a complex process and probably oc
curs in many areas of the BRAIN
including the LIMBIC SYSTEM and the temporal lobes. There are three main steps:
registration, storage, and
recall. During registration, information from the sense organs and the cerebral
cortex is put into codes
for storage in the short-term memory system. The codes are usually acoustic (bas
ed on the sounds and words
that would be used to describe the information) but may use any of the five sens
es. This system can take
only a few chunks of information at a time: for example, only about seven longis
h numbers can be retained
and recalled at once the next new number displaces an earlier one that is then f
orgotten. And if a
subject is asked to describe a person just met, he or she will recall only seven
or so facts about that
person. This depends on attention span and can be improved by concentration and
rehearsal for example, by
reciting the list of things that must be remembered. Material needing storage fo
r several minutes
M
444 Menarche
M
stays in the short-term memory. More valuable information goes to the lo
ng-term memory where it can be
kept for any period from a few minutes to a lifetime. Storage is more reliable i
f the information is in
meaningful codes it is much easier to remember peoples names if their faces and p
ersonalities are
memorable too. Using techniques such as mnemonics takes this into account. The f
inal stage is retrieval.
Recognising and recalling the required information involves searching the memory
. In the short-term memory,
this takes about 40-thousandths of a second per item a rate that is surprisingly
consistent, even in
people with disorders such as SCHIZOPHRENIA. Most kinds of forgetting or AMNESIA
occur during retrieval.
Benign forgetfulness is usually caused by interference from similar items becaus
e the required information
was not clearly coded and well organised. Retrieval can be improved by recreatin
g the context in which the
information was registered. This is why the police reconstruct scenes of crimes,
and why revision for exams
is more effective if facts are learnt in the form of answers to mock questions.
Loss of memory or amnesia
mainly affects long-term memory (information which is stored indefinitely) rathe
r than short-term memory
which is measured in minutes. Shortterm memory may, however, be affected by unco
nsciousness caused by
trauma. Drivers involved in an accident may be unable to recall the event or the
period leading up to it.
The cause of amnesia is disease of or damage to the parts of the brain responsib
le for memory. Degenerative
disorders such as ALZHEIMERS DISEASE, brain tumours, infections (for example, ENC
EPHALITIS), STROKE,
SUBARACHNOID HAEMORRHAGE and alcoholism all cause memory loss. Some psychiatric
illnesses feature loss of
memory and AGEING is usually accompanied by some memory loss, although the age o
f onset and severity vary
greatly.
Menarche The start of MENSTRUATION. The average age at which it occurs i
n British females is 125 years
a year or two after the first physical indications of PUBERTY start. There is co
nsiderable racial and
geographical variation.
Mendelism The term applied to a law enunciated by G. J. Mendel that the
offspring is not intermediate
in type between its parents, but that the type of one or other parent is predomi
nant. Characteristics are classed as either dominant or recessive. The offspring of the
first generation tend to
inherit the dominant characteristics, whilst the recessive characteristics remai
n latent and appear in some
of the offspring of the second generation. If individuals possessing recessive c
haracters unite, recessive
characters then become dominant characters in succeeding generations. (See GENET
ICS.)
Mendelson Syndrome Inhalation of regurgitated stomach contents, usually
as a complication of general
ANAESTHESIA. It may cause death from ANOXIA or result in extensive lung damage.
Menires Disease Named after the Frenchman, Prosper Menire, who first descri
bed it in 1861, the
disease is characterised by TINNITUS, deafness and intermittent attacks of VERTI
GO. The first manifestation
is usually deafness on one side; then as a rule, many months later there is a su
dden attack, without
any warning, of intense vertigo. The acute giddiness usually lasts for two or th
ree hours with some
unsteadiness persisting for a few days. The time interval between attacks varies
from a week to a few
months. When they do recur, they tend to do so in clusters. The tinnitus, which
tends to be low-pitched,
comes on at about the same time as the deafness; it is often described as being
like rushing water or
escaping steam. The deafness becomes gradually worse until it is complete. The c
ondition is due to
excessive fluid in the labyrinth of the ears (see EAR). The cause of this accumu
lation is not known,
although it has been suggested that it might be a form of ALLERGY, or might be d
ue to spasm of small blood
vessels. The disorder is diagnosed from AUDIOMETRY, the CALORIC TEST and other i
nvestigations.
Treatment Acute vertigo symptoms can sometimes be alleviated with drugs
such as CYCLIZINE HYDROCHLORIDE
and NICOTINIC ACID, but the disorder is notoriously difficult to
treat and no certain cure is available. Surgical decompression of the fl
uid in the ears balancing
mechanism may relieve vertigo and prevent the disease from worsening. The vestib
ular nerve to the ear can
also be cut to relieve vertigo while preserving hearing.
Meninges The membranes surrounding the BRAIN and SPINAL CORD. The membra
nes include the
ecautions.
Immuno-compromised patients those with AIDS or on CYTOTOXIC drugs are vulnerable
to infections. Spread
to contacts may occur in schools and similar communities. Many people harbour th
e meningococcus without
developing meningitis. In recent years small clusters of cases, mainly in school
children and young people
at college, have occurred in Britain. Symptoms include malaise accompanied by fe
ver, severe headache,
PHOTOPHOBIA, vomiting, irritability, rigors, drowsiness and neurological disturb
ances. Neck stiffness and a
positive KERNIGS SIGN appearing within a few hours of infection are key diagnosti
c signs. Meningococcal
and pneumococcal meningitis may co-exist with SEPTICAEMIA, a much more serious c
ondition in terms of death
rate or organ damage and which constitutes a grave emergency demanding rapid tre
atment.
Diagnosis and treatment are urgent and, if bacterial meningitis is suspe
cted, antibiotic treatment
should be started even before laboratory confirmation of the infection. Analysis
of the CEREBROSPINAL FLUID
(CSF) by means of a LUMBAR PUNCTURE is an essential step in diagnosis, except in
patients for whom the test
would be dangerous as they have signs of raised intracranial pressure. The CSF i
s clear or turbid in viral
meningitis, turbid or viscous in tuberculous infection and turbulent or purulent
when meningococci or
staphylococci are the infective agents. Cell counts and biochemical make-up of t
he CSF are other diagnostic
pointers. Serological tests are done to identify possible syphilitic infection,
which is now rare in
Britain. Patients with suspected meningitis should be admitted to hospital quick
ly. General pracitioners
are encouraged to give a dose of intramuscular penicillin before sending the chi
ld to hospital. Treatment
in hospital is usually with a cephalosporin, such as ceftazidime or ceftriaxone.
Once the sensitivity of
the organism is known as a result of laboratory studies on CSF and blood, this m
ay be changed to penicillin
or, in the case of H. influenzae, to amoxicillin. Local infections such as SINUS
ITIS or middle-ear
infection require treatment, and appropriate
M
446 Meningocele
M
surgery for skull fractures or meningeal tears should be carried out as
necessary. Tuberculous
meningitis is treated for at least nine months with anti-tuberculous drugs (see
TUBERCULOSIS). If bacterial
meningitis causes CONVULSIONS, these can be controlled with diazepam (see TRANQU
ILLISERS; BENZODIAZEPINES)
and ANALGESICS will be required for the severe headache. Coexisting septicaemia
may require full intensive
care with close attention to intravenous fluid and electrolyte balance, control
of blood clotting and blood
pressure. Treatment of close contacts such as family, school friends, medical an
d nursing staff is
recommended if the patient has H. influenzae or N. meningitidis: RIFAMPICIN prov
ides effective prophylaxis.
Contacts of patients with pneumococcal infection do not need preventive treatmen
t. Vaccines for
meningococcal meningitis may be given to family members in small epidemics and t
o any contacts who are
especially at risk such as infants, the elderly and immuno-compromised individua
ls. The outlook for a
patient with bacterial meningitis depends upon age the young and old are vulnera
ble; speed of onset
sudden onset worsens the prognosis; and how quickly treatment is started hence t
he urgency of diagnosis
and admission to hospital. Recent research has shown that children who suffer me
ningitis in their first
year of life are ten times more likely to develop moderate or severe disability
by the age of five than
contemporaries who have not been infected. (See British Medical Journal, 8 Septe
mber 2001, page 523.)
Prevention One type of bacterial meningitis, that caused by Haemophilus,
has been largely controlled by
IMMUNISATION; meningococcal C vaccine has largely prevented this type of the dis
ease in the UK. So far, no
vaccine against group B has been developed, but research continues. Information
on meningitis can be
obtained from the Meningitis Trust and the Meningitis Research Foundation. Menin
gocele Meningocele is a
protusion of the MENINGES of the brain through a defect in the skull. (See SPINA
BIFIDA.)
Meningococcus See NEISSERIACEAE.
Meningoencephalitis Meningoencephalitis is the term applied to infection
of the membranes, or MENINGES,
of
the brain and the underlying brain matter. In practically all cases of M
ENINGITIS there is some
involvement of the underlying brain, and it is when this involvement is consider
able that the term,
meningoencephalitis, is used. One form that has attracted attention in recent ye
ars is that caused by
amoebae (see AMOEBA), particularly that known as Naegleria fowleri, in which the
infection is acquired
Menstruation
Cyclical therapy is necessary to avoid abnormal bleeding in women who ha
ve reached the menopause. If
oestrogens are given alone, there is an increased risk of endometrial hyperplasi
a (overgrowth of the
ENDOMETRIUM) which may lead to endometrial cancer, so these are restricted to wo
men who have had a
hysterectomy and are no longer at risk. Other women can be given oestrogen-proge
stogen combinations. There
is good evidence that oestrogen alone or in combination can prevent the bone-los
s associated with the
menopause by reducing the demineralisation of bone which normally occurs after t
he menopause; and, if it is
started early and continued for years, it may prevent the development of osteopo
rosis. Oestrogen is far
more effective than calcium supplements and has been shown greatly to reduce fra
ctures affecting the spine,
wrists and legs after the age of 50. However, HRT is no longer licensed for firs
tline treatment to prevent
osteoporosis, as increased risk of stroke, breast cancer and coronary heart dise
ase cannot justify
treatment for long periods unless the woman has severe menopausal symptoms. HRT
is recommended for
short-term use only in menopausal women whose lives are inconvenienced by vasomo
tor instability (severe
flushes, etc.) or vaginal atrophy, although the latter may respond to local oest
rogen treatment creams or
pessaries. In terms of oestrogenic activity, natural oestrogen such as oestradio
l, oestrone and oestriol
are more appropriate for HRT than synthetic oestrogens like ethinyloestradiol, m
estranol and
diethylstilboestrol. Many experts believe that controversy surrounding the risks
and benefits of HRT have
been settled by a large randomised trial (the Womens Health Initiative), publishe
d in 2003, which showed
that combined treatment increases the risk of breast tumours, stroke and coronar
y heart disease (in the
first year). Oestrogen alone (given to women who have had a hysterectomy) also i
ncreases the risk of
stroke. Five years of combined treatment may double the risk of breast cancer, a
nd the heart-disease risk
is nearly doubled during the first year of use. This is in spite of the benefici
al effects of HRT on blood
lipids. However, there are others who consider that different dose combinations
of different hormones may
one day prove beneficial, so research continues. HRT can also provoke minor adve
rse effects such as breast
tenderness, fluid retention, leg cramps and nausea. The risk of abnormal blood c
lotting means that HRT is
not normally
447
recommended for women who smoke heavily or have had THROMBOSIS, severe H
YPERTENSION, stroke or liver
disease. HRT has, however, brought symptomatic benefits to many menopausal women
, who can then justify
taking the other increased risks only fully understood since the large trial res
ults were published. As
the evidence stands at present, careful consideration of each womans medical hist
ory and the severity of
her menopausal symptoms is necessary in deciding what combination of drugs shoul
d be given and for how
long. In general, the indications should be severe menopausal symptoms that can
be controlled by the lowest
dose for the shortest time. Using HRT to alleviate mild symptoms, or to prevent
future bone loss, is
probably of insufficient benefit to counter the other risks described above.
Menorrhagia Menorrhagia means an over-abundance of the menstrual dischar
ge. (See MENSTRUATION,
DISORDERS OF.)
Menstruation A periodic change occurring in (female) human beings and th
e higher apes, consisting
chiefly in a flow of blood from the cavity of the womb (UTERUS) and associated w
ith various slight
constitutional disturbances. It begins between the ages of 12 and 15, as a rule
although its onset may be
delayed until as late as 20, or it may begin as early as ten or 11. Along with i
ts first appearance, the
body develops the secondary sex characteristics: for example, enlargement of the
BREASTS, and
characteristic hair distribution. The duration of each menstrual period varies i
n different persons from 2
8 days. It recurs in the great majority of cases with regularity, most commonly
at intervals of 28 or 30
days, less often with intervals of 21 or 27 days, and ceasing only during pregna
ncy and lactation, until
the age of 45 or 50 arrives, when it stops altogether as a rule ceasing early if
it has begun early, and
vice versa. The final stoppage is known as the MENOPAUSE or the CLIMACTERIC.
Menstruation depends upon a functioning ovary (see OVARIES) and this upo
n a healthy PITUITARY GLAND.
The regular rhythm may depend upon a centre in the HYPOTHALAMUS, which is in clo
se connection with the
pituitary. After menstruation, the denuded uterine ENDOMETRIUM is regenerated un
der the influence of the
follicular hormone, oestradiol. The epithelium of the endometrium proliferates,
and about a fortnight after
the beginning of
M
448 Menstruation
menstruation great development of the endometrial glands takes place und
er the influence of
progesterone, the hormone secreted by the CORPUS LUTEUM. These changes are made
for the reception of the
fertilised OVUM. In the absence of fertilisation the uterine endometrium breaks
down in the subsequent
menstrual discharge.
M
Disorders of menstruation In most healthy women, menstruation proceeds r
egularly for 30 years or more,
with the exceptions connected with childbirth. In many women, however, menstruat
ion may be absent,
excessive or painful. The term amenorrhoea is applied to the condition of absent
menstruation; the terms
menorrhagia and metrorrhagia describe excessive menstrual loss the former if the
excess occurs at the
regular periods, and the latter if it is irregular. Dysmenorrhoea is the name gi
ven to painful
menstruation. AMENORRHOEA If menstruation has never occurred, the amenorrhoea is
termed primary; if it
ceases after having once become established it is known as secondary amenorrhoea
. The only value of these
terms is that some patients with either chromosomal abnormalities (see CHROMOSOM
ES) or malformations of the
genital tract fall into the primary category. Otherwise, the age of onset of sym
ptoms is more important.
The causes of amenorrhoea are numerous and treatment requires dealing with the p
rimary cause. The commonest
cause is pregnancy; psychological stress or eating disorders can cause amenorrho
ea, as can poor nutrition
or loss of weight by dieting, and any serious underlying disease such as TUBERCU
LOSIS or MALARIA. The
excess secretion of PROLACTIN, whether this is the result of a micro-adenoma of
the pituitary gland or
whether it is drug induced, will cause amenorrhoea and possibly GALACTORRHOEA as
well. Malfunction of the
pituitary gland will result in a failure to produce the gonadotrophic hormones (
see GONADOTROPHINS) with
consequent amenorrhoea. Excessive production of cortisol, as in CUSHINGS SYNDROME
, or of androgens (see
ANDROGEN) as in the adreno-genital syndrome or the polycystic ovary syndrome wil
l result in
amenorrhoea. Amenorrhoea occasionally follows use of the oral contraceptive pill
and may be associated with
both hypothyroidism (see under THYROID GLAND, DISEASES OF) and OBESITY. Patients
should be reassured that
amenorrhoea can often be successfully treated and does not necessarily affect th
eir ability to have normal
sexual relations and to conceive. When
weight loss is the cause of amenorrhoea, restoration of body weight alon
e can result in spontaneous
menstruation (see also EATING DISORDERS Anorexia nervosa). Patients with raised
concentration of serum
gonadotrophin hormones have primary ovarian failure, and this is not amenable to
treatment. Cyclical
the best way to help them. The next stage in assessment is the mentalstate exami
nation. This is how
psychiatrists examine minds, or at least their current state. Mental-state exami
nation entails asking more
questions and using careful observation to assess feelings, thoughts and mental
symptoms, as well as the
way the mind is working (for example, in terms of memory and concentration). Dur
ing first consultations
psychiatrists usually make diagnoses and explain them. The boundary between a li
fe problem that will clear
up spontaneously and a mental illness that needs treatment is sometimes quite bl
urred; one consultation may
be enough to put the problem in perspective and help to solve it. Further assess
ment in the clinic may be
needed, or some additional tests. Simple blood tests can be done in outpatient c
linics but other
investigations will mean referral to another department, usually on another day.
Further assessment and tests Psychologists work in or alongside the psyc
hiatric team, helping in both
assessment and treatment. The range of psychological tests studies memory, intel
ligence, personality,
perception and capability for abstract thinking. PHYSICAL TESTS Blood tests and
brain scans may be useful
to rule out a physical illness causing psychological symptoms. SOCIAL ASSESSMENT
Many patients have social
difficulties that can be teased out and helped by a psychiatric social worker. Ap
proved social workers
have special training in the use of the Mental Health Act, the law that authoris
es compulsory admissions to
psychiatric hospitals and compulsory psychiatric treatments. These social worker
s also know about all the
mentalhealth services offered by local councils and voluntary organisations, and
can refer clients to them.
The role of some social workers has been widened greatly in recent years by the
expansion of community
care. OCCUPATIONAL THERAPY ASSESSMENT Mentalhealth problems causing practical di
sabilities for instance,
inability to work, cook or look after oneself can be assessed and helped by occu
pational therapists.
PSYCHOLOGICAL TESTS
Treatment The aims of psychiatric treatment are to help sufferers shake
off, or at least cope
short-term problems in the nervous system and kidney may occur if the blood conc
entration of lithium is too
high therefore it must be monitored by regular blood tests. Carbamazepine, a tre
atment for EPILEPSY, has
also been found to stabilise mood, and also necessitates blood tests. Antipsycho
tic drugs, also called
neuroleptics, and major tranquillisers are the only effective treatments for rel
ieving serious mental
illnesses with hallucinations and delusions. They are used mainly in schizophren
ia and include the
short-acting drugs chlorpromazine and clozapine as well as the long-lasting inje
ctions given once every few
weeks like fluphenazine decanoate. In the long term, however, some of the older
antipsychotic drugs can
cause a brain problem called TARDIVE DYSKINESIA that affects control of movement
and is not always
reversible. And the antipsychotic drugs short-term side-effects such as shaking a
nd stiffness sometimes
have to be counteracted by other drugs called anticholinergic drugs such as proc
yclidine and benzhexol.
Newer antipsychotic drugs such as clozapine do not cause tardive dyskinesia, but
clozapine cannot be given
as a longlasting injection and its concentration in the body has to be monitored
by regular blood tests to
avoid toxicity. OTHER PHYSICAL TREATMENTS The other two physical treatments used
in psychiatry are
particularly controversial: electroconvulsive therapy (ECT) and psychosurgery. I
n ECT, which can be
life-saving for patients who have severe life-threatening depression, a small el
ectric current is passed
through the brain to induce a fit or seizure. Before the treatment the patient i
s anaesthetised and given a
muscle-relaxing injection that reduces the magnitude of the fit to a slight twit
ching or shaking.
Scientists do not really understand how ECT works, but it does, for carefully se
lected patients.
Psychosurgery operating on the brain to alleviate psychiatric illness or difficu
lt personality traits
is extremely uncommon these days. Stereo-tactic surgery, in which small cuts are
made in specific brain
fibres under X-ray guidance, has superM
Mercury
Fellowship, many of the 1015 homicides a year carried out by people with
severe mental illnesses
result from inadequate community care. Further information can be obtained from
the Mental Health Act
Commission, and from MIND, the National Association for Mental Health. MIND also
acts as a campaigning and
advice organisation on all aspects of mental health.
Mental health problems in children Emotional and behavioural problems ar
e common in children and
adolescents, affecting up to one-fifth at any one time. But these problems are o
ften not clear-cut, and
they may come and go as the child develops and meets new challenges in life. If
a child or teenager has an
emotional problem that persists for weeks rather than days and is associated wit
h disturbed behaviour, he
or she may have a recognisable mental health disorder. Anxiety, phobias and depr
ession are fairly common.
For instance, surveys show that up to 2.5 per cent of children and 8 per cent of
adolescents are depressed
at any one time, and by the age of 18 a quarter will have been depressed at leas
t once. Problems such as
OBSESSIVE COMPULSIVE DISORDER, ATTENTION DEFICIT DISORDER (HYPERACTIVITY SYNDROM
E), AUTISM, ASPERGERS
SYNDROME and SCHIZOPHRENIA are rare. Mental-health problems may not be obvious a
t first, because children
often express distress through irritability, poor concentration, difficult behav
iour, or physical symptoms.
Physical symptoms of distress, such as unexplained headache and stomach ache, ma
y persuade parents to keep
children at home on school days. This may be appropriate occasionally, but regul
arly avoiding school can
lead to a persistent phobia called school refusal. If a parent, teacher or other
person is worried that a
child or teenager may have a mental-health problem, the first thing to do is to
ask the child gently if he
or she is worried about anything. Listening, reassuring and helping the child to
solve any specific
problems may well be enough to help the child feel settled again. Serious proble
ms such as bullying and
child abuse need urgent professional involvement. Children with emotional proble
ms will usually feel most
comfortable talking to their parents, while adolescents may prefer to talk to fr
iends, counsellors, or
other mentors. If this doesnt work, and if the symptoms persist for weeks rather
than days, it may be
necessary to
453
seek additional help through school or the familys general practitioner.
This may lead to the child
and family being assessed and helped by a psychologist, or, less commonly, by a
child psychiatrist. Again,
listening and counselling will be the main forms of help offered. For outright d
epression, COGNITIVE
BEHAVIOUR THERAPY and, rarely, antidepressant drugs may be used.
454 Mesalazine
fungicides. Mercury has been widely used in dental amalgams for filling
teeth. Because of their
toxicity, mercury compounds must not be taken internally. Mercury has traditiona
lly been used in
thermometers for recording body temperature, and in sphygmomanometers for measur
ing a persons BLOOD
PRESSURE. These instruments have been largely replaced in the UK by electronic d
evices that do not require
mercury.
Mesalazine An aminosalicylate drug used for the treatment of mild to mod
erate ULCERATIVE COLITIS and
the maintenance of remission. It should be used with caution by pregnant women.
Mescaline
M
Derived from the Mexican peyote cactus, Anhalonium lewinii, this is a ha
llucinogen used for many
centuries by Indian tribes in Mexico as an intoxicant to produce ecstatic states
for religious
celebrations. In recent times its ability to produce temporary psychotic symptom
s has been used to
investigate the mechanism of PSYCHOSIS. Mescaline has similar effects to those o
f LSD: changes in mood and
thought, illusions, self-absorption and an altered perception of time. Experienc
e of the drug may
subsequently provoke panic attacks, deliberate self-injury, real psychosis and s
ometimes addiction (see
DEPENDENCE).
Mesencephalon The small section of brain stem excluding the pons and med
ulla linking the hindbrain
to the forebrain. (See BRAIN.)
Mesentery Mesentery is the double layer of peritoneal membrane which sup
ports the small INTESTINE. It
is of a fan shape, and its shorter edge is attached to the back wall of the abdo
men for a distance of about
15 cm (6 inches), while the small intestine lies within its longer edge, for a l
ength of over 6 metres (20
feet). The terms mesocolon, mesorectum, etc., are applied to similar folds of PE
RITONEUM that support parts
of the colon, rectum, etc.
Mesmerism See HYPNOTISM.
Mesocolon The double fold of PERITONEUM by which the large INTESTINE is
suspended from the back wall of
the abdomen.
Mesoderm The middle layer of the three germ layers of the EMBRYO during
its early development. It
develops into cartilage, bone, blood, muscle, kidneys, testes and connective tis
sue.
Mesothelioma A malignant tumour of the PLEURA, the membrane lining the c
Meteorism
Pagets disease (see under BONE, DISORDERS OF). PORPHYRIAS, HYPERLIPIDAEMI
A, HYPERCALCAEMIA and gout
are other examples of disordered metabolism. There are also more than 200 identi
fied disorders described as
inborn errors of metabolism. Some cause few problems; others are serious threats
to an individuals life.
Individual disorders are, fortunately, rare probably one child in 10,000 or 100,
000; overall these inborn
errors affect around one child in 1,000. Examples include GALACTOSAEMIA, PHENYLK
ETONURIA, porphyrias, TAY
SACHS DISEASE and varieties of mucopolysaccharidosis, HOMOCYSTINURIA and heredit
ary fructose (a type of
sugar) intolerance.
Metabolism This means tissue change, and includes all the physical and c
hemical processes by which the
living body is maintained as well as those by which the energy is made available
for various forms of
work. The constructive, chemical and physical, processes by which food materials
are adapted for the use of
the body are collectively known as ANABOLISM. The destructive processes by which
energy is produced with
the breaking-down of tissues into waste products is known as CATABOLISM. Basal m
etabolism is the term
applied to the energy changes necessary for essential processes such as the beat
ing of the heart,
respiration, and maintenance of body warmth. This can be estimated, when a perso
n is placed in a state of
complete rest, by measuring the amounts of oxygen and carbon dioxide exchanged d
uring breathing under
certain standard conditions. (See also CALORIE.)
Metabolites A biochemical compound that is involved in the mechanism of
the bodys METABOLISM. The
compounds are either produced during metabolism or are in the food eaten by an i
ndividual.
Metacarpal Bones The five long bones which occupy the HAND between the c
arpal bones at the wrist and
the phalanges of the fingers. The large rounded knuckles at the root of the finger
s are formed by the
heads of these bones.
Metamyelocyte An immature granulocyte (white blood cell) usually found i
n the bone marrows bloodmaking
tissue. It can, however, appear in the blood in a range of diseases, including i
nfection.
455
Metaphysis The extremity of a long bone where it joins the epiphysis (se
e BONE Growth of bones).
Metaplasia The term applied to a change of one kind of tissue into anoth
er. Although not usually
harmful, it may be pre-cancerous if occurring in the cervix (neck of the womb or
UTERUS), URINARY BLADDER,
or lining of the airways (bronchi).
456 Metformin
of the
ABDOMEN from excess gas or air in the INTESTINE or peritoneal cavity. On
percussion
the abdomen sounds resonant, like a drum. Causes include obstruction of
the intestines, aerophagy (the
swallowing of air), and IRRITABLE BOWEL SYNDROME (IBS). Treatment is of the unde
rlying condition. (See also
FLATULENCE.)
toxic form. The latter is caused by certain drugs, including acetanilide
, phenacetin, the sulphonamides
and benzocaine. The treatment of the toxic form is the withdrawal of the causati
ve drug. In the more severe
cases the administration of methylene blue or ascorbic acid may also be needed,
and these are the drugs
used in the hereditary form.
Metformin
Methane
One of the BIGUANIDES, metformin lowers the blood sugar by increasing ce
llular uptake of glucose. It is
active when taken by mouth and is used to treat some patients with DIABETES MELL
ITUS, usually in addition
to another hypoglycaemic drug.
An odourless, colourless, highly flammable gas. It occurs naturally in g
as from coal mines and oil
wells, where it is a hazard because of its explosive properties. Natural gas suppl
ied to homes and
industries is almost 100 per cent methane. Unlike coal gas, it is not poisonous
unless present in large
amounts, when it may displace oxygen and thus asphyxiate (suffocate) anyone expo
sed to it. Decomposition of
organic matter produces methane.
Methadone Hydrochloride
M
Also known as Physeptone , this is a synthetic drug structurally similar t
o MORPHINE, one of many
opioid drugs used to treat severe pain. Methadone is, however, less sedating and
has a longer half-life.
Furthermore, it is more reliable when taken orally. Although vomiting is common,
this is generally less
severe than with morphine. Methadone is valuable as a suppressant for non-produc
tive cough, acting on the
medullary cough centre in the central nervous system. It is also helpful in weanin
g addicts off morphine
and heroin, having a slower onset of DEPENDENCE and a less severe withdrawal syn
drome. When used for
prolonged periods, methadone should not be given more often than twice daily, to
avoid the risks of
accumulation and opioid overdosage.
Methylphenidate
but the difficulty in treating them with a safe and effective antibiotic
mean that they are more
dangerous. It is likely that lapses in normal hygienic practice such as frequent
handwashing has
resulted in an increase in MRSA disease.
Methionine Methionine is an essential amino acid (see AMINO ACIDS; INDIS
PENSABLE AMINO ACIDS) that
contains sulphur; it is necessary for normal growth in infants and to maintain n
itrogen balance in adults.
Methotrexate One of the ANTIMETABOLITES used to treat certain forms of m
alignant disease. Acting to
inhibit the ENZYME dihydrofolate reductase, which is essential for purine and py
rimidine synthesis, it is
given orally, intravenously, intramuscularly or intrathecally. Methotrexate is u
sed as maintenance therapy
for childhood acute lymphoblastic LEUKAEMIA, while other uses include CHORIOCARC
INOMA, nonHodgkins
LYMPHOMA, and various solid tumours. Intrathecally, it is used in the prophylaxi
s of childhood acute
lymphoblastic leukaemia, and as treatment for established meningeal cancer or ly
mphoma. Side-effects
include suppression of myelocytes in bone marrow, inflammation of mucous membran
es, and, rarely,
PNEUMONITIS. It should be avoided whenever significant renal impairment is prese
nt, while significant
pleural effusion or ascites is also a contraindication. Blood counts should be c
arefully monitored whenever
intrathecal methotrexate is given. Oral or parenteral folinic acid helps to prev
ent, or to speed recovery
from, myelosuppression or mucositis. Methotrexate is used in dermatology, where
it may be indicated for
cases of severe uncontrolled PSORIASIS unresponsive to conventional therapy; it
may also be indicated for
severe active RHEUMATOID ARTHRITIS. Because of its potentially severe haematolog
ical, pulmonary,
gastrointestinal, and other toxicities it should be used only by specialists and
appropriate renal and
liver function tests carried out before and during treatment. It should be avoid
ed in pregnancy, and
conception should be avoided for at least six months after stopping, as should b
reast feeding. Concurrent
administration of aspirin or other NONSTEROIDAL ANTI-INFLAMMATORY (NSAIDS) reduc
es methotrexate
DRUGS
excretion, increasing its toxicity, and should therefore be avoided when
ever possible.
457
Methyl Methyl is an organic radical whose chemical formula is CH3, and w
hich forms the centre of a wide
group of substances known as the methyl group. For example, methyl alcohol is ob
tained as a by-product in
the manufacture of beetsugar, or by distillation of wood; methyl salicylate is t
he active constituent in
oil of wintergreen; methyl hydride is better known as marsh gas. Methyl alcohol,
or wood spirit (see
METHANOL), is distilled from wood and is thus a cheap form of alcohol. It has ac
tions similar to, but much
more toxic than, those of ethyl alcohol. It has a specially pronounced action on
the nervous system, and in
large doses is apt to cause neuritis, especially of the optic nerves, leading to
blindness, partial or
complete.
Methylbenzene See TOLUENE.
Methylcellulose A COLLOID which absorbs water to swell to about 25 times
its original volume. It is
used in the treatment of CONSTIPATION and also in the management of OBESITY. The
rationale for its use in
obesity is that by swelling up in the stomach, it reduces the appetite.
Methyldopa A centrally acting anti-hypertensive (see HYPERTENSION) drug
often used in conjunction with
a diuretic (see DIURETICS). It can be effective in controlling high blood pressu
re in pregnancy. The drug
is also safe to use in patients with ASTHMA or heart failure.
Methylene Blue Methylene blue, or methylthionin chloride, is used in a d
ose of 75100 mg, as a
1-per-cent intravenous injection, in the treatment of METHAEMOGLOBINAEMIA, which
may occur following high
doses of local anaesthetics such as prilocaine.
Methylphenidate A drug that stimulates the CENTRAL NERVOUS SYSTEM. Its a
ction is similar to
DEXAMPHETAMINE. A controlled drug, one of its trade names is Ritalin and it is (c
ontroversially) used in
the treatment of ATTENTION DEFICIT DISORDER (HYPERACTIVITY SYNDROME) in children
, in conjunction with
behavioural treatment and family support. Because of the potential for side-effe
cts, its administration
should be under specialist supervision.
M
458 Methylprednisolone
Methylprednisolone A mineralcorticoid drug (see CORTICOSTEROIDS) with an
action comparable to that of
PREDNISOLONE, but effective at a somewhat lower dose.
Methyl Salicylate Also called oil of Wintergreen, the liquid has analges
ic (see ANALGESICS) and
counter-irritant properties. Rubbed into the skin, the oil helps to relieve pain
in LUMBAGO, SCIATICA and
rheumatic conditions.
Methysergide A drug used to prevent attacks of MIGRAINE. The drug requir
es hospital supervision, as it
has to be used with care because of the toxic effects it sometimes produces for
example, nausea,
drowsiness and retroperitoneal FIBROSIS.
Metoclopramide
M
This drug antagonises the actions of DOPAMINE. Given orally, intramuscul
arly, or intravenously, it is
used to treat nausea and vomiting, particularly in gastrointestinal disorders, o
r when associated with
cytotoxics or radiotherapy. It is useful in the early treatment of MIGRAINE. Cau
tion is indicated in
prescribing metoclopramide for elderly and young patients, and whenever hepatic
or renal impairment is
present, and it should be avoided in pregnancy or cases of PORPHYRIAS. Adverse e
ffects include
extrapyramidal effects (see under EXTRAPYRAMIDAL SYSTEM) and HYPERPROLACTINAEMIA
with occasional TARDIVE
DYSKINESIA on prolonged administration. There have also been occasional reports
of drowsiness,
restlessness, diarrhoea, depression and neuroleptic malignant syndrome, with rar
e cardiac conduction
abnormalities following intravenous administration.
national System of Units (SI). It is equivalent to 3937 inches.
Metritis Inflammation of the uterus (see EASES OF).
UTERUS, DISMetronidazole An antimicrobial drug particularly active against anaerobi
c (see ANAEROBE) bacteria and
PROTOZOA. Given by mouth, by rectum or intravenously, it is used to treat infect
ions of the urinary,
genital, and digestive systems for example, TRICHOMONIASIS, amoebiasis (see DYSE
NTERY), GIARDIASIS, and
acute ulcerative GINGIVITIS, and is a useful treatment for dental abscesses. Top
ically, it is used in the
management of ROSACEA and it reduces the odour produced by anaerobic bacteria in
fungating tumours. It may
cause a DISULFIRAM-like reaction with alcohol; caution is similarly indicated in
patients with impaired
liver function or hepatic encephalopathy, and who are pregnant or breast feeding
. Rare side-effects include
Microbiology
their main indications are vaginal candidiasis and dermatophyte skin inf
ections. Miconazole is used as
a cream or ointment; it may also be given orally (for oral or gastrointestinal i
nfections), or parenterally
(for systemic infections such as aspergillosis or candidiasis). (See MYCOSIS.)
Microangiopathy Disease of the CAPILLARIES.
Microbe See BACTERIA; MICROBIOLOGY.
Microbicides Gels or creams,
reduce the risk of anal or
vaginal transmission of viruses such
kill or to inactivate the
virus, creating a barrier to mucosal
ng hold after it has
entered the body. Large-scale trials
rin sulphate and PRO-2000
gel.
be spheres (cocci);
straight (bacilli), curved (vibrio), or flexuous (spirilla) rods; or oval cells
(coccobacilli). On
examination by light microscopy, bacteria may be visible in characteristic confi
gurations (as pairs of
cocci [diplococci], or chains [streptococci], or clusters); actinomycete bacteri
a grow as filaments with
externally produced spores. Bacteria grow essentially by increasing in cell size
and dividing by fission, a
process which in ideal laboratory conditions some bacteria may achieve about onc
e every 20 minutes. Under
natural conditions, growth is usually much slower. Eukaryotic micro-organisms co
mprise fungi, algae, and
protozoa. These organisms are larger, and they have in common a well-developed i
nternal compartmentation
into subcellular organelles; they also have a nucleus. Algae additionally have c
hloroplasts, which contain
photosynthetic pigments; fungi lack chloroplasts; and protozoa lack both a cell
wall and chloroplasts but
may have a contractile vacuole to regulate water uptake and, in some, structures
for capturing and
ingesting food. Fungi grow either as discrete cells (yeasts), multiplying by bud
ding, fission, or
conjugation, or as thin filaments (hyphae) which bear spores, although some may
show both morphological
forms during their life-cycle. Algae and protozoa generally grow as individual c
ells or colonies of
individuals and multiply by fission. Micro-organisms of medical importance inclu
de representatives of the
five major microbial groups that obtain their essential nutrients at the expense
of their hosts. Many
bacteria and most fungi, however, are saprophytes (see SAPROPHYTE), being major
contributors to the natural
cycling of carbon in the environment and to biodeterioration; others are of ecol
ogical and economic
importance because of the diseases they cause in agricultural or horticultural c
rops or because of their
beneficial relationships with higher organisms. Additionally, they may be of ind
ustrial or biotechnological
importance. Fungal diseases of humans tend to be most important in tropical envi
ronments and in
immuno-compromised subjects. Pathogenic (that is, disease-causing) microorganism
s have special
characteristics, or
M
460 Microcephaly
M
Microcyte
virulence factors, that enable them to colonise their hosts and overcome
or evade physical,
biochemical, and immunological host defences. For example, the presence of capsu
les, as in the bacteria
that cause anthrax (Bacillus anthracis), one form of pneumonia (Streptococcus pn
eumoniae), scarlet fever
(S. pyogenes), bacterial meningitis (Neisseria meningitidis, Haemophilus influen
zae) is directly related to
the ability to cause disease because of their antiphagocytic properties. Fimbria
e are related to virulence,
enabling tissue attachment for example, in gonorrhoea (N. gonorrhoeae) and chole
ra (Vibrio cholerae).
Many bacteria excrete extracellular virulence factors; these include enzymes and
other agents that impair
the hosts physiological and immunological functions. Some bacteria produce powerf
ul toxins (excreted
exotoxins or endogenous endotoxins), which may cause local tissue destruction an
d allow colonisation by the
pathogen or whose specific action may explain the disease mechanism. In Staphylo
coccus aureus, exfoliative
toxin produces the staphylococcal scalded-skin syndrome, TSS toxin-1 toxic-shock
syndrome, and enterotoxin
food poisoning. The pertussis exotoxin of Bordetella pertussis, the cause of who
oping cough, blocks
immunological defences and mediates attachment to tracheal cells, and the exotox
in produced by
Corynebacterium diphtheriae causes local damage resulting in a pronounced exudat
e in the trachea. Viruses
cause disease by cellular destruction arising from their intracellular parasitic
existence. Attachment to
particular cells is often mediated by specific viral surface proteins; mechanism
s for evading immunological
defences include latency, change in viral antigenic structure, or incapacitation
of the immune system for
example, destruction of CD 4 lymphocytes by the human immunodeficiency virus.
A very small, single-celled living organism that cannot usually be seen
by the naked eye. The most
important micro-organisms in medicine are those that cause disease. This pathogen
ic group, however, forms
only a small proportion of the enormous number of known microorganisms. The main
pathogenic ones are
BACTERIA. Others are fungi and RICKETTSIA. Though not true cells, viruses (see V
IRUS) are usually
classified as micro-organisms. (See also MICROBIOLOGY.)
Microcephaly
Micropsia
Abnormal smallness of the head, usually associated with LEARNING DISABIL
ITY. It may occur as a result
of infection of the fetus by, for example, RUBELLA (German measles) or from hypo
xic damage to the brain
Migraine
and inner ear surgery; for the removal of tumours from the brain or spin
al cord; and for resuturing
damaged blood vessels and nerves.
Microsporum One of the three genera of dermatophytes (fungi) which cause
tinea (see RINGWORM).
Microsporum of human or animal origin is an important cause of tinea capitis, or
ringworm of the scalp.
Microsurgery The conduct of very intricate surgical operations using spe
cially refined operating
microscopes (see MICROSCOPE) and miniaturised precision instruments for example,
forceps, scalpels,
scissors, etc. Microsurgery is used in previously inaccessible areas of the brai
n, eye, inner ear and
spinal cord, as well as in the suturing of severed nerves and small blood vessel
s following traumatic
injuries to the limbs or fingers. The technique is also used to reverse
461
Mid-Life Crisis A colloquial description of the feelings of anxiety and
distress experienced by some
individuals in early middle age. They realise that by 45 years of age they are n
o longer young, and men in
particular try to turn the clock back by changing jobs, dressing trendily, takin
g up energetic or unusual
sports or engaging in extramarital liaisons. Sometimes those in midlife crises d
evelop mild or even serious
DEPRESSION. The feelings of anxiety and insecurity usually disappear with time b
ut some people may benefit
from counselling.
Midwife
A laboratory instrument for cutting sections of biological tissues for s
tudy under a MICROSCOPE. It is
widely used in biological and PATHOLOGY laboratories.
A member of the profession which provides care and advice during pregnan
cy, supervises the mothers
labour and delivery, and looks after her and the baby after birth (see also PREG
NANCY AND LABOUR). Should a
pregnancy or labour develop complications, the midwife will seek medical advice.
Most midwives are
registered general nurses who have also done an 18month course in midwifery. Tra
ined midwives are
registered with the UK Central Council for Nursing Midwifery and Health Visiting
and work in hospitals or a
domiciliary setting. Midwives practise in hospitals, health units or in a domici
liary (home) setting.
Microwaves
Midwifery
Non-ionising electro-magnetic radiations in the frequency range of 30300,
000 megahertz. They are
emitted from electronic devices, such as heaters, some domestic ovens, televisio
n receivers, radar units
and DIATHERMY units. There is no scientific evidence to justify the claims that
they are harmful to humans,
or that they produce any harmful effect in the GENES. The only known necessary p
recaution is the protection
of the eyes in those using them in industry, as there is some evidence that prol
onged exposure to them in
this may induce cataract (see EYE, DISORDERS OF).
See MIDWIFE; PREGNANCY AND LABOUR.
VASECTOMY.
Microtome
Micturition The act of URINATION (see also URINARY BLADDER; URINE).
Middle Ear That portion of the
lying between the and the INNER EAR. It contains the ossicles, the three
small bones that transmit
sound. TYMPANIC MEMBRANE
Midges See BITES AND STINGS.
EAR
Migraine The word migraine derives from HEMICRANIA, the Greek for half a
skull, and is a common
condition characterised by recurring intense headaches. It is much more usual in
women than in men and
affects around 10 per cent of the population. It has been defined as episodic hea
dache accompanied by
visual or gastrointestinal disturbances, or both, attacks lasting hours with tot
al freedom between
episodes. It usually begins at puberty although young children can be affected an
d tends to stop in
middle age: in women, for example, attacks often cease after MENOPAUSE. It frequ
ently disappears during
pregnancy. The disorder tends to run in families. In susceptible individuals, at
tacks may be provoked by a
wide variety of causes including: anxiety, emotion, depression, shock, and excit
ement; physical and mental
fatigue; prolonged focusing on computer, television or cinema screens; noise, es
pecially loud and
high-pitched sounds; certain foods such as chocolate, cheese, citrus fruits, pas
try; alcohol; prolonged
lack of food; irregular meals; menstruation and the pre-menstrual period.
M
462 Milia
M
Anything that can provoke a headache in the ordinary individual can prob
ably precipitate an attack in a
migrainous subject. It seems as if there is an inherited predispostion that trig
gers a mechanism whereby in
the migrainous subject, the headache and the associated sickness persist for hou
rs, a whole day or even
longer. The precise cause is not known, but the generally accepted view is that
in susceptible individuals,
one or other of these causes produces spasm or constriction of the blood vessels
of the brain. This in turn
is followed by dilatation of these blood vessels which also become more permeabl
e and so allow fluid to
pass out into the surrounding tissues. This combination of dilatation and outpou
ring of fluid is held to be
responsible for the headache. Two types of migraine have been recognised: classi
cal and common. The former
is relatively rare and the headache is preceded by a slowly extending area of bl
indness in one or both
eyes, usually accompanied by intermittent lights. The phenomenon lasts for up to 3
0 minutes and is
followed by a bad, often unilateral headache with nausea, sometimes vomiting and
sensitivity to light.
Occasionally, passing neurological symptoms such as weakness in a limb may accom
pany the attack. The common
variety has similar but less severe symptoms. It consists of an intense headache
, usually situated over one
or other eye. The headache is usually preceded by a feeling of sickness and dist
urbance of sight. In 1520
per cent of cases this disturbance of sight takes the form of bright lights: the
so-called AURA of
migraine. The majority of attacks are accompanied by vomiting. The duration of t
he headache varies, but in
the more severe cases the victim is usually confined to bed for 24 hours.
sickness. The less food that is taken during an attack the better, provi
ded that the individual drinks
as much fluid as he or she wants. Group therapy, in which groups of around ten m
igrainous subjects learn
how to relax, is often of help in more severe cases, whilst in others the inject
ion of a local anaesthetic
into tender spots in the scalp reduces the number of attacks. Drug treatment can
be effective and those
afflicted by migraine may find a particular drug or combination of drugs more su
itable than others.
ANALGESICS such as PARACETAMOL, aspirin and CODEINE phosphate sometimes help. A
combination of buclizine
hydrochloride and analgesics, taken when the visual aura occurs, prevents or dim
inishes the severity of an
attack in some people. A commonly used remedy for the condition is ergotamine ta
rtrate, which causes the
dilated blood vessels to contract, but this must only be taken under medical sup
ervision. In many cases
METOCLOPRAMIDE (an antiemetic), followed ten minutes later by three tablets of e
ither aspirin or
paracetamol, is effective if taken early in an attack. In milder attacks, aspiri
n, with or without codeine
Milk Teeth The temporary teeth of children. (For the time of their appea
rance, see under TEETH.)
Millilitre Millilitre is the 1,000th part of 1 litre. It is practically
the equivalent of a cubic
centimetre (1 cm3 = 0999973 ml); ml is the usual abbreviation.
Mind (1) The seat of consciousness of the human BRAIN. The mind understa
nds, reasons and initiates
action and is also the source of emotions. This is a simplistic definition for a
concept that has been and
continues to be the subject of vigorous debate among theologians, philosophers,
biologists, psychologists,
psychiatrists and other doctors, their arguments being too complex for inclusion
in a dictionarys
definition. (2) MIND: The National Association for Mental Health, a voluntary ch
aritable body that works in
the interests of those with MENTAL ILLNESS, advising, educating and campaigning
for and supporting them.
Mineralcorticoid See CORTICOSTEROIDS.
Minim A pre-metric unit of measurement of volume. It is about one-60th par
t of a fluid drachm and is
used in pharmacy.
Minimum Lethal Dose (MLD) See MLD.
Minimally Invasive Surgery (MIS) More popularly called keyhole surgery, MI
S is surgical intervention,
whether diagnostic or curative, that causes patients the least possible physical
trauma. It has
revolutionised surgery, growing from a technique used by gynaecologists, urologi
sts and innovative general
surgeons to one regularly used in general surgery, GYNAECOLOGY, UROLOGY, thoraci
c surgery, orthopaedic
surgery (see ORTHOPAEDICS) and OTORHINOLARYNGOLOGY.
MIS is commonly carried out by means of an operating laparoscope (a type
of ENDOSCOPE) that is slipped
through a small incision in the skin. MIS now accounts for around 50 per cent
M
464 Minocycline
Removal of stones from gall-bladder using the technique of minimally inv
asive surgery.
of all operations carried out in the UK. A small
M attachment on the end of the laparoscope provides an image that can be magnified on a screen, leaving the surgeons ha
nds free to operate while his
assistant operates the laparoscope. Halogen bulbs, fibreoptic cables and rod len
ses have all contributed to
the technical advancement of laparoscopes. Operations done in this manner includ
e extracorporeal shock-wave
LITHOTRIPSY for stones in the gall-bladder, biliary ducts and urinary system; re
moval of the gall-bladder;
appendicectomy; removal of the spleen and adrenal glands; and thoracic sympathec
tomy. MIS is also used to
remove cartilage or loose pieces of bone in the kneejoint. This method of surger
y usually means that
patients can be treated on a day or overnight basis, allowing them to resume nor
mal activities more quickly
than with conventional surgery. It is safer and lessens the trauma and shock for
patients needing surgery.
MIS is also more cost effective, allowing hospitals to treat more patients in a
year. Surgeons undertake
special training in the use of MIS, a highly skilled technique, before they are
permitted to use the
procedures on patients. The use of MIS for hernia repair, colon surgery and repa
irs of duodenal
perforations is under evaluation and its advantages will be enhanced by the deve
lopment of robotic surgical
techniques.
Minocycline One of the tetracycline broad-spectrum antibiotic drugs (see
TETRACYCLINES). Minocycline
has a broader spectrum than the others and is effective against Neisseria mening
itidis, which causes
bacterial MENINGITIS. It should not be prescribed for patients with kidney disea
se.
Minoxidil A vasodilator drug taken orally to treat people with serious H
YPERTENSION. Minoxidil is also
used as a lotion to treat male-pattern baldness (in both sexes). The drug can ca
use fluid retention, weight
gain and excessive growth of the hair.
Miosis Condition of constriction (reduction in size) of the pupil (see E
YE). It may be the result of
disease affecting the AUTONOMIC NERVOUS SYSTEM. Bright light causes miosis and s
ome drugs for example,
PILOCARPINE or OPIUM have the same effect.
Miscarriage See ABORTION.
Misoprostol A PROSTAGLANDIN analogue used to treat duodenal and gastric
ulcers, and those induced by
NON-STEROIDAL ANTI-INFLAMMATORY DRUGS
Low potential for abuse: generally compound preparations containing small amount
s of opioids: kaolin and
morphine (antidiarrhoeal medicine), codeine linctus (cough suppressant). (See al
so CONTROLLED DRUGS.)
Mites A mite is an arthropod belonging to a group of insects called ACAR
INA. It may be parasitic or
free-living. Most mites are less than 1 mm long and medically significant ones i
nclude those that cause
DERMATITIS (dermatophagoides) and the harvest mite, which transmits scrub typhus
(see under TYPHUS FEVER).
Mitochondria The rod-like bodies in the CELLS of the body which contain
the enzymes (see ENZYME)
necessary for the activity of the cell. They have been described as the power pla
nt of the cell
Mitosis The process of cell division for somatic cells and for the ovum
after fertilisation. Each
chromosome becomes doubled by splitting lengthwise and forming two chromatids wh
ich remain held together by
the centromere. These chromatids are exact copies of the original chromosomes an
d contain duplicates of all
the genes they bear. When cell division takes place, the pull of the spindle spl
its the centromere and each
double chromatid separates, one passing to one pole of the nucleus and the other
to the opposite pole. The
nucleus and the cell itself then also divide, forming two new daughter cells con
taining precisely the same
23 pairs of chromosomes and carrying exactly the same complement of genes as did
the mother cell. (See
FERTILISATION; GENES; CHROMOSOMES; HEREDITY.)
Mitral Incompetence A defect in the MITRAL VALVE of the HEART which allo
ws blood to leak from the left
VENTRICLE into the left ATRIUM. It is also known as mitral regurgitation; incomp
etence may occur along with
MITRAL STENOSIS. The left ventricle has to work harder to compensate for the fau
lty valve, so it enlarges,
but eventually the ventricle cannot cope with the extra load and left-sided hear
t failure may develop. A
common cause of
M
Monocyte
Molecular Biology The study of molecules (see MOLECULE) that are part of
the structure of living
organisms.
Molecule The smallest possible amount of a substance comprising two or m
ore linked atoms which retains
the chemical characteristics of that substance. Molecules vary greatly in their
size and complexity,
ranging from oxygen (two linked oxygen atoms) and water (two hydrogen atoms and
one oxygen) to large
complex molecules such as deoxyribonucleic acid (DNA) comprising thousands of at
oms of carbon, hydrogen,
oxygen, nitrogen and phosphorus that form the double-helix structure which helps
to form GENES, the basic
building blocks of the hereditary material of living things.
Molluscum Contagiosum Common papular eruption of the skin caused by a vi
rus. Most common in children,
it is highly contagious and often transmitted in swimming pools and sauna baths.
Mollusca are often
multiple and persistent in children with atopic eczema (see DERMATITIS), and epi
demics may occur in
boarding schools. The typical molluscum is 23 mm in diameter, skincoloured and tr
anslucent, with a dimpled
centre. The armpits and adjacent chest, upper inner thighs and genital areas are
common sites in young
children. In adults the infection is usually transmitted sexually and affects th
e pubic area and lower
belly. Mollusca eventually disappear spontaneously, but cure can be expedited by
curettage (removal with a
CURETTE) under surface anaesthesia.
Mongolian Blue Spots Irregularly shaped areas of bluish-black pigmentati
on found occasionally on the
buttocks, lower back or upper arms in newborn infants of African, Chinese and Ja
panese parentage, and
sometimes in the babies of black-haired Europeans. They measure from one to seve
ral centimetres in
diameter, and usually disappear in a few months. They are commonly mistaken for
bruises.
Mongolism See DOWNS (DOWN) SYNDROME.
Moniliasis The infection caused by monilia, the genus of fungi now known
as Candida albicans (see
CANDIDA). The infection may occur in the mouth where it is known as thrush lungs
, intestine, vagina,
skin, or nails.
467
Monoamine Oxidase Inhibitors (MAOIs) These are drugs that destroy, or pr
event the action of, monoamine
oxidase (MAO). Monoamines, which include NORADRENALINE and tyramine, play an imp
ortant part in the
metabolism of the BRAIN, and there is some evidence that excitement is due to an
accumulation of monoamines
in the brain. MAO is a naturally occurring ENZYME which is concerned in the brea
468 Monomania
kidney-shaped nucleus. Present in the tissues and lymphatic system as we
ll as in the circulation, it
ingests foreign particles such as tissue debris and bacteria. Monocytes are abou
t 20 m in diameter and 1
mm3 of blood contains around 7,500 of them, many times fewer than the five milli
on erythrocytes (red blood
cells).
Monomania
M
EPSTEIN BARR MONONUCLEOSIS.
VIRUS,
which
causes
Monozygotic Twins Twins who develop from a single OVUM fertilised by a s
ingle SPERMATOZOON. Also known
as identical or uniovular twins (see MULTIPLE BIRTHS).
Monomania is a form of MENTAL ILLNESS, in which the affected person has
delusion (see DELUSIONS) upon
one subject, although he or she can converse rationally and is a responsible ind
ividual upon other matters.
Morbid Anatomy
Mononucleosis
Morbidity
An acute viral infection in which the patient developes a sore throat, s
wollen lymph glands and fever.
Also known as glandular fever, infectious mononucleosis is caused by members of
the herpes group of viruses
the EPSTEIN BARR VIRUS and CYTOMEGALOVIRUS (CMV). The disease is more common amo
ng adolescents aged
1517, an age when their immune defence mechanisms are not fully developed. In the
UK many thousands of
teenagers catch the disease every year, and kissing is believed to be the method
of transmission among many
of them. The blood contains many atypical lymphocytes (see LYMPHOCYTE) and the d
iagnosis is confirmed with
the heterophil antibodies test. Patients normally recover within six weeks witho
ut treatment, but they may
feel tired and depressed for several months afterwards. Some cases of MYALGIC EN
CEPHALOMYELITIS (ME) and
other chronic fatigue syndromes occur after infection with this virus.
The condition of being diseased. The morbidity rate is the number of cas
es of disease occurring within
a particular number of the population.
Monoplegia PARALYSIS
Treatment
Innumerable preventives and remedies have been proposed. Cinnarizine 30
mg orally is useful 2 hours
before travel, then 15 mg every 8 hours during the journey if necessary. Dimenhy
drinate and promethazine
are also commonly taken for motion sickness.
Motor A term usually applied to nerves, used to describe anything that r
esults in movement. Motor
nerves stimulate muscles to contract, producing movement. (See also SENSORY.)
Motor Neurone Disease (MND) A group of disorders of unknown origin. Cert
ain cells in the neurological
systems MOTOR nerves degenerate and die. Upper and lower motor neurones may be af
fected but sensory cells
retain their normal functions. Three types of MND are identified: amyotrophic la
teral sclerosis (AML 50
per cent of patients); progressive muscular atrophy (25 per cent), in which the
prognosis is better than
for AML; and bulbar palsy (25 per cent). Men are affected more than women, and t
he disorder affects about
seven people in every 100,000. Those affected develop progressive weakness and w
asting of their muscles.
The diagnosis is confirmed with various tests including the measurement of elect
rical activity in muscles,
electromyography, muscle BIOPSY, blood tests and X-ray examination of the spine.
There is no medical
treatment: patients need physical and psychological support with aids to help th
em overcome disabilities.
The Motor Neurone Disease
M
Mucus
tooth-forming tissue remnants. Oral cancers represent about 5 per cent o
f all reported malignancies,
and in England and Wales around 3,300 people are diagnosed annually as having ca
ncer of the mouth and
PHARYNX. Cancer of the mouth is less common below the age of 40 years and is mor
e common in men. It is
often associated with chronic irritation from a broken tooth or ill-fitting dent
ure. It is also more common
in those who smoke and those who chew betel leaves. Leukoplakia (see above) may
be a precursor of cancer.
Spread of the cancer is by way of the lymph nodes in the neck. Early treatment b
y surgery, radiotherapy or
chemotherapy will often be effective, except for the posterior of the tongue whe
re the prognosis is very
poor. Although surgery may be extensive and potentially mutilating, recent advan
ces in repairing defects
and grafting tissues from elsewhere have made treatment more acceptable to the p
atient.
471
therefore form wherever there is mucous membrane.
Mucocutaneous Lymph Node Syndrome See KAWASAKI DISEASE.
Mucolytic The term used to describe the property of destroying, or lesse
ning the tenacity of, MUCUS. It
is most commonly used to describe drugs which have this property and are therefo
re used in the treatment of
BRONCHITIS. The inhalation of steam, for example, has a mucolytic action.
Mucopolysaccaridhosis
See APPENDIX 1: BASIC FIRST AID.
A collection of familial metabolic disorders, the best known of which is
Hurlers syndrome (see Others
include Hunters, GARGOYLISM). Maroteaux-Lamy and Scheies syndromes. The disorders,
which result from a
faulty geneproducing abnormality in a specific ENZYME, affect one child in 10,00
0. Those affected usually
die before reaching adulthood.
MRI
Mucosa
MRI, or magnetic resonance imaging, is a noninvasive method of imaging t
he body and its organs. It may
also be used to study tissue metabolism. The body is placed in a magnetic field
which causes certain atomic
nuclei to align in the direction of the field. Pulses of radio-frequency radiati
on are then applied;
interpretation of the frequencies absorbed and re-emitted allows an image in any
body plane to be built up.
Different tissues for example, fat and water can be separately identified and, i
f the resonance signal
for the fat is suppressed, then only the signal from any abnormalities in the fa
birth to twins is ten times more likely to have another multiple pregnancy than
one who has not previously
had twins. The statistical chance of a third pair of twins is 1:512,000. Identic
al twins do not run in
families. The relative proportion of twins of each type varies in different race
s. Identical twins have
much the same frequency all over the world: around 3 per 1,000 maternities. Frat
ernal twins are rare in
Mongolian races: less than 3 per 1,000 maternities. In Caucasians they occur two
or three times as often as
identical twins: between 7 (Spain and Portugal) and 10 (Czech and Slovak Republi
cs and Greece) per 1,000
maternities. They are more common in AfroCaribbeans, reaching 30 per 1,000 mater
nities in certain West
African populations. Rarely, uniovular twins may not develop as separate individ
uals, being physically
joined in some way. They are called conjoined or (traditionally) Siamese twins.
Depending on the extent of
common structures shared by the infants this ranges from a common umbilical cord
to twins with conjoined
heads or a common liver the infants may be successfully separated by surgery. (S
ee CONJOINED TWINS.)
Parents of twins, triplets, etc. can obtain advice and help from the Twins and M
ultiple Births Association
(TAMBA).
Multiple Personality Disorder The individual with this psychiatric disor
der has two or more different
personalities, often contrasting. The dominant personality at the time determine
s the behaviour and
attitude of the individual, who customarily seems not to know about the other pe
rsonality or
personalities. The switch from one personality to another is abrupt and the ment
al condition of the
differing personalities is usually normal. It is possible that child abuse is a
factor in the disorder,
which is treated by psychotherapy. The classic multiple personality was the fict
ional form of Dr Jekyll and
Mr Hyde.
Multiple Sclerosis (MS) Multiple sclerosis is a progressive disease of t
he
Mumps
and SPINAL CORD, which, although slow in its onset, in time may produce
marked symptoms such as
PARALYSIS and tremors (see TREMOR), and may ultimately result in a severely disa
bled invalid. The disorder
consists of hardened patches, from the size of a pin-head to that of a pea or la
rger, scattered here and
there irregularly through the brain and spinal cord. Each patch is made up of a
mass of the CONNECTIVE
TISSUE (neuroglia), which should be present only in sufficient amount to bind th
e nerve-cells and fibres
together. In the earliest stage, the insulating sheaths (MYELIN) of the nerve-fi
bres in the hardened
patches break up, are absorbed, and leave the nerve-fibres bare, the connective
tissue being later formed
between these. BRAIN
Cause Although this is one of the most common diseases of the central ne
rvous system in Europe there
are around 50,000 affected individuals in Britain alone the cause is still not k
nown. The disease comes
on in young people (onset being rare after the age of 40), apparently without pr
evious illness. The ratio
of women-to-men victims is 3:2. It is more common in first and second children t
han in those later in birth
order, and in small rather than big families. There may be a hereditary factor f
or MS, which could be an
autoimmune disorder: the bodys defence system attacks the myelin in the central n
ervous system as if it
were a foreign tissue.
Symptoms These depend greatly upon the part of the brain and cord affect
ed by the sclerotic patches.
Temporary paralysis of a limb, or of an eye muscle, causing double vision, and t
remors upon exertion, first
in the affected parts, and later in all parts of the body, are early symptoms. S
tiffness of the lower limbs
causing the toes to catch on small irregularities in the ground and trip the per
son in walking, is often an
annoying symptom and one of the first to be noticed. Great activity is shown in
the reflex movements
obtained by striking the tendons and by stroking the soles of the feet. The latt
er reflex shows a
characteristic sign (Babinski sign) in which the great toe bends upwards and the
other toes spread apart as
the sole is stroked, instead of the toes collectively bending downwards as in th
e normal person. Tremor of
the eye movements (nystagmus) is usually found. Trembling handwriting, interfere
nce with the functions of
the bladder, giddiness, and a peculiar staccato or scanning speech are common sympto
ms at a later
stage. Numbness and tingling in the extremities occur commonly,
473
particularly in the early stages of the disease. As the disease progress
es, the paralyses, which were
transitory at first, now become confirmed, often with great rigidity in the limb
s. In many patients the
disease progresses very slowly. People with multiple sclerosis, and their relati
ves, can obtain help and
guidance from the Multiple Sclerosis Society. Another helpful organisation is th
e Multiple Sclerosis
Resources Centre. Those with sexual or marital problems arising out of the illne
ss can obtain information
from SPOD (Association to Aid the Sexual and Personal Relationships of People wi
th a Disability). (See
APPENDIX 2: ADDRESSES: SOURCES OF INFORMATION, ADVICE, SUPPORT AND SELFHELP.)
Treatment is difficult, because the most that can be done is to lead a l
ife as free from strain as
possible, to check the progress of the disease. The use of INTERFERON beta seems
to slow the progress of MS
and this drug is licensed for use in the UK for patients with relapsing, remitti
ng MS over two years,
provided they can walk unaided a controversial restriction on this (expensive) t
reatment. CORTICOSTEROIDS
may be of help to some patients. The NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE
(NICE) ruled in 2001 that
the use of the drugs interferon beta and glatiramer acetate for patients with mu
ltiple sclerosis was not
cost-effective but recommended that the Department of Health, the National Assem
bly for Wales and the drug
manufacturers should consider ways of making the drugs available in a cost-effec
tive way. Subsequently the
government said that it would consider funding a risk-sharing scheme in which supp
ly of drugs to patients
would be funded only if treatment trials in individuals with MS showed that they
were effective. The
Department of Health has asked NICE to assess two CANNABIS derivatives as possib
le treatments for multiple
sclerosis and the relief of post-operative pain. Trials of an under-thetongue sp
ray and a tablet could, if
successsful, lead to the two drugs being available around 2005. It is important
to keep the nerves and
muscles functioning, and therefore the patient should remain at work as long as
he or she is capable of
doing it, and in any case should exercise regularly.
Mumps Mumps, also known as epidemic parotitis, is an infectious disease
characterised by inflammatory
swelling of the PAROTID GLAND and other
M
474 Munchausens Syndrome SALIVARY GLANDS often occurring as an EPIDEMIC and affec
ting mostly young
people. Its
name comes from the old verb, mump, meaning to mope or assume a disconsola
te appearance an apt
description of the victim of the disease at its height.
Causes Mumps is due to infection with a virus and is highly infectious f
rom person to person. It is
predominantly a disease of childhood and early adult life, but it can occur at a
ny age. Epidemics usually
occur in the winter and spring. It is infectious for two or three days before th
e swelling of the glands
appears. A vaccine is now available that gives a high degree of protection again
st the disease, the
incidence of which is falling sharply. The vaccine is combined with those for ME
ASLES and RUBELLA see MMR
VACCINE; IMMUNISATION.
M
Symptoms There is an incubation period of 23 weeks after infection before
the glands begin to swell.
The gland first affected is generally the parotid, situated in front of and belo
w the ear. The swelling
usually spreads to the submaxillary and sublingual glands lying beneath the jaw.
The patient is feverish
and the gland is tender. The swelling disappears after about five days. In 1530 p
er cent of males,
inflammation of the testicles (orchitis) develops. This usually occurs during th
e second week of the
illness, but may not occur until 23 weeks later; it may result in partial ATROPHY
of the testicles, but
practically never in INFERTILITY. In a much smaller proportion of females with m
umps, inflammation of the
OVARIES or BREASTS may occur. Inflammation of the PANCREAS, accompanied by tende
rness in the upper part of
the abdomen and digestive disturbances, sometimes results, and MENINGITIS is als
o an occasional
complication. The various complications are found much more often when the disea
se affects adults than when
it occurs in childhood. Treatment There is no specific treatment but
pitals with symptoms and signs (often simulated) suggestive of serious p
hysical illness. More common
among men than women, it differs from MALINGERING in that no obvious reward resu
lts from the imagined or
simulated symptoms. Patients may simulate signs and symptoms in a bizarre way fo
r instance, by swallowing
blood or inserting needles into the chest. Abdominal symptoms are particularly c
ommon. They often have a
history of multiple hospital admissions and operations, and show extensive patho
logical lying and lack of
personal rapport. Although the cause is unclear, it is thought to be a form of h
ysterical behaviour in a
severely disordered personality. Patients are often masochistic, attention-seeki
ng, and constantly trying
to obtain ANALGESICS. Occasionally there may be a degree of treatable DEPRESSION
, but on the whole
management is very difficult as patients often abscond from psychiatric treatmen
t. A variation of the
syndrome Munchausens syndrome by proxy, better termed fabricated and induced illne
ss has been
identified, in which the persons affected inflict damage upon others, usually ch
ildren (or even animals) in
their care. Factitious illness refers to simulating symptoms, such as stating th
at the child has blood in
its urine when it is actually the parents blood. Induced illness includes such ev
ents as injecting dirty
water into a babys muscles, dropping mild caustic into their eyes, adding salt to
a babys milk or
diluting it 5050 with water, and so on. Much debate has ensued about the suggesti
on that some sudden
infant deaths are due to smothering rather than natural causes, as a type of ind
uced illness. As a
consequence of two successful appeals against conviction for murder in 2004, the
UK attorney general
ordered a review of all criminal and family court cases in which disputed medica
l evidence had formed the
basis of the decision. Paediatricians are concerned that one result is likely to
be an increase in
undetected child abuse.
and plenty of fluid should be available. The child may need to be in bed
for a few days and should not
return to school until the symptoms have settled. Adults with orchitis may need
strong painkillers, and
CORTICOSTEROIDS may be required to reduce the painful swelling.
Murmur
Munchausens Syndrome
Muscarine
Munchausens syndrome, also known as hospital addiction syndrome, is a disor
der in which the patient
presents repeatedly to hosThe poisonous principle found in some toadstools (see FUNGUS POISONING).
It is a cholinergic substance
with pharmacological properties
ANALGESICS
The uneven, rustling sound heard by AUSCULTATION over the HEART and vari
ous blood vessels in abnormal
conditons. For example, murmurs heard when the stethoscope is applied over the h
eart are highly
characteristic of valvular disease of this organ.
Muscle
resembling those of ACETYLCHOLINE, a chemical neurotransmitter released
at the junctions (synapses) of
parasympathetic nerves and at the junctions where nerves enter muscles.
Muscle Muscular tissue is divided, according to its function, into three
main groups: voluntary muscle,
involuntary muscle, and skeletal muscle of which the first is under control of t
he will, whilst the
latter two discharge their functions independently. The term striped muscle is oft
en given to voluntary
muscle, because under the microscope all the voluntary muscles show a striped ap
pearance, whilst
involuntary muscle is, in the main, unstriped or plain. Heart muscle is partiall
y striped, while certain
muscles of the throat, and two small muscles inside the ear, not controllable by
willpower, are also
striped.
Structure of muscle Skeletal or voluntary muscle forms the bulk of the b
odys musculature and contains
more than 600 such muscles. They are classified according to their methods of ac
tion. A flexor muscle
closes a joint, an extensor opens it; an abductor moves a body part outwards, an
adductor moves it in; a
depressor lowers a body part and an elevator raises it; while a constrictor (sph
incter) muscle surrounds an
orifice, closing and opening it. Each muscle is enclosed in a sheath of fibrous
tissue, known as fascia or
epimysium, and, from this, partitions of fibrous tissue, known as perimysium, ru
n into the substance of the
muscle, dividing it up into small bundles. Each of these bundles consists in tur
n of a collection of
fibres, which form the units of the muscle. Each fibre is about 50 micrometres i
n thickness and ranges in
length from a few millimetres to 300 millimetres. If the fibre is cut across and
examined under a
high-powered microscope, it is seen to be further divided into fibrils. Each fib
re is enclosed in an
elastic sheath of its own, which allows it to lengthen and shorten, and is known
as the sarcolemma. Within
the sarcolemma lie numerous nuclei belonging to the muscle fibre, which was orig
inally developed from a
simple cell. To the sarcolemma, at either end, is attached a minute bundle of co
nnective-tissue fibres
which unites the muscle fibre to its neighbours, or to one of the connective-tis
sue partitions in the
muscle, and by means of these connections the fibre affects muscle contraction.
Between the muscle fibres,
and enveloped in a sheath of connective tissue, lie here and there special struc
tures known as
musclespindles. Each of these contains thin muscle
475
fibres, numerous nuclei, and the endings of sensory nerves. (See TOUCH.)
The heart muscle comprises
short fibres which communicate with their neighbours via short branches and have
no sarcolemma. Plain or
unstriped muscle is found in the following positions: the inner and middle coats
of the STOMACH and
INTESTINE; the ureters (see URETER) and URINARY BLADDER; the TRACHEA and bronchi
al tubes; the ducts of
glands; the GALL-BLADDER; the UTERUS and FALLOPIAN TUBES; the middle coat of the
blood and lymph vessels;
the iris and ciliary muscle of the EYE; the dartos muscle of the SCROTUM; and in
association with the
various glands and hairs in the SKIN. The fibres are very much smaller than thos
e of striped muscle,
although they vary greatly in size. Each has one or more oval nuclei and a delic
ate sheath of sarcolemma
enveloping it. The fibres are grouped in bundles, much as are the striped fibres
, but they adhere to one
another by cement material, not by the tendon bundles found in voluntary muscle.
Development of muscle All the muscles of the developing individual arise
from the central layer
(mesoderm) of the EMBRYO, each fibre taking origin from a single cell. Later on
in life, muscles have the
power both of increasing in size as the result of use, for example, in athletes
and also of healing,
after parts of them have been destroyed by injury. An example of the great exten
t to which unstriped muscle
can develop to meet the demands made on it is the uterus, whose muscular wall de
velops so much during
pregnancy that the organ increases from the weight of 3040 g (11 oz.) to a weight o
f around 1 kg (2
lb.), decreasing again to its former small size in the course of a month after c
hildbirth.
Physiology of contraction A muscle is an elaborate chemico-physical syst
em for producing heat and
mechanical work. The total energy liberated by a contracting muscle can be exact
ly measured. From 2530 per
cent of the total energy expended is used in mechanical work. The heat of contra
cting muscle makes an
important contribution to the maintenance of the heat of the body. (See also MYO
GLOBIN.) The energy of
muscular contraction is derived from a complicated series of chemical reactions.
Complex substances are
broken down and built up again, supplying each other with energy for this purpos
e. The first reaction is
the breakdown of adenyl-pyrophosphate into
M
dystrophy, affects particularly the upper part of the lower limbs of children. T
he muscles of the buttocks,
thighs and calves seem excessively well developed, but nevertheless the child is
clumsy, weak on his legs,
and has difficulty in picking himself up when he falls. In another form of the d
isease, which begins a
little later, as a rule at about the age of 14, the muscles of the upper arm are
first affected, and those
of the spine and lower limbs become weak later on. In a third type, which begins
at about this age, the
muscles of the face, along with certain of the shoulder and upper arm muscles, s
how the first signs of
wasting. All the forms have this in common: that the affected muscles grow weake
r until their power to
contract is quite lost. In the first form, the patients seldom reach the age of
20, falling victims to some
disease which, to ordinary people, would not be serious. In the other forms the
wasting, after progressing
to a certain extent, often remains stationary for the rest of life. Myopathy may
also be acquired when it
is the result of disease such as thyrotoxicosis (see under THYROID GLAND, DISEAS
ES OF), osteomalacia (see
under BONE, DISORDERS OF) and CUSHINGS DISEASE, and the myopathy resolves when th
e primary disease is
treated.
Treatment Some myopathies may be the result of inflammation or arise fro
m an endocrine or metabolic
abnormality. Treatment of these is the treatment of the cause, with supportive p
hysiotherapy and any
necessary physical aids while the patient is recovering. Treatment for the hered
itary myopathies is
supportive since, at present, there is no cure although developments in gene res
earch raise the
possibility of future treatment. Physiotherapy, physical aids, counselling and s
upport groups may all be
helpful in caring for these patients. The education and management of these chil
dren raise many
difficulties. Much help in dealing with these problems can be obtained from Musc
ular Dystrophy Campaign.
Myositis ossificans, or deposition of bone in muscles, may be congenital
or acquired. The congenital
form, which is rare, first manifests itself as painful swellings in the muscles.
These gradually harden and
extend until the child is
M
CELLS. A mutagen does not usually increase the range of mutations. Chemicals, io
nising radiation, and
viruses may act as mutagens.
Mutation A change occurring in the genetic material (DNA) in the CHROMOS
OMES of a cell. It is caused by
a fault in the replication of a cells genetic material when it divides to form tw
o daughter cells.
Mutations may occur in somatic cells which may result in a local growth of the n
ew type of cells. These may
be destroyed by the bodys defence mechanism or they may develop into a tumour. If
mutation occurs in a
germ cell or gamete the organisms sex cells the outcome may be a changed inherite
d characteristic in
succeeding generations. Mutations occur rarely, but a small steady number are ca
used by background
radiation in the environment. They are also caused by mutagens (see MUTAGEN). (S
ee also GENETIC DISORDERS.)
Mutism See under VOICE AND SPEECH.
Myalgia Pain in a muscle. (See MUSCLES, DISORDERS OF; BORNHOLM DISEASE;
LUMBAGO.)
Myalgic Encephalomyelitis (ME) A syndrome in which various combinations
of extreme fatiguability,
muscle pain, lack of concentration, panic attacks, memory loss and depression oc
cur. Its existence and
causes have been the subject of controversy reflected in the variety of names gi
ven to the syndrome:
CHRONIC FATIGUE SYNDROME (CFS), post-viral fatigue syndrome, Royal Free disease,
epidemic neuromyasthenia
and Icelandic disease. ME often follows virus infections of the upper respirator
y tract or gut, but it is
not clear whether this is an association or cause-andeffect. It may occur in epi
demics or as individual
cases. Physical examination shows no evidence of diagnosable disease and there i
s no diagnostic test
diagnosis usually being made by excluding other possible disorders. The suf-
Mycosis 479
ferer usually recovers in time, although sometimes recovery may take man
y months or even years. The
most severely affected may be bedridden and may need tube-feeding. There is no s
pecific curative treatment,
but symptomatic treatment such as resting in the early stages may help. Some exp
erts believe that the
illness has a psychological element, and sufferers have been treated with COGNIT
IVE BEHAVIOUR THERAPY. In
1998 the Chief Medical Officer set up a multidisciplinary working group, includi
ng patients, to consider
possible cures and treatments for ME/CFS. The report (2002) concluded that the d
isorder should be
recognised as chronic and treatable, but there was no clear agreement on cause(s
) and treatment(s).
Meanwhile research continues, including a programme by the Centre of Disease Con
trol in Atlanta, USA.
Sufferers may find it helpful to consult the ME Association.
Myasthenia Gravis A serious disorder in which the chief symptoms are mus
cular weakness and a special
tendency for fatigue to come on rapidly when efforts are made. The prevalence is
around 1 in 30,000.
Two-thirds of the patients are women, in whom it develops in early adult life. I
n men it tends to develop
later in life. It is a classical example of an autoimmune disease (see AUTOIMMUN
ITY). The body develops
ANTIBODIES which interfere with the working of the nerve endings in muscle that
are acted on by
ACETYLCHOLINE. It is acetylcholine that transmits the nerve impulses to muscles:
if this transmission
cannot be effected, as in myasthenia gravis, then the muscles are unable to cont
ract. Not only the
voluntary muscles, but those connected with the acts of swallowing, breathing, a
nd the like, become
progressively weaker. Rest and avoidance of undue exertion are necessary, and re
gular doses of neostigmine
bromide, or pyridostigmine, at intervals enable the muscles to be used and in so
me cases have a curative
effect. These drugs act by inhibiting the action of cholinesterase an ENZYME pro
duced in the body which
destroys any excess of acetylcholine. In this way they increase the amount of av
ailable acetylcholine which
compensates for the deleterious effect of antibodies on the nerve endings. The T
HYMUS GLAND plays the major
part in the cause of myasthenia gravis, possibly by being the source of the orig
inal acetylcholine
receptors to which the antibodies are being formed. Thymectomy (removal of the t
hymus) is often used in the
management of patients with myasthenia gravis. The incidence of remission following thymectomy increases with the number of years after the o
peration. Complete remission or
substantial improvement can be expected in 80 per cent of patients. The other im
portant aspect in the
management of patients with myasthenia gravis is IMMUNOSUPPRESSION. Drugs are no
w available that suppress
antibody production and so reduce the concentration of antibodies to the acetylc
holine receptor. The
problem is that they not only suppress abnormal antibody production, but also su
ppress normal antibody
production. The main groups of immunosuppressive drugs used in myasthenia gravis
are the CORTICOSTEROIDS
and AZATHIOPRINE. Improvement following steroids may take several weeks and an i
nitial deterioration is
often found during the first week or ten days of treatment. Azathioprine is also
effective in producing
clinical improvement and reducing the antibodies to acetylcholine receptors. The
se effects occur more
slowly than with steroids, and the mean time for an azathioprine remission is ni
ne months. The Myasthenia
Gravis Association, which provides advice and help to sufferers, was created and
is supported by
myasthenics, their families and friends.
Mycobacterium A gram-positive (see GRAMS STAIN) rod-like genus of aerobic
BACTERIA, some species of
which are harmful to humans and animals. For example, M. tuberculosis (Kochs baci
llus) and M. leprae
cause, respectively, TUBERCULOSIS and LEPROSY.
Mycoplasma A genus of micro-organisms which differ from bacteria in that
they lack a rigid cell wall.
They are responsible for widespread epidemics in cattle and poultry. For a long
time the only member of the
genus known to cause disease in humans was Mycoplasma pneumoniae which is respon
sible for the form of
PNEUMONIA known as primary atypical pneumonia particularly common in children, f
or whom it is the single
most common cause of the diseaase when contracted out of hospital. Another, Myco
plasma genitalium, has now
been isolated which is responsible for certain cases of non-gonococcal urethriti
s. Mycoplasma infections
respond to TETRACYCLINES.
Mycosis The general term applied to diseases due to the growth of fungi
in the body. Among some of the
simplest and commonest mycoses are
M
480 Mycosis Fungoides RINGWORM, FAVUS, and thrush (CANDIDA). The MADURA FOOT of
India, ACTINOMYCOSIS,
and occasional cases of PNEUMONIA and suppurative ear disease are also due to the growth of moulds in the bodily
tissues. Other forms of mycosis
include ASPERGILLOSIS, candidiasis CANDIDA), CRYPTOCOCCOSIS and (see HISTOPLASMO
SIS.
Mycosis Fungoides An old term for a chronic eruption of the skin charact
erised by erythematous (see
ERYTHEMA) itching plaques (raised patches on the skin resulting from the merging
or enlargement of papules
see PAPULE), which, if left untreated, eventually form tumours and ulcers. The d
isease is now known to be
a form of cancer of lymphocytes (see LYMPHOCYTE) called T-cell LYMPHOMA. It may
be responsive to
PHOTOCHEMOTHERAPY in its early stages and to RADIOTHERAPY when more advanced.
Mydriasis
M
Dilation or widening of the pupil of the EYE. Occurring naturally when i
t is dark, or when someone is
emotionally aroused, mydriasis can also result from the administration of ATROPI
NE eye drops. Alcohol
consumption also has a mydriatic effect.
Myectomy Removal of all or part of a muscle by surgery. It may be used t
o correct a SQUINT (caused by
unbalanced eye muscles) or to remove a FIBROID from the muscular wall of the UTE
RUS.
Myelin A substance made up of protein and phospholipid that forms the sh
eath surrounding the axons of
some neurons (see NEURON(E)). These are described as myelinated or medullated ne
rve fibres, and electric
impulses pass along them faster than along non-myelinated nerves. Myelin is prod
uced by Schwann cells which
occur at intervals along the nerve fibre. (See MULTIPLE SCLEROSIS (MS).)
Myelitis Myelitis is inflammation of the SPINAL CORD.
Myeloblast Present in the blood-producing tissue in the BONE MARROW, thi
s is a cell with a large
nucleus and scanty cytoplasm. It is the precursor cell of a granulocyte (see GRA
NULOCYTES). Myeloblasts
sometimes appear in the blood of patients with various diseases including acute
myeloblastic LEUKAEMIA.
Myelocyte The name given to one of the cells of BONE MARROW from which t
he granular white cells of the
blood are produced. They are found in the blood in certain forms of LEUKAEMIA.
Myelography The injection of a radio-opaque substance into the central c
anal of the SPINAL CORD in
order to assist in the diagnosis of diseases of the spinal cord or spine using X
-ray examination. Because
of the high risk of causing damage to the spinal cord (arachnoiditis), it has be
en largely superceded by
MRI.
Myrrh 481
Myelosuppression A fall in the production of blood cells in the BONE MAR
ROW. This fall often occurs
after CHEMOTHERAPY for cancer. ANAEMIA, infection and abnormal bleeding are symp
tomatic of
myelosuppression.
Myiasis Infestation of the SKIN, deeper tissues or the INTESTINE by larv
ae of the tropical tumbu fly.
Myocardial Infarction See HEART, DISEASES OF
Coronary thrombosis.
Myocarditis Inflammation of the muscular wall of the HEART.
Myocardium Myocardium is the muscular substance of the HEART. (See also
MUSCLE.)
Myoclonus A brief, twitching muscular contraction which may involve only
a single muscle or many
muscles (see MUSCLE). It may be too slight to cause movement of the affected lim
b, or so violent as to
throw the victim to the floor. The cause is not known, but in some cases may be
a form of EPILEPSY. A
single myoclonic jerk in the upper limbs occasionally occurs in minor motor epil
epsy (petit mal). The
myoclonic jerks which many people experience on falling asleep are a perfectly n
ormal phenomenon.
Myoglobin The protein which gives MUSCLE its red colour. It has the prop
erty of combining loosely and
reversibly with OXYGEN; this means that it is the vehicle whereby muscle extract
s oxygen from the
HAEMOGLOBIN in the blood circulating through it, and then releases the oxygen fo
r use in muscle METABOLISM.
Myoglobinuria The occurrence of MYOGLOBIN in the URINE. This is the oxyg
en-binding pigment in muscle
and mild myoglobinuria may occur during exercise. Severe myoglobinuria will resu
lt from serious injuries,
particularly crushing injuries, to muscles.
Myoma The term applied to a TUMOUR, almost invariably of a simple nature
, which consists mainly
of muscle fibres (see MUSCLE Structure of muscle). These muscle tumours
often occur in the UTERUS.
Myomectomy Removal by surgery of fibroids (see FIBROID) from the muscula
r wall of the UTERUS.
Myometrium The muscular coat of the UTERUS.
Myopathy See under MUSCLES, DISORDERS OF.
Myopia Sort-sightedness (see under EYE, DISORDERS OF Errors of refractio
n).
482 Myxoedema
Myxoedema See under THYROID GLAND, DISEASES OF
Hypothyroidism.
Myxoma A benign TUMOUR comprising gelatinous CONNECTIVE TISSUE, most com
monly occurring beneath the
SKIN although the condition may develop in the ABDOMEN, URINARY BLADDER,
M
BONE and, rarely, the HEART. Treatment involves surgery, which is usuall
y successful.
Myxoviruses These include the INFLUENZA viruses A, B and C; and the PARA
INFLUENZA VIRUSES, types 1 to
3. Myxoviruses, which are one of a group of RNA-containing viruses, have an affi
nity for protein receptors
in red blood cells.
NAI
N
See NON-ACCIDENTAL INJURY (NAI).
Nail See SKIN.
Nail-Biting Nabilone
A CANNABIS-related drug given by mouth and licensed for use in treating
severe nausea and vomiting,
particularly when they result from treatment with anticancer drugs.
Naevus A congenitally determined tissue abnormality. In the SKIN, naevi
of blood vessels are best
known, but a MOLE is a MELANOCYTE naevus, and warty streaked and linear naevi of
the epidermis occasionally
occur. There are several patterns of vascular naevi:
Naevus simplex Also known as salmon patch. About one-third of white childr
en are born with macular
pink areas of ERYTHEMA on the nape, brow or eyelids which usually disappear afte
r a few months, but patches
on the nape may persist.
Naevus flammeus Also known as portwine stain and present at birth. It is u
nilateral, usually on the
face, and may be extensive. It tends to darken with age and is permanent. Laser
treatment is effective.
Strawberry naevus (cavernous haemangioma) is usually not present at birt
h but appears within a few
weeks and grows rapidly, reaching a peak in size after 612 months, when the lobul
ated red nodule may
resemble a ripe strawberry. Untreated, the naevus disappears spontaneously over
several years. It may occur
anywhere and may be very troublesome when occurring around an eye or on the nappy
area. If possible it
should be left alone, but where it is causing problems other than simply cosmeti
c ones it is best treated
by an expert. This may involve medical treatment with steroids or interferon or
laser therapy.
Spider naevus is due to a dilated
ARTERIcausing a minute red papule in the skin, the small branching vessels res
embling spider legs. A few
spider naevi are common in young people, but multiple naevi are common in pregna
ncy and may also be a
warning sign of chronic liver disease. OLE
A common practice in schoolchildren, most of whom gradually give it up a
s they approach adolescence.
Too much significance should therefore not be attached to it; in itself it does
no harm, and punishment or
restraining devices are not needed. It is a manifestation of tension or insecuri
ty, the cause of which
484 Naloxone
overdosage with these drugs but has now been superseded by NALOXONE.
Naloxone An effective drug in the treatment of opioid poisoning. It bloc
ks the effects of most opiates;
given intravenously, it acts within 23 minutes. The drug is also given to newborn
babies whose breathing
has been depressed by narcotic drugs given to their mothers to relieve pain duri
ng childbirth.
Naltrexone A drug that is an ANTAGONIST to narcotic substances (see NARC
OTICS). Given orally, it is
used in the maintenance treatment of HEROIN and other opiate-dependent people.
Nandrolone
N
One of the ANABOLIC STEROIDS, with the property of building PROTEIN. It
is of little value in medical
care, although is licensed for use in aplastic ANAEMIA; it has also been used in
the past to treat
osteoporosis in women (see under BONE, DISORDERS OF), but is no longer recommend
ed for this purpose. Its
use as a bodybuilder by some athletes and others has caused controversy: those f
ound using it are barred
from most recognised athletic events. Nandrolone should never be taken by pregna
nt women or by people with
liver disease or prostate cancer. Sideeffects include ACNE; VIRILISATION with hi
gh doses including voice
changes, cessation of periods, and inhibition of sperm production; and liver tum
ours after prolonged use.
Nanometre A nanometre is a millionth of a millimetre. The approved abbre
viation is nm. (See APPENDIX 6:
MEASUREMENTS IN MEDICINE.)
Nappy Rash A common form of irritant contact DERMATITIS in the nappy are
a in babies under one year old.
Wetting of the skin by urine, abrasion, and chemical changes due to faecal conta
mination all play a part.
Good hygiene and use of disposable absorbent nappies have much reduced its incid
ence. An ointment
containing a barrier, such as titanium dioxide, may help; other medications such
as mild CORTICOSTEROIDS or
antibiotics should be used very cautiously and only under the guidance of a doct
or, as harmful effects may
result especially from overuse.
Naproxen See under NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS).
Narcissism An abnormal mental state characterised by excessive admiratio
n of ones self. In Greek
mythology, Narcissus so loved staring at his own reflection in water that he eve
ntually fell in and
drowned.
Narcolepsy A condition in which uncontrollable episodes of sleep occur t
wo or three times a day. It
starts at any age and persists for life. The attacks, which usually last for 1015
minutes, come on
suddenly at times normally conducive to sleep, such as after a meal, or sitting
in a bus, but they may
occur when walking in the street. In due course, usually after some years, they
are associated with
cataplectic attacks (see CATAPLEXY), when for a few seconds there is sudden musc
ular weakness affecting the
whole body. The cataplectic attacks can be controlled by the TRICYCLIC ANTIDEPRE
SSANT DRUGS, imipramine or
clomipramine. Familial narcolepsy is well recognised, and recently a near-100-pe
r-cent association between
narcolepsy and the histocompatability antigen HLA-DR2 (see HLA SYSTEM) has been
discovered, which suggests
that narcolepsy is an immunorelated disease. The Narcolepsy Association (UK) has
been founded to help
patients with this strange disorder.
Narcosis A condition of stupor (see under UNCONSCIOUSNESS), resembling s
leep, that is usually caused by
a drug. It may also occur as a result of liver or kidney failure which causes UR
AEMIA. The affected person
has significantly reduced awareness and is hard to arouse. Treatment is of the u
nderlying cause and the
normal precautions for caring for an unconscious or semiconscious subject should
be taken. (See APPENDIX 1:
BASIC FIRST AID.).
Narcotics Substances that induce stupor and eventually UNCONSCIOUSNESS.
Used in the relief of severe
pain, people can become first tolerant of them so requiring larger doses and the
n dependent (see also
ANALGESICS; HYPNOTICS; TOLERANCE; DEPENDENCE).
Nasal Congestion The nose and nasal sinuses (see SINUS) produce up to a
litre of MUCUS in 24 hours,
most of which enters the stomach via the NASOPHARYNX. Changes in the nasal linin
g mucosa occur in response
to changes in humidity and atmospheric temperature; these may cause severe
MORTEM EXAMINATION.
Necrosis Death of a limited portion of tissue, the term being most commo
nly applied to bones when, as
the result of disease or injury, a fragment dies and separates. (See BONE, DISEA
SES OF.)
Necrotising Fasciitis Also known as CELLULITIS. A potentially lethal inf
ection caused by the
gram-positive (see GRAMS STAIN) bacterium Streptococcus pyogenes which has the pr
operty of producing
dangerous exotoxins. The infection, which starts in the layer of FASCIA under th
e SKIN, may spread very
rapidly, destroying tissue as it spreads. Urgent antibiotic treatment may check
the infection, and surgery
is sometimes required, but even with treatment patients may die (see STREPTOCOCC
US).
Needle-Stick Injury
The term applied to a slight opacity on the cornea (see EYE) producing a
haze in the field of vision,
and also to any oily preparation to be sprayed from a nebuliser an apparatus for
splitting up a fluid
into fine droplets.
Accidental perforation of the skin by an injection needle, commonly of t
he hand or finger and usually
by a nurse or doctor administering a therapeutic injection. The term also refers
to accidental injuries
from injection needles discarded by drug abusers. Dangerous infections such as v
iral HEPATITIS or HIV may
be acquired from needle-stick injuries, and there are strict procedures about th
e disposal of used syringes
and needles in medical settings.
Nebulisers
Needling
A nebuliser makes an aerosol (see under INHALANTS) by blowing air or oxy
gen through a solution of a
drug. Many inhaled drugs such as SALBUTAMOL, ipratropium and beclomethasone
An operation performed in the treatment of cataracts (see under EYE, DIS
ORDERS OF), in which the
anterior lens capsule of the EYE is torn open with a needle, allowing the aqueou
s
Myopia. See under EYE, DISORDERS OF Errors of refraction.
Nebula
Neonatology 487
fluid to dissolve the opaque soft lens matter, which is gradually washed
away into the bloodstream.
This extra-capsular extraction may need to be repeated several times before all th
e opaque lens matter
disperses. Although a relatively simple procedure, it is unsuitable for patients
over the age of 35 (when
the nucleus of the lens becomes increasingly hard), and CRYOSURGERY and LASER th
erapy have become the
preferred methods of treatment. Needling is also used for certain minor dermatol
ogical procedures, such as
removal of small facial cysts and scabies mites.
Nefopam Hydrochloride A non-opioid analgesic drug (see ANALGESICS) of us
e in the relief of pain that
fails to respond to other non-opioid analgesics. It causes little depression of
respiration but
side-effects may be a problem.
Negativism Negativism means a morbid tendency in a person to do the oppo
site of what he or she is
desired or directed to do. It is especially characteristic of those suffering fr
om SCHIZOPHRENIA, but is
not uncommon in non-psychotic persons.
for the treatment of certain forms of ENTERITIS due to E. coli.
Neonatal Pertaining to the first month of life.
Neonatal Intensive Care The provision of a dedicated unit with special f
acilities, including one-to-one
nursing and appropriate technology, for caring for premature and seriously ill n
ewborn babies.
Paediatricians and neonatologists are involved in the running of such units. Not
every maternity unit can
provide intensive care: for example, the provision of artificial ventilation, ot
her than as a holding
procedure until a baby can be transferred to a better-equipped and better-servic
ed unit. Such hospitals
tend to have special-care baby units, which are capable of looking after the nee
ds of most, but not all,
premature or ill babies.
Neonatal Mortality
A roundworm. (See ASCARIASIS.)
Neonatal mortality is the mortality of infants under one month of age. I
n England and Wales this has
fallen markedly in recent decades: from more than 28 per 1,000 live births in 19
39 to 3.6 in 2002. This
improvement can be attributed to various factors: better antenatal supervision o
f expectant mothers; care
to ensure that expectant mothers receive adequate nourishing food; improvements
in the management of the
complications of pregnancy and of labour; and more skilled resuscitation at birt
h for those who need it.
Nearly three-quarters of neonatal deaths occur during the first week of life. Fo
r this reason, increasing
emphasis is being laid on this initial period of life. In Britain, in the last f
our decades of the 20th
century, the number of deaths in the first week of life fell dramatically from 1
3.2 to just over 2.7 per
1,000 live births. The chief causes of deaths in this period are extreme prematu
rity (less than 28 weeks
gestation), birth asphyxia with oxygen lack to the brain, and congenital abnorma
lities. After the first
week the commonest cause is infection.
Neomycin
Neonatology
Neomycin is one of the AMINOGLYCOSIDES, derived from Streptomyces fradia
e. It has a wide antibacterial
spectrum, being effective against the majority of gram-negative (see GRAMS STAIN)
bacilli. Its use is
limited by the fact that it is liable to cause deafness and kidney damage. Its m
ain use is for application
to the skin either in solution or as an ointment for the treatment of infection;
it is also given by
mouth
The branch of PAEDIATRICS responsible for the medical care of newborn ba
bies. Problems may be short
term for example, those linked to prematurity or life-long such as CEREBRAL PALS
Y. After the first few
weeks of life, paediatricians take over the responsibility for any specialist me
dical care required, with
general practitioners looking after the infants primarycare needs.
Negligence See MEDICAL NEGLIGENCE.
Neisseriaceae A family of bacteria of which three varieties cause diseas
e. Neisseria meningitidis
causes meningococcal MENINGITIS and SEPTICAEMIA. It is divided into three groups
: A, B and C; group B
accounts for most meningitis cases in the UK, mostly affecting children. Neisser
ia gonorrhoeae causes
GONORRHOEA. The bacteria are gram-negative (see GRAMS STAIN) cocci usually occurr
ing in pairs. A third
variety is Moraxella catarrhalis: this occurs in the nose and throat and sometim
es causes ear infection and
low-grade infection of the respiratory tract.
Nematode
N
488 Neoplasm
Neoplasm TUMOUR.
(e.g. urea, drugs, etc.). The tubules eventually empty the filtrate, whi
ch by now is urine, into the
renal pelvis from where it flows down the ureters into the bladder. (See KIDNEYS
.)
Neostigmine
Nephropathy
This means literally a new formation and is another word for a benign or n
on-malignant
An ANTICHOLINESTERASE drug which enhances neuromuscular transmission the
passage of chemical messages
between nerve and muscle cells in voluntary and involuntary muscles in patients
with the disorder
MYASTHENIA GRAVIS. Its effect lasts for about four hours. A disadvantage is that
it has a marked
cholinergic action affecting heart rhythm, causing excessive salivation and tear
secretion, constricting
the BRONCHIOLES and stimulating the gastrointestinal tract.
Nephrectomy The operation for removal of the kidney. (See KIDNEYS, DISEA
SES OF.)
Nephritis Inflammation of the kidneys. (See KIDNEYS, DISEASES OF Glomeru
lonephritis.)
Nephroblastoma N
Nephroblastoma, or Wilms tumour, is the commonest kidney tumour in infanc
y (see also KIDNEYS, DISEASES
OF Tumours of the kidney). It is a malignant tumour, which occurs in around 1 pe
r 10,000 live births. The
survival rate with modern treatment (removal of the kidney followed by radiother
apy and chemotherapy) is
now around 80 per cent.
Nephrolithiasis A condition in which the kidney.
CALCULI
are present in
Nephrology The branch of medicine concerned with the study and managemen
t of kidney disease. A
specialist in these diseases is called a nephrologist.
Nephron Each kidney comprises over a million of these microscopic units
which regulate and control the
formation of URINE. A tuft of capillaries invaginates the Bowmans capsule, which
is the blind-ending tube
(GLOMERULUS) of each nephron. Plasma is filtered out of blood and through the Bo
wmans capsule into the
renal tubule. As the filtrate passes along the tubule, most of the water and ele
ctrolytes are reabsorbed.
deformities result and the joints become fixed. This is particularly noticeable
when the ulnar nerve is
injured, the hand and fingers taking up a clawlike position. The skin may also b
e affected.
Treatment Damaged or severed (peripheral) nerve fibres should be sewn to
gether, using microsurgery.
Careful realignment of the nerve endings gives the fibres an excellent chance of
regenerating along the
right channels. Full recovery is rare but, with regular physiotherapy to keep pa
ralysed muscles in good
shape and to prevent their shortening, the patient can expect to obtain a reason
able return of function
after a few weeks, with improvement continuing over several months.
Nervous Breakdown A non-medical description of a variety of emotional cr
ises ranging from an outburst
of hysterical behaviour to a major neurotic illness that may have a lasting effe
ct on an individuals life.
Sometimes the term is used to describe an overt psychotic illness for example, S
CHIZOPHRENIA (see also
MENTAL ILLNESS; NEUROSIS).
Nervous Impulse This is transmitted chemically, by the formation at nerv
e-endings of chemical
substances. When, for example, a NERVE to a muscle is stimulated, there appears
at the NEUROMUSCULAR
JUNCTION the chemical substance, ACETYLCHOLINE. Acetylcholine also appears at en
dings of the
parasympathetic nerves (see NERVOUS SYSTEM) and transmits the effect of the para
sympathetic impulse. When
an impulse passes down a sympathetic nerve, the effect of it is transmitted at t
he nerve-ending by the
chemical liberated there: ADRENALINE or an adrenaline-like substance.
Nervous System This extensive, complex and finely tuned network of billi
ons of specialised cells called
neurones (see NEURON(E)) is responsible for maintaining the bodys contacts with a
nd responses to the
outside world. The network also provides internal communication links in concert
with HORMONES, the
bodys chemical messengers between the bodys diverse organs and tissues, and, impor
tantly, the BRAIN
stores
N
Neuroleptics
pain may be helped by the analgesic carbamazepine or by destroying (free
zing, local alcohol injection
or surgery) the affected nerve.
491
SKULL.
In polyneuritis, usually due to some general or constitutional cause, th
e nerve-fibres themselves in
the small nerves degenerate and break down. The condition is protracted because,
for recovery to occur, the
growth of new nervefibres from the healthy part of the nerve has to take place.
The cause of polyneuritis
may be infection by a virus for example, HERPES ZOSTER or a bacterium, as in LEP
ROSY. Neuritis may also
be the result of agents such as alcohol, lead or products from industrial or agr
icultural activities.
ORGANOPHOSPHORUS insecticides are believed by some to be a factor in neuritis an
d other neurological
conditions.
Neurasthenia
Neuroblastoma
An out-of-date term that was used to describe an ill-defined state of ne
rvous exhaustion in which,
although the patient suffers from no definite disease, he or she becomes incapab
le of sustained exertion.
The condition which it represented is now believed to be a form of NEUROSIS or p
sychosomatic disease. It
was also used in the past to describe what is now called
A malignant growth comprising embryonic nerve cells. It may start in any
part of the AUTONOMIC NERVOUS
SYSTEM. The medulla of the adrenal gland (see under ENDOCRINE GLANDS) is a commo
n site; secondary growths
develop in other tissues. Neuroblastomas are the most common extracranial solid
tumour of childhood. The
incidence is around eight cases per one million children. Treatment is by surger
y followed by radiotherapy
and CYTOTOXIC drugs. About 30 per cent of sufferers survive for at least five ye
ars after treatment.
Neural Tube The structure in the EMBRYO from which the BRAIN and SPINAL
CORD develop.
Neural Tube Defects Congenital abnormalities resulting from the failure
of the NEURAL TUBE to form
normally. The resulting conditions include SPINA BIFIDA, MENINGOCELE and defects
in the bones of the
CHRONIC FATIGUE SYNDROME (CFS).
Neurectomy An operation in which part of a NERVE is excised: for example
, for the relief of NEURALGIA.
492 Neurology
Troublesome side-effects may require control by ANTICHOLINERGIC drugs. T
he main antipsychotic drugs
are: (i) chlorpromazine, methotrimeprazine and promazine, characterised by prono
unced sedative effects and
a moderate anticholinergic and extrapyramidal effect; (ii) pericyazine, pipothia
zine and thioridazine,
which have moderate sedative effects and marked anticholinergic effects, but les
s extrapyramidal effects
than the other groups; (iii) fluphenazine, perphenazine, prochlorperazine, sulpi
ride and trifluoperazine,
which have fewer sedative effects and fewer anticholinergic effects, but more pr
onounced extrapyramidal
effects.
Neurology
N
The branch of medical practice and science which is concerned with the s
tudy of the NERVOUS SYSTEM and
its disorders. Specialists in neurology neurologists examine a patients nerves, s
ensory and motor
functions and reflexes. They use modern imaging techniques for example, CT scann
ing (see COMPUTED
TOMOGRAPHY) and MRI to aid diagnosis. Until relatively recently, many neurologic
al conditions could be
treated only with palliative methods. Now there is much improved understanding o
f the nervous system and
its disorders, with closer liaison between psychiatrists (see PSYCHIATRY) and ne
urologists.
Neuroma Neuroma means a TUMOUR connected with a NERVE such tumours being
generally composed of
fibrous tissue, and of a painful nature.
Neuromuscular Blockade In clinical practice, the transmission of impulse
s at the NEUROMUSCULAR JUNCTION
may be blocked to paralyse temporarily a patient for a surgical procedure, or to
assist treatment on the
intensive care unit. There are two main types of drug, both of which competitive
ly block the ACETYLCHOLINE
receptors on the motor end plates. (1) Depolarising neuromuscular blocking agent
s: these act by first
producing stimulation at the receptor, and then by blocking it. There are charac
teristic muscle
fasciculations before the rapid onset of paralysis which is of short duration (l
ess than five minutes with
the commonly used drug, suxamethonium). The drug is removed from the receptor by
the enzyme,
CHOLINESTERASE. (2) Non-depolarising neuromuscular blocking agents: these drugs
occupy the receptor and
prevent acetylcholine from becoming attached to it. However, in sufficiently hig
h concentrations, acetylcholine will compete with the drug and dislodge it from the
receptor; the effect of these
drugs is reversed by giving an anticholinesterase, which allows the amount of ac
etylcholine at the
neuromuscular junction to build up. These drugs have varying durations of action
, but all are slower in
onset and of longer duration than the depolarisers.
Neuromuscular Junction The area where a motor NERVE ends close to the MU
SCLE membrane so can initiate
muscle contraction. The motor-nerve ending is separated from the motor end plate
by the synaptic cleft
which is only 5070 nm wide. When a nerve impulse arrives at the motor-nerve endin
g, molecules of
ACETYLCHOLINE are released which cross the synaptic cleft and attach to receptor
s on the motor end plate.
This initiates depolarisation of the muscle which in turn initiates the process
of contraction.
Acetylcholinesterase (an ENZYME) rapidly breaks down the molecules of acetylchol
ine, thus ending their
action and freeing the receptor in preparation for the next impulse.
Neuron(e) Also known as a nerve cell, this is the basic cellular buildin
g-block of the NERVOUS SYSTEM,
which contains billions of neurones linked in a complex network and acting in di
fferent combinations to
keep the body informed about the outside world, and then to organise and activat
e appropriate responses.
There are three main types of neurone:
Sensory These carry signals to the central nervous system (CNS) the BRAI
N and SPINAL CORD from
sensory receptors. These receptors respond to different stimuli such as touch, p
ain, temperature, smells,
sounds and light.
Motor These carry signals from the CNS to activate muscles or glands.
Interneurons These provide the interconnecting electrical network within t
he CNS.
Structure Each neurone comprises a cell body, several branches called de
ndrites, and a single
filamentous fibre called an AXON. Axons may be anything from a few millimetres t
o a metre long; at their
end are several branches acting as terminals through which electrochemical signa
ls are sent to target
cells, such as those of muscles, glands or the dendrites of another axon. Axons
of several neurones are
grouped
Neuron(e)
493
together to form nerve tracts within the brain or spinal cord or nerve-f
ibres outside the CNS. Each
nerve is surrounded by a sheath and contains bundles of fibres. Some fibres are
medullated, having a sheath
of MYELIN which acts as insulation, preventing nerve impulses from spreading bey
ond the fibre conveying
them. The cellular part of the neurones makes up the grey matter of the brain an
d 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 system composed of
nerve fibres.
Functions of nerves The greater part of
Diagram of neurone.
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 mu
scles 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 sensatio
n. An impulse travels at a
rate of about 30 metres (100 feet) per second. (See NERVOUS IMPULSE.) The anteri
or roots of spinal nerves
consist of motor fibres leading to muscles, the posterior roots of sensory fibre
s coming from the skin. The
terms, EFFERENT and AFFERENT, are applied to these roots, because, in addition t
o motor fibres, fibres
controlling blood vessels and secretory glands leave the cord in the anterior ro
ots. 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 wi
th his or her
Diagram showing nervous connections between the central nervous system a
nd muscle and skin.
N
NHS Direct
and some viral infections. Genetic and toxic neuropathies are also seen.
Neurosis A general term applied to mental or emotional disturbance in wh
ich, as opposed to PSYCHOSIS,
there is no serious disturbance in the perception or understanding of external r
eality. However, the
boundaries between neurosis and psychosis are not always clearly defined. Neuros
es are usually classified
into anxiety neuroses, depressive neuroses, phobias (see PHOBIA), HYPOCHONDRIASI
S, HYSTERIA and obsessional
neuroses.
Anxiety neurosis, or anxiety state, constitutes the most common form of
neurosis; fortunately it is
also among the most responsive to treatment. Once the neurosis develops, suffere
rs are in a state of
persistent anxiety and worry, tensed up, always fatigued and unable to sleep at ni
ght. In addition, there
are often physical complaints for example, palpitations, sweating, apparent disc
omfort on swallowing
(globus), and headache.
Obsessional neuroses are much less common and constitute only about 5 pe
r cent of all neuroses. Like
other neuroses, they usually develop in early adult life. (See MENTAL ILLNESS.)
Neurosurgery Surgery performed on some part of the NERwhether brain, spi
nal cord or nerves. Disorders
treated by neurosurgeons include damage to the brain, spinal cord and nerves as
a result of injury; tumours
in the CENTRAL NERVOUS SYSTEM; abnormalities of blood vessels in or supplying bl
ood to the brain for
example, ANEURYSM; brain abscess; bleeding inside the skull; and certain birth d
efects such as
HYDROCEPHALUS and SPINA BIFIDA. VOUS SYSTEM,
Neurotransmitter A chemical substance which transmits the action of a NE
RVE to a cell (see CELLS). It
is released from nerve-endings and transmits the impulse across synapses (see SY
NAPSE) to other nerves. In
the central nervous system the substances acting as neurotransmitters include AC
ETYLCHOLINE, NORADRENALINE,
DOPAMINE and SEROTONIN. The main transmitter in the peripheral system is acetylc
holine, while for the
sympathetic system it is noradrenaline. In recent years a new group of neurotran
smitters called
neuropeptides has been identified, comprising large protein molecules. One of th
e best-known is that of
endorphins, which the brain uses to control pain. (See also NEURON(E); NERVOUS S
YSTEM; PAIN.)
Neutron A neutron is one of the particles that enter into the structure
of the atomic nucleus. (See
ISOTOPE.)
Neutropenia A reduction in the number of neutrophil LEUCOCYTES per cubic
millimetre of circulating
blood to a figure below that found in health. There is still some disagreement o
her tissues.
Nifedipine A
member of the CALCIUM-CHANNEL group of cardiovascular drugs. It relaxes
vascular smooth muscle and
dilates coronary and peripheral arteries. Nifedipine has been used to prevent an
d treat ANGINA PECTORIS and
certain types of HYPERTENSION. BLOCKERS
Night Blindness See under BLINDNESS.
Night Sweats Copious PERSPIRATION occurring in bed at night and found in
conditions such as
TUBERCULOSIS, BRUCELLOSIS and lymphomas (see LYMPHOMA), as well as thyrotoxicosi
s (see under THYROID GLAND,
DISEASES OF), anxiety states and menopausal flushes (see MENOPAUSE).
Nipple The small, sensitive prominence at the tip of each breast (see BR
EASTS) containing (in women)
the small openings through which milk can pass from the milk glands in the breas
t tissue. The nipple and
its surrounding area (the areola) are darker than the adjacent skin. The area be
comes darker during
pregnancy.
Nipples, Diseases of See BREASTS, DISEASES OF.
Nitrates Chemical compounds that have a valuable role in the treatment o
f ANGINA PECTORIS. They are
very effective in dilating the ARTERIES supplying the HEART; their prime benefit
, however, is to reduce the
return of venous blood to the heart (via the superior and inferior venae cavae),
thus reducing the demands
on the left ventricle, which pumps deoxygenated blood to the lungs. Undesirable
side-effects such as
flushing, headache and postural HYPOTENSION may restrict the use of nitrates. Am
ong the nitrate drugs
Nocturnal Enuresis
497
used is GLYCERYL TRINITRATE which, taken under the tongue (sublingually)
, provides quick, symptomatic
relief of angina, lasting for up to half an hour. Alternative administration can
be via a spray product.
Isorbide dinitrate taken sublingually is a more stable preparation, suitable for
patients who need nitrates
infrequently. The drugs effect may last for 12 hours in modified-release form. Pa
tients taking long-acting
nitrates or preparations absorbed through the skin (transdermal) may develop
ANALGESICS; PAIN)
TOLERANCE.
Excess passing of URINE during the night. Among its many causes are glom
erulonephritis (see under
KIDNEY, DISEASES OF) and enlargement of the PROSTATE GLAND.
Nitrazepam A tranquilliser introduced as a hypnotic. It is long-acting a
nd may produce drowsiness next
day. Addiction can occur. (See TRANQUILLISERS; HYPNOTICS; BENZODIAZEPINES.)
Nitric Oxide (NO) A naturally occurring chemical that performs a wide ra
nge of biological roles. It is
involved in the laying down of memories in the BRAIN; in killing viruses, bacter
ia and cancer cells; and in
helping to control blood pressure. NO, comprising a nitrogen atom attached to an
oxygen one, is one of the
smallest of biologically active compounds as well as having such diverse functio
ns. The chemical is a
muscle relaxant and is important in maintaining the heart and circulation in goo
d condition. NO is also the
toxic agent released by macrophages (see MACROPHAGE) to kill invading germs and
spreading cancer cells. It
acts as an essential NEUROTRANSMITTER and protects nerve cells against stress. R
esearchers are studying how
it might be used to treat diseases, for example by using it as an inhaled gas in
certain respiratory
conditions.
Nitrofurantoin A synthetic nitrofuran derivative which has a wide range
of antibacterial activity and
is effective against many gram-positive and gramnegative (see GRAMS STAIN) microorganisms. It is used
mainly in the treatment of infections of the lower URINARY TRACT.
Nitrogen Mustards The nitrogen analogues of mustard gas are among the mo
st important ALKYLATING AGENTS
used in the treatment of various forms of malignant disease. They include chlorm
ethine, busulphan,
chlorambucil and melphalan.
Nitrous Oxide Gas Also known as laughing gas, this is (at ordinary press
ures) a colourless,
sweetish-smelling gas. It is used with oxygen to provide relief of pain (see
498 Node
Node The term node is widely used in medicine. For instance, the smaller
lymphatic glands are often
termed LYMPH NODES. It is also applied to a collection of nerve cells forming a
subsidiary nerve centre
found in various places in the sympathetic nervous system (see NERVOUS SYSTEM),
such as the sinuatrial node
and the atrioventricular node which control the beating of the HEART.
Noise See DEAFNESS; OCCUPATIONAL DISEASES.
Noma Another name for CANCRUM ORIS.
Nomifensine See ANTIDEPRESSANT DRUGS.
Non-Accidental Injury (NAI)
N
(See also CHILD ABUSE). Though NAI has traditionally been seen as abuse
against children and they are
still the main victims such injuries can also be inflicted on vulnerable adults.
Adults with learning
difficulties, dementias or physical disabilities sufficiently serious as to requ
ire institutional care (or
who make heavy demands on relatives) are sometimes the victims of NAI. Health pr
ofessionals, social workers
and relatives should bear this possibility in mind when discovering unusual, sev
ere or repeated bruising or
fractures in vulnerable adults, even in circumstances where NAI may seem unlikel
y. (See also MUNCHAUSENS
SYNDROME; PAEDOPHILIA.)
Non-Conventional Medicine An umbrella term to describe alternative, comp
lementary, folk and other types
of healing practices that are outside the definition of conventional western-typ
e medical practice. (See
COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM).)
Non-Hodgkins Lymphoma See LYMPHOMA.
Non-Proprietary Name See GENERIC DRUG; APPROVED NAMES FOR MEDICINES.
Non-Specific Urethritis (NSU) An inflammatory condition of the URETHRA d
ue to a cause or causes other
than GONORRHOEA. The most common is CHLAMYDIA trachomatis there has been a rise
of over 75 per cent in
the incidence in the UK over the past
five years to around 70,000 a year. It produces pelvic inflammatory dise
ase in women, which often
results in sterility, the risk of ECTOPIC PREGNANCY, and recurrent pelvic pain.
Most cases respond well to
TETRACYCLINES. Abstinence from sexual intercourse should be observed during trea
tment and until cure is
complete. Children born to infected mothers may have their eyes infected during
birth, producing the
condition known as ophthalmia neonatorum. This is treated by the application to
the eye of
chlortetracycline eye ointment. The lungs of such a child may also be infected,
resulting in pneumonia.
Non-Steroidal AntiInflammatory Drugs (NSAIDs) These act by inhibiting th
e formation of PROSTAGLANDINS
which are mediators of INFLAMMATION. They act both as ANALGESICS to relieve pain
, and as inhibitors of
inflammation. Aspirin is a classic example of such a compound. Newer compounds h
ave been synthesised with
the aim of producing fewer and less severe side-effects. They are sometimes pref
erred to aspirin for the
treatment of conditions such as RHEUMATOID ARTHRITIS, OSTEOARTHRITIS, sprains, s
trains and sports injuries.
Their main side-effects are gastrointestinal: gastric ulcers and gastric haemorr
hage may result (see
STOMACH, DISEASES OF). This is because prostaglandins are necessary for the prod
uction of the mucous
protective coat in the stomach and, when the production of prostaglandin is inhi
bited, the protection of
the stomach is compromised. NSAIDs should therefore be used with caution in pati
ents with DYSPEPSIA and
gastric ulceration. The various nonsteroidal anti-inflammatory drugs differ litt
le from each other in
efficacy, although there is considerable variation in patient response. Ibuprofe
n is one of the first
choices in this group of drugs as it combines good efficacy with a low incidence
of side-effects and
administration is only required twice daily. Other drugs in this series include
diclofenac, fenbufen,
fenclofenac, fenoprofen, feprazone, flurbiprofen, indomethacin, indoprofen, keto
profen, ketorolac,
naproxen, piroxicam, sulindac, tiaprofenic acid and tolmetin.
Noradrenaline A precursor of ADRENALINE in the medulla of the suprarenal
glands (see ADRENAL GLANDS).
It is also present in the BRAIN. Its main function is to mediate the transmissio
n of impulses in the
SYMPATHETIC NERVOUS SYSTEM; it also has a transmitter function in the brain.
Nose, Disorders of
Norepinephrine See NORADRENALINE.
Norethisterone A synthetic preparation that has the action of PROGESTERO
NE, but is active when given by
mouth.
Norm The expected value for something measurable. Most people have measu
rements lying to either side of
the norm. Traditionally in medicine, only those lying beyond two standard deviat
ions from the norm are
considered likely to be abnormal (approximately 3 per cent of those measured). (
See STANDARD DEVIATION.)
Normal A term used in several different senses. Generally speaking, it i
s applied to anything which
agrees with the regular and established type. In chemistry, the term is applied
to solutions of acids or
bases of such strength that each litre contains the number of grams correspondin
g to the molecular weight
of the substance in question. In physiology the term normal is applied to solution
s of such strength
that, when mixed with a body fluid, they are ISOTONIC and cause no disturbance:
for example, normal saline
solution.
Normoblast The precursor of an erythrocyte (see ERYTHROCYTES; BLOOD) whi
ch still contains the remnant
of a NUCLEUS.
Normotensive Having a BLOOD PRESSURE within the NORMAL range for an indi
viduals age and sex.
Nortriptyline One of the sedative.
ANTIDEPRESSANT DRUGS;
499
bone (sphenoidal sinus); and in the lateral part of the ethmoid bone (et
hmoidal sinus). The sinuses
drain into the interior of the nose, as does the Eustachian or auditory tube fro
m the middle ear (see EAR).
Nose, Disorders of Certain skin diseases particularly CHILBLAIN, ACNE, L
UPUS and ERYSIPELAS tend to
affect the NOSE, and may be very annoying. Redness of the skin may be caused by
poor circulation in cold
weather.
Acute inflammation is generally the result of a viral infection (see COL
D, COMMON) affecting the mucous
membrane and paranasal sinuses (see SINUSITIS); less commonly it results from th
e inhalation of irritant
gases. Boils may develop just inside the entrance to the nose, causing pain; the
se are potentially
troublesome as infection can spread to the sinuses. HAY FEVER is one distressing
form of acute rhinitis.
Nucleic Acid
then try to avoid, although in the case of pollen this is difficult. Dec
ongestant drugs, ANTIHISTAMINE
DRUGS, and CORTICOSTEROIDS may help, as can SODIUM CROMOGLYCATE inhaled regularl
y during the pollen season.
A desensitisation course to a particular allergen sometimes provides long-term r
elief. Atrophic rhinitis is
caused by a deterioration in the nasal mucous membrane as a result of chronic ba
cterial infection, nasal
surgery or AGEING. Symptoms include persistent nasal infection and discharge and
loss of sense of smell.
ANTIBIOTICS and, in some cases, OESTROGENS alleviate the symptoms. Hypertrophic
rhinitis results from
repeated nasal infection, and is characterised by thickened nasal membranes and
congestion of the nasal
veins. Removal of thickened mucosa may help severe cases. Vasomotor rhinitis occ
urs when the mucosa becomes
oversensitive to stimuli such as pollutants, temperature changes or certain food
s or medicines. It may
occur as a result of emotional disturbances and is common in pregnancy. Viral rh
initis occurs as a result
of infection by the common cold virus; treatment is symptomatic. Sinusitis is so
metimes a complication.
Nosology The term applied to scientific classification of diseases.
Nostrils
501
Leptospirosis Malaria Marburg disease Measles Meningitis Meningococcal s
epticaemia (without meningitis)
Mumps Ophthalmia neonatorum Paratyphoid fever Plague Rabies Relapsing fever Rube
lla Scarlet fever Smallpox
Tetanus Tuberculosis Typhoid fever Typhus Viral haemorrhagic fever (including La
ssa fever) Viral hepatitis
Whooping cough Yellow fever Reporting AIDS is voluntary (and in confidence) to t
he Director, Communicable
Diseases Surveillance Centre (PHLS).
NSAIDs See NON-STEROIDAL DRUGS (NSAIDS).
ANTI-INFLAMMATORY
NSU See NON-SPECIFIC URETHRITIS (NSU).
See NOSE.
Nucha
Notifiable Diseases
The Latin name for the back of the neck. (Adjective nuchal.)
nd development. About 60
per cent of RNs work in NHS hospitals and community trusts. But an increasing nu
mber are choosing to work
elsewhere, either in the private sector or in jobs such as school nursing, occup
ational health or for NHS
Direct, the nurse-led telephone helpline. Others have dropped out of nursing alt
ogether. The health service
is facing a shortage of qualified nurses and many trust employers have resorted
to overseas recruitment
drives. The government has launched a major nurse recruitment and retention camp
aign and is promoting
family-friendly employment practices to lure those with a nursing qualification
currently working outside
the NHS back into the workforce. Nursing is a mainly female profession and a thi
rd of nurses work
part-time. Nurses pay has for long compared unfavourably with other professional
employment opportunities,
despite being determined by an independent Pay Review Body. With the recruitment
of nurses a perennial
problem, the governments strategy, Making a Difference, is to set up a new pay sy
stem offering greater
flexibility and opportunities for nurses and other health-service staff. In 2005
, a newly qualified staff
nurse earned around 16,000 a year, while one of the new grade of consultant nurse
s could command an annual
salary of between 27,000 and 42,000. Nurse consultants were introduced in spring 2
000 as a means of
allowing nurses to progress up the career ladder while maintaining a clinical ro
le. The nurse of today is
increasingly likely to be part of a multidisciplinary team, working alongside a
range of other
professionals from doctors and physiotherapists to social workers and teachers.
A further sign of the times
is that many registered nurses are being asked to act in a supervisory role, del
egating tasks to
nonregistered nurses working as health-care assistants and auxiliaries. In recog
nition of the latters
increasing role, the Royal College of Nursing, the main professional association
and trade union for
nurses, has now agreed to extend membership to health-care assistants with a Sco
ttish/National Vocational
Qualification at level three.
Nystatin
Midwifery Midwives (see MIDWIFE) are practitioners who offer advice and
support to women before, during
and after pregnancy. They are regulated by the Council for Nursing and Midwifery
(formerly the UK Central
Council for Nursing, Midwifery and Health Visiting). Registered nurses can take
an 18month course to become
a midwife, and there is also a three-year programme for those who wish to enter
the profession directly.
Midwifery courses lead to a diploma or degree-level qualification. Most midwives
work for the NHS and, as
with nursing, there are problems recruiting and retaining staff.
Health visiting
mmunity with a range of
including families, the
health and offer advice
a range of topics
503
from diet to child behavioural problems. They are employed by health tru
sts, primary-care groups and
primary-care trusts.
Nutrition The process by which the living organism physiologically absor
bs and uses food to ensure
growth, energy production and repair of tissues. The science of nutrition includ
es the study of diets and
deficiency diseases (see DIET).
Nystagmus See under EYE, DISORDERS OF.
Nystatin An antibiotic, isolated from Streptomyces noursei, active again
st Candida albicans (see
CANDIDA). It is not absorbed from the gut but is useful in gastrointestinal and
skin candidosis.
N
O Oat Cell
A type of cell found in one highly malignant form of lung cancer. The ce
ll is small and either oval or
round. The nucleus stains darkly and the cytoplasm is sparse and difficult to id
entify. Oat-cell, or
small-cell, carcinoma of the bronchus is usually caused by smoking, and comprise
s around 30 per cent of all
bronchial cancers. It responds to radiotherapy and chemotherapy but, because the
growth has usually spread
widely by the time it is diagnosed, the prognosis is poor. Results of surgery ar
e unsatisfactory.
Obesity A condition in which the energy stores of the body (mainly fat)
are too large. It is a
prevalent nutritional disorder in prosperous countries increasingly so among chi
ldren and young people.
The Quetelet Index or BODY MASS INDEX, which relates weight in kilograms (W) to
height2 in metres (H2), is
a widely accepted way of classifying obesity in adults according to severity. Fo
r example: Grade of obesity
BMI (W/H2) III II I not obese
output, per person and also when expressed against fat-free mass than do
their lean counterparts.
Most obese people do not appear to have a reduced capacity for thermogenesis. Al
though a genetic component
to obesity remains a possibility, it is unlikely to be great or to prevent weigh
t loss from being possible
in most patients by reducing energy intake. Environmental influences are believe
d to be more important in
explaining the familial association in obesity. An inactive lifestyle plays a mi
nor role in the development
of obesity, but it is unclear whether people are obese because they are inactive
or are inactive because
they are obese. For the majority of obese people, the explanation must lie in an
excessive energy intake.
Unfortunately, it is difficult to demonstrate this directly since the methods us
ed to assess how much
people eat are unreliable. For most obese people it seems likely that the defect
lies in their failure to
regulate energy intake in response to a variety of cognitive factors (e.g. ease
of fitting of clothes) in
the long term. Unfortunately, it can be possible to identify by the time of thei
r first birthday, many of
the children destined to be obese. Rarely, obesity has an endocrine basis and is
caused by hypothyroidism
(see under THYROID GLAND, DISEASES OF), HYPOPITUITARISM, HYPOGONADISM or CUSHINGS
SYNDROME.
Symptoms Obesity has adverse effects on and mortality (see DEATH RATE) w
hich are greatest in young
adults and increase with the severity of obesity. It is associated with an incre
ased mortality and/or
morbidity from cardiovascular disease, non-insulin-dependent diabetes mellitus,
diseases of the
gall-bladder, osteoarthritis, hernia, gout and possibly certain cancers (i.e. co
lon, rectum and prostate in
men, and breast, ovary, endometrium and cervix in women). Menstrual irregulariti
es and ovulatory failure
are often experienced by obese women. Obese people are also at greater risk when
they undergo surgery. With
the exception of gallstone formation, weight loss will reduce these health risks
.
MORBIDITY
>
40
3040 25299 <25
Causes Whatever the causes of obesity, the fact remains that energy inta
ke (in the form of food and
drink) must exceed energy output (in the form of activity and exercise) over a s
ufficiently long period of
time. Obesity tends to aggregate in families. This has led to the suggestion tha
t some people inherit a
thrifty gene which predisposes them to obesity in later life by lowering their ene
rgy output. Indeed,
patients often attribute their obesity to such a metabolic defect. Total energy
output is made up of the
resting metabolic rate (RMR), which represents about 70 per cent of the total; t
he energy cost of physical
activity; and thermogenesis, i.e. the increase in energy output in response to f
ood intake, cold exposure,
some drugs and psychological influences. In general, obese people are consistent
ly found to have a higher
RMR and total energy
Treatment Creation of an energy deficit is essential for weight loss to
occur, so the initial line of
treatment is a slimming diet. An average deficit of 1,000 kcal/day (see CALORIE)
will produce a loss of 1
kg of fat/week and should be aimed for. Theoretically, this can be achieved by i
ncreasing energy
expenditure or reducing energy intake. In practice, a low-energy diet is the usu
al form of treatment since
attempts to
Occiput The lower and hinder part of the head, where it merges into the
neck.
Occlusion The way that the TEETH fit together when the jaws close. Also
the closing or obstruction of a
duct, hollow organ, or blood vessel.
Occult Describing something that is not easily seen. Occult blood in the
faeces is present in very
small amounts and can be identified only by a chemical test or under the microsc
ope.
Occupational Health, Medicine and Diseases Occupational health The effec
t of work on human health, and
the impact of workers health on their work. Although the term encompasses the ide
ntification and treatment
of specific occupational diseases, occupational health is also an applied and mu
ltidisciplinary subject
concerned with the prevention of occupational ill-health caused by chemical, bio
logical, physical and
psychosocial factors, and the promotion of a healthy and productive workforce. O
ccupational health includes
both mental and physical health. It is about compliance with health-and-safety-a
t-work legislation (and
common law duties) and about best practice in providing work environments that r
educe risks to health and
safety to lowest practicable levels. It includes workers fitness to work, as well
as the management of the
work environment to accommodate people with disabilities, and procedures to faci
litate the return to work
of those absent with long-term illness. Occupational health incorporates several
professional groups,
including occupational physicians, occupational health nurses, occupational hygi
enists, ergonomists,
disability managers, workplace counsellors, health-and-safety practitioners, and
workplace
physiotherapists. In the UK, two key statutes provide a
O
for example, cardiovascular disease and cancers where the causes are mul
tifactorial. The toll would,
however, dwarf the number of deaths caused by accidents at work. Around 250 peop
le are killed by accidents
at work in the UK each year mesothelioma, from exposure to asbestos at work, alo
ne kills more than 1,300
d by repeated movement,
excessive force, and awkward postures and these include tenosynovitis (inflammat
ion of a tendon) and
epicondylitis. The greatest controversy surrounds upper-limb disorders that do n
ot present obvious tissue
or nerve damage but nevertheless give significant pain and discomfort to the ind
ividual. These are
sometimes referred to as repetitive strain injury or diffuse RSI. The diagnosis of s
uch conditions is
controversial, making it difficult for sufferers to pursue claims for compensati
on through the courts.
Psychosocial factors, such as high demands of the job, lack of control and poor
social support at work,
have been implicated in the development of many upper-limb disorders, and in pre
vention and management it
is important to deal with the psychological as well as the physical risk factors
. Occupations known to be
at particular risk of work-related upperlimb disorders include poultry processor
s, packers, electronic
assembly workers, data processors, supermarket check-out operators and telephoni
sts. These jobs often
contain a number of the relevant exposures of dynamic load, static load, a full
or excessive range of
movements and awkward postures. (See UPPER LIMB DISORDERS.)
Physical agents A number of physical agents cause occupational ill-healt
h of which the most important
is occupational deafness. Workplace noise exposures in excess of 85 decibels for
a working day are likely
to cause damage to hearing which is initially restricted to the vital frequencie
s associated with speech
around 34 kHz. Protection from such noise is imperative as hearing aids do nothin
g to ameliorate the
neural damage once it has occurred. Hand-arm vibration syndrome is a disorder of
the vascular and/or neural
endings in the hands leading to episodic blanching (white finger) and numbness whi
ch is exacerbated by
low temperature. The condition, which is caused by vibrating tools such as chain
saws and pneumatic
hammers, is akin to RAYNAUDS DISEASE and can be disabling. Decompression sickness
is caused by a rapid
change in ambient pressure and is a disease associated with deep-sea divers, tun
nel workers and high-flying
aviators. Apart from the direct effects of pressure change such as ruptured
O
where the course leading to the diploma of the College of Occupational Therapist
s can be
Ochronosis A rare condition in which the ligaments and cartilages of the
body, and sometimes the
conjunctiva (see EYE), become stained by dark brown or black pigment. This may o
ccur in chronic carbolic
poisoning, or in a congenital disorder of metabolism in which the individual is
unable to break down
completely the tyrosine of the protein molecule the intermediate product, homoge
ntisic acid, appearing in
the urine, this being known as alkaptonuria.
Oedema
Causes Oedema is not a disease, it is a sign usually of underlying local
or systemic disease. It may
sometimes be visible as a swelling. Oedema occurs when the normal mechanisms for
maintaining a balance
between fluid in the tissues and in the blood are upset. That balance depends ma
inly on the blood pressure
that keeps the blood flowing through the circulatory system thus forcing fluid o
ut of the capillaries
and the osmotic drawing force of the blood proteins which pulls water into the b
loodstream. The KIDNEYS
also have an essential role in maintaining this balance. Among the disorders tha
t may disturb this balance
are heart failure, NEPHROTIC SYNDROME, kidney failure, CIRRHOSIS of the liver an
d a diet deficient in
protein. Injury may also cause oedema and ascites (fluid in the abdominal cavity
) can occur as a result of
cirrhosis of the liver or cancer in the abdominal organs. Treatment The underlyi
ng cause of oedema should
be treated and, if this is not feasible or effective, the excess fluid should be
excreted by boosting the
output of the kidney. Restriction of sodium in the diet and the administration o
f DIURETICS are effective
methods of achieving this.
Oedema of the Lungs This occurs as a result of left ventricular failure
(see HEART, DISEASES OF). There
is an abrupt increase in the venous and capillary pressure in the pulmonary vess
els, followed by flooding
of fluid into the interstitial spaces and alveoli. The commonest cause of acute
pulmonary oedema is
myocardial infarction (see HEART, DISEASES
O
Olfactory Nerves
513
Oestradiol is responsible for the development of the female sexual chara
cteristics, of the BREASTS, and
of part of the changes that take place in the UTERUS before MENSTRUATION.
Oestrone
Oestradiol Valerate
This is an executive agency of the UK government formed by an amalgamati
on in 1990 of the Central
Statistical Office and the Office of Population Censuses and Surveys (OPCS). The
ONS compiles and publishes
statistics on national and local populations, including their social and economi
c situation and
contributions to the countrys economy. It also records the demographic patterns o
f births, marriages and
deaths, including the medical cause of death. The former OPCS organised a nation
al ten-yearly census and
ONS is carrying on this activity. The census is based on the actual presence of
individuals in a house or
institutions on a given night. The figures provide government departments and lo
cal authorities with
information for planning services.
See OESTROGENS.
Oestriol See OESTROGENS.
Oestrogen Receptor A site on the membrane surrounding a cell (see CELLS)
that binds to the hormone
OESTROGENS. This activates the cells reaction to the hormone. Anti-oestrogen drug
s such as TAMOXIFEN used
to treat breast cancer (see BREASTS, DISEASES OF) prevent the oestrogen from bin
ding to these receptors.
Oestrogens Natural or synthetic substances that induce the changes in th
e UTERUS that precede
OVULATION. They are also responsible for the development of the secondary sex ch
aracteristics in women:
that is, the physical changes that take place in a girl at puberty, such as enla
rgement of the BREASTS,
appearance of pubic and axillary hair, and the deposition of fat on the thighs a
nd hips. They are used in
the management of disturbances of the MENOPAUSE, and also in the treatment of ca
ncer of the prostate (see
PROSTATE GLAND, DISEASES OF) and certain cases of cancer of the breast. The oest
rogenic hormones of the
ovary are OESTRADIOL and oestrone. The rapid degradation of natural oestrogens l
imits their use as
therapeutic agents. Chemical substitution of the steroid molecule, as in ethinyl
oestradiol, or the use of
a non-steroidal synthetic oestrogen such as STILBOESTROL, greatly reduces the ra
te of degradation and
enhances the therapeutic action. A further development has been the use of compo
unds which are not actually
oestrogenic themselves, but which are slowly metabolised to oestrogenic substanc
514 Oligaemia
by means of hair-like receptors positioned in the mucous membrane lining
the roof of the nasal cavity
(see NOSE).
Oligaemia A diminution of the quantity of blood in the circulation.
Olig(o)Omphalocele Another name for exomphalos a HERNIA of abdominal organs thr
ough the UMBILICUS.
Onchocerciasis
An abnormally low excretion of URINE, such as occurs in acute NEPHRITIS.
Infestation with the filarial worm, Onchocerca volvulus, found in many p
arts of tropical Africa, in
Central and South America, and in the Yemen and Saudi Arabia. After a period of
918 months, the young
filarial worms, injected into the body by the bite of an infected simulium gnat,
mature, mate and start
producing young microfilariae. The females live for up to 15 years and during th
is period each may produce
several thousand microfilariae a day. It is these microfilariae, which have a li
fe-span of up to two years,
that produce the characteristic features of the disease: an itching rash of the
skin and the appearance of
nodules in different parts of the body. The worm may invade the optic nerve of t
he EYE and so cause
blindness; hence the name of African river-blindness. Treatment consists of diet
hylcarbamazine and suramin.
An international campaign is now underway in an attempt to destroy simulium in t
he affected zones.
Omentum
Oncogenes
A long fold of peritoneal membrane (see PERITONEUM), generally loaded wi
th more or less fat, which
hangs down within the cavity of the ABDOMEN in front of the bowels. It is formed
by the layers of
peritoneum that cover the front and back surfaces of the stomach in their passag
e from the lower margin of
this organ to cover the back and front surfaces of the large intestine. Instead
of passing straight from
one organ to the other, these layers dip down and form a sort of fourfold apron.
This omentum is known as
the greater omentum, to distinguish it from two smaller peritoneal folds, one of
which passes between the
liver and stomach (the hepatogastric omentum), and the other between the liver a
nd duodenum (the
hepatoduodenal omentum). Together they are known as the lesser omentum.
found in mammalian cells and viruses that can cause cancer. They are bel
ieved to manufacture the
proteins that control the division of cells. In certain circumstances this contr
ol malfunctions and a
normal cell may be changed into one with MALIGNANT properties. Extensive researc
h is being done with
oncogenes with the aim of finding ways to prevent or control cancers.
A prefix which means little or scanty: for example, oliguria, excretion
of smaller than normal
quantities of urine.
Oligomenorrhoea Infrequent MENSTRUATION.
Oligospermia A less-than-normal number of sperm (see SPERMATOZOON) prese
nt in each unit volume of
seminal fluid (each ml of semen usually contains 20 million sperm). The conditio
n may be permanent or
temporary and is a major cause of INFERTILITY in men. It may be caused by ORCHIT
IS, an undescended testis,
or VARICOCELE, and should be investigated.
Oliguria
O
inflammatory erosion of the oesophagus (see OESOPHAGUS, DISEASES OF).
Omeprazole This is a proton-pump inhibitor drug (see PROTON-PUMP INHIBIT
ORS) which inhibits
gastric-acid secretion by blocking a key enzyme system in the parietal cells of
the STOMACH. The drug is
used to treat (short-term) gastric ulcer (see under STOMACH, DISEASES OF) and DU
ODENAL ULCER, as well as
strictures and
GENES
Oncologist A doctor who specialises in the treatment of cancers (see CAN
CER; ONCOLOGY). Increasingly,
cancer is being treated by multidisciplinary teams which include surgeons, physi
cians, radiotherapists and
oncologists. The latter are non-surgical cancer specialists and are divided into
clinical and medical
branches: clinical oncologists concentrate mainly on RADIOTHERAPY treatments; me
dical oncologists are
trained in the medical management of cancer patients diagnosing and classifying
cancers and arranging
drug, psychosocial and palliative care. The latter claim a pivotal role in liais
ing with primary-care
services, clinical oncologists and those providing palliative care, as well as o
ther medical and surgical
colleagues involved
Ocyte
in the treatment and care of patients with cancer. With the constant evo
lution of cancer care and the
introduction of new treatments such as GENE THERAPY, the role of oncologists and
their relation with other
specialists dealing with cancer will also evolve; but the strategic aim will rem
ain to provide patients
with up-to-date, comprehensive, coordinated care in hospitals and the community.
Oncology The management of MALIGNANT disease a major health problem sinc
e successful management
requires close liaison between the patient, surgeons, physicians, oncologists, h
aematologists,
paediatricians and other specialists. Diagnosis may involve various investigatio
ns and often requires a
BIOPSY. Once a diagnosis has been established, treatment may involve surgery, ra
diotherapy or chemotherapy
(or various combinations as required) see below, and main dictionary entries.
Surgery may be most common, and is often the only treatment, for some ga
strointestinal tumours,
soft-tissue tumours, gynaecological tumours and advanced cancers of the head and
neck.
Radiotherapy uses ionising radiation to kill tumour cells. Radiation is
by naturally occurring isotopes
(see ISOTOPE) or artificially produced X-RAYS. Germ-cell tumours (see SEMINOMA;
TERATOMA) and malignant
lymphomas (see LYMPHOMA) appear to be particularly sensitive to irradiation, and
many head and neck
tumours, gynaecological cancers, and localised cancers of the PROSTATE GLAND and
URINARY BLADDER are
curable with radiotherapy. It is also a valuable means of reducing pain from bon
e metastases (see
METASTASIS). Unpleasant side-effects are common: chiefly lethargy, loss of appet
ite and dry, itchy skin
symptoms.
Chemotherapy is also an important treatment in germ-cell tumours (see ab
ove); in some forms of
LEUKAEMIA and lymphoma; in ovarian cancer (following surgery see OVARIES, DISEAS
ES OF); and in small-cell
lung cancer (although most patients die within 18 months see LUNGS, DISEASES OF)
. It is also used in some
breast cancers (see BREASTS, DISEASES OF); advanced myeloma (see MYELOMATOSIS);
sarcomas (see under
CANCER); and some childhood cancers (such as WILMS TUMOUR). More than 20 substanc
es are in common use, the
major classes being ALKYLATING AGENTS (e.g. cyclophosphamide, chlorambucil, busu
l515
fan); ANTIMETABOLITES (e.g. methotrexate); VINCA ALKALOIDS (e.g. vincris
tine, vinblastine); and
antitumour ANTIBIOTICS (e.g. actinomycin D). Choice of agent and the appropriate
regimen requires expert
guidance. Common side-effects include nausea and vomiting, bonemarrow suppressio
n and ALOPECIA, with each
substance having its own spectrum of unwanted effects. Good doctor-patient commu
nication, with the sharing
of information and bringing the patient into the decision-making process, is vit
al even if time-consuming
and exhausting. Equally imortant treatment is PALLIATIVE, for example to ensure
effective pain or nausea
control. Common sources of pain in cancer may involve bone, nerve compression, s
oft tissue, visceral,
myofascial, constipation, muscle spasm, low-back pain, joint pain (e.g. capsulit
is) and chronic
post-operative pain. Patients may be suffering from more than one pain, all of w
hich should be identified.
The aim should be to eliminate pain. There are three rungs of the analgesic ladd
er; if one rung fails, the
next one should be tried: (1) non-opioid drugs for example, aspirin, PARACETAMOL
, NON-STEROIDAL
ANTIINFLAMMATORY DRUGS (NSAIDS); (2) weak opioids for example, CODEINE, DIHYDROC
ODEINE,
dextropropoxyphene; (3) strong opioids for example, MORPHINE, DIAMORPHINE, bupre
norphine. Oral treatment
is always preferable, unless prevented by severe vomiting. (See also CANCER; ONC
OLOGIST; PAIN; PALLIATIVE
CARE.)
Onychia Disease of the nails (see SKIN Nail; NAILS, DISEASES OF).
Onychogryphosis A distortion of the nail (see under SKIN) in which it is
much thickened, overgrown and
twisted on itself. This usually affects a toe-nail and is the result of chronic
irritation and
inflammation.
Onycholysis Separation of the nail (see nail-bed.
under SKIN)
from the
Onychomycosis A fungus infection of the nail (see under SKIN), caused by
CANDIDA or DERMATOPHYTES (see
also RINGWORM).
Ocyte An immature OVUM. When the cell undergoes MEIOSIS in the ovary it b
ecomes an ovum and is
O
516 Ogenesis
ready for fertilisation by the spermatozoa. Only a small number of the m
any ocytes produced survive
until PUBERTY, and not all of them will become ova and be ejected into the FALLO
PIAN
Ophthalmology The study of the structure and function of the EYE and the
diagnosis and treatment of the
diseases that affect it.
TUBES.
Ophthalmoplegia
Ogenesis The production of mature egg cells (ova see OVUM) by the OVARIES
. Germ cells in the ovary
multiply to produce oogonia which divide by MEIOSIS to form ocytes in the FETUS.
Ophthalmoscope
Ophorectomy Removal, by operation, of an ovary (see OVARIES). When the ov
ary is removed for the
presence of a cyst, the term ovariotomy is usually employed (see OVARIES, DISEAS
ES OF).
An instrument for examining the interior of the EYE. There are different
types of ophthalmoscope; all
have a light source to illuminate the inside of the eye and a magnifying lens to
make examination easier.
Ophoritis
Opiate
Another name for ovaritis or inflammation of an ovary (see OVARIES; OVAR
IES, DISEASES OF).
A preparation of OPIUM.
Ophoron
A substance with a pharmacological action that is like that of OPIUM or
its derivatives.
Another name for the ovary (see OVARIES).
Opioid
Opioid Poisoning
Operating Microscope
O
Paralysis of the muscles of the EYE. Internal ophthalmoplegia refers to
paralysis of the iris and
ciliary body; external ophthalmoplegia refers to paralysis of one or all of the
muscles that move the eyes.
A binocular MICROSCOPE used for MICROSURGERY on, for example, the EYE an
d middle EAR; this microscope
is also used for suturing nerves and blood vessels damaged or severed by trauma
and for rejoining
obstructed FALLOPIAN TUBES in the treatment of INFERTILITY in women.
Operation A surgical procedure using instruments or sometimes just the h
ands; for example, when
manipulating a joint or setting a simple fracture. Operations range from simple
removal of a small skin
lesion under local anaesthetic to a major event such as transplanting a heart wh
ich takes several hours and
involves many doctors, nurses and technical staff. Increasingly, operations are
done on an outpatient or
day-bed basis, thus enabling many more patients to be treated than was the case
25 years ago, and
permitting them to resume a normal life often within 24 hours. (See also SURGERY
; MINIMALLY INVASIVE
SURGERY (MIS).)
Ophthalmia
and CODEINE are natural opium found in the opium poppy (Papaver somnifer
um). The other opioids are
either synthetic or semi-synthetic analogues of these. Their main use is in the
treatment of moderate to
severe PAIN, but they are also used as antidiarrhoeal and antitussive agents. As
a result of induced
tolerance (see DEPENDENCE) and great individual variability, the amount of opioi
d substances required to
cause serious consequences varies enormously. The most common effects of opioid
overdose are vomiting,
drowsiness, pinpoint pupils, BRADYCARDIA, CONVULSIONS and COMA. Respiratory depr
ession is common and may
lead to CYANOSIS and respiratory arrest. HYPOTENSION occurs occasionally and in
severe cases
non-cardiogenic pulmonary oedema and cardiovascular collapse may occur. Cardiac
ARRHYTHMIA may occur with
some opioids. Some opioids have a HISTAMINE-releasing effect which may result in
an urticarial rash (see
URTICARIA), PRURITUS, flushing and hypotension. Activated CHARCOAL should be giv
en following overdose and
NALOXONE administered to reverse respiratory depression and deep coma. MORPHINE
ALKALOIDS
See under EYE, DISORDERS OF.
Opisthotonos
Ophthalmologist A
doctor
with
OPHTHALMOLOGY.
specialist
training
in
The name for a position assumed by the body during one of the convulsive
seizures of TETANUS. The
muscles of the back, by their
Oral
spasmodic contraction, arch the body in such a way that the person for a
time may rest upon the bed
only by their heels and head.
Opium The dried juice of the unripe seed-capsules of the white Indian po
ppy, Papaver somniferum.The
action of opium depends upon the 20 25 ALKALOIDS it contains. Of these, the chief
is MORPHINE, the amount
of which varies from around 917 per cent. Other alkaloids include codeine, narcot
ine, thebaine,
papaverine, and naceine. The importation into Britain of opium is strictly regul
ated under the Dangerous
Drugs Acts. Similar regulations govern the sale and distribution of any preparat
ion of morphine or
diamorphine (heroin) stronger than 1 part in 500. (See DEPENDENCE.)
Action The action of opium varies considerably, according to the source
of the drug and the preparation
used. In small doses, opium produces a state of gentle excitement, the person fi
nding their imagination
more vivid, their thoughts more brilliant, and their power of expression greater
than usual. This stage
lasts for some hours, and is succeeded by languor. In medicinal doses this stage
of excitement is short and
is followed by deep sleep. When potentially poisonous doses are taken, sleep com
es on quickly, and passes
into coma and death (see OPIOID POISONING). The habitual use of opium produces g
reat TOLERANCE, so that
opium users require to take large quantities daily before experiencing its pleas
urable effects. The need
for opium also confers tolerance, so that people suffering great pain may take,
with apparently little
effect beyond dulling the pain, quantities which at another time would be danger
ous.
Opportunistic A description usually applied to infection resulting from
an organism that does not
normally cause disease in a healthy individual. It is also used to describe wide
spread infection by an
organism that usually causes local infection. The bodys defence mechanism can usu
ally combat these
organisms, but if it is impaired as happens in AIDS/HIV or other immune deficien
cies opportunistic
infection, such as PNEUMONIA, may develop. Some viral and fungal infections beha
ve in this way.
Antimicrobial treatment is often effective, even though the weakness in the bodys
defence mechanism cannot
be rectified.
517
Opsonins Substances present in the SERUM of the blood which act upon bac
teria, so as to prepare them
for destruction by the white cells of the blood.
Optic Concerned with the EYE or vision.
Optic Atrophy A deterioration in the fibres of the optic nerve (see EYE)
resulting in partial or
complete loss of vision. It may be caused by damage to the nerve from inflammati
on or injury, or the
atrophy may be secondary to disease in the eye.
Optic Chiasma This is formed by a crossing-over of the two optic nerves
(see EYE) which run from the
back of the eyeballs to meet in the mid line beneath the brain. Nerve fibres fro
m the nasal part of the
retina cross to link up with fibres from the outer part of the retina of the opp
osite eye. The linked
nerves form two separate optic tracts which travel back to the occipital lobes o
f the brain.
Optic Disc Otherwise known as the blind spot of the EYE, the disc is the
beginning of the optic nerve
the point where nerve fibres from the retinas rods and cones (the light- and colo
ur-sensitive cells) leave
the eyeball.
Optician Someone who fits and sells glasses or contact lenses. An ophtha
lmic optician (optometrist) is
trained to perform eye examinations to test for long- and short-sightedness and
to prescribe corrective
lenses, but they do not treat disorders of the eye, referring patients with a di
sorder to a family doctor
or ophthalmologist.
Optic Nerve See EYE.
Optic Neuritis Inflammation of the optic nerve (see EYE) which may resul
t in sudden loss of part of a
persons vision. It is usually accompanied by pain and tenderness on touch. The ca
use is uncertain,
although in some cases it may be a prcursor of MULTIPLE SCLEROSIS (MS): CORTICOS
TEROIDS may help by
improving the loss of visual acuity, but seems not to check the long-term inflam
matory activity.
Oral An adjective referring to the mouth, or to substances taken by mout
h.
O
together with connective tissue and liberally supplied with blood vessels; it pe
rforms vital functions in
the breakdown of substances absorbed from the gastrointestinal tract. Other exam
ples of organs are the
KIDNEYS, BRAIN and HEART. (See also TRANSPLANTATION.)
Organic Disease A term used in contradistinction to the word functional,
to indicate that some
structural change is responsible for the faulty action of an ORGAN or other part
of the body.
Organic Substances Those which are obtained from animal or vegetable bod
ies, or which resemble in
chemical composition those derived from this source. Organic chemistry has come
to mean the chemistry of
the carbon compounds.
Organophosphorus Organophosphorus insecticides act by inhibiting the act
ion of cholinesterase (see
ACETYLCHOLINE). For this reason they are also toxic to humans and must therefore
be handled with great
care. The most widely used are PARATHION and MALATHION. Organophosphorus has als
o been used to make nerve
gases (see BIOLOGICAL WARFARE).
Treatment After contamination with insecticides, decontaminate (remove c
lothes, wash skin). Those
treating should wear gloves, mask, apron and goggles. For symptoms give 2 mg of
ATROPINE IV every 30
minutes until full atropinisation (dry mouth, pulse >70). Up to three days treatm
ent may be needed. Severe
poisoning may require pralidoxine mysalate: available from designated centres, t
his drug should be given
intravenously within 24 hours of exposure.
Organ Transplantation See TRANSPLANTATION.
Orchitis
Orgasm
Inflammation of the testicle. (See TESTICLE, DISEASES OF.)
The climax of sexual intercourse. In men this coincides with ejaculation
of the semen when
Ossification
the muscles of the pelvis force the seminal fluid from the prostate into
the urethra and out through
the urethral orifice. In women, orgasm is typified by irregular contractions of
the muscular walls of the
vagina followed by relaxation. The sensation is more diffuse in women than in me
n and tends to last longer
with successive orgasms sometimes occurring.
Oriental Sore This term is a synonym for cutaneous LEISHothers include:
Cochin, Delhi, Kandahar,
Lahore, Madagascar, Natal, Old World tropical, tropical sore, etc. As with many
of the local names for this
infection, it is now rarely used.
MANIASIS;
Orlistat An inhibitor of the pancreatic enzyme LIPASE, which breaks down
fats in food to their
constituent parts. By inhibiting lipase, the drug reduces absorption of dietary
fat from the INTESTINE. It
is used as an ADJUVANT to a modest low-calorie diet in people with a BODY MASS 2
INDEX of 30 kg/m or more.
The drug should be prescribed only if diet alone has, over a period of four cons
ecutive weeks, resulted in
a person losing 2.5 kg or more. Orlistat may cause oily liquid faeces, urgency t
o defecate, excessive wind
and, sometimes, headaches, tiredness and anxiety. (See OBESITY.)
Ornithosis Ornithosis is an infection of birds with the micro-organism k
nown as Chlamydia psittaci,
which is transmissible to humans.
Oropharynx The part of the PHARYNX that lies between the soft PALATE and
the HYOID bone.
Orphenadrine A drug used in the treatment of PARKINSONISM.
Orthodontics Orthodontics is the branch of dentistry concerned with the
prevention and treatment of
dental irregularities and malocclusion.
Orthopaedics Originally the general measures, both surgical and mechanic
al, for the correction or
prevention of deformities in children. Now, that branch of medical science deali
ng with skeletal deformity
(congenital or acquired), fractures and infections of bones, replacement of arth
ritic joints (hips, knees
and fingers see
519
ARTHROPLASTY) and the treatment of bone tumours. (See BONE, DISORDERS OF
; JOINTS, DISEASES OF.)
Orthopnoea A form of difficulty in breathing so severe that the patient
cannot bear to lie down, but
must sit or stand up. As a rule, it occurs only in serious affections of the hea
rt or lungs.
520 Osteitis
Osteitis
A pathological rather than a clinical entity. The term refers to the rep
lacement of BONE by a highly
cellular and vascular connective tissue. It is the result of osteoclastic and os
teoblastic activity and is
due to excessive PARATHYROID activity. It is thus seen in a proportion of patien
ts with primary
hyperparathyroidism and in patients with uraemic osteodystrophy; that is, the se
condary hyperparathyroidism
that occurs in patients with chronic renal disease.
The primary problem is seen as a change in structure of cartilage and BO
NE, rather than an inflammatory
SYNOVITIS. Osteoarthritis usually implies a loss of the central load-bearing are
a of articular hyaline
cartilage, with outgrowth of cartilage at the articular margin and subsequent os
sification to form bony
outgrowths known as OSTEOPHYTES. Osteophytes form with increasing age, whether o
r not there is significant
cartilage loss, and in the elderly may lead to local frictional symptoms, and in
the spine, to nerve
compression. The condition has a wide range of causes, of which some, like dyspl
asia and trauma, are known
and others have yet to be identified. The main clinical problems occur in the hi
p and knee. The cartilage
loss in the hip usually occurs in the sixth or seventh decade. It may affect bot
h hips in fairly rapid
succession, or only one hip; such patients often have no problems in other joint
s. Cartilage loss in the
knee occurs from the fifth decade onwards and is often associated with cartilage
loss in small joints in
the hand and elsewhere. Cartilage loss in the distal interphalangeal joints of t
he hand is associated with
the formation of bony swellings known as Heberdens nodes.
Osteoarthritis
Treatment Management is largely directed at
Despite major efforts, it has proved impossible to produce a single clea
r definition of osteoarthritis
and this probably reflects the muddled nature of a concept which will need repla
cing. Unfortunately, there
is confusion because the term is also used to cover joint pain that appears to h
ave a mechanical basis in
the absence of clinical or radiographic evidence of CARTILAGE loss.
maintaining activity, with physical and social support as necessary. ANA
LGESICS may be of some value,
particularly in the management of NON-STEROIDAL ANTInight pain. INFLAMMATORY DRU
GS (NSAIDS) may help
patients with early-morning stiffness and may also reduce pain on movement and n
ight pain. Their benefit,
however, tends to be less marked than in RHEUMATOID ARTHRITIS and their
Osteitis means inflammation in the substance of a BONE. Traumatic osteit
is is a condition particularly
common in footballers, in which the victim complains of pain in the groin follow
ing exercise, particularly
if this has involved much hip rotation. Examination reveals difficulty in spread
ing the legs and marked
tenderness over the symphysis pubis. It responds well to rest and the administra
tion of non-steroidal
antiinflammatory drugs (NSAIDS) such as ibuprofen or indomethacin.
Osteitis Deformans See PAGETS DISEASE OF BONE.
Osteitis Fibrosa Cystica
O
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
long-term usage has considerable toxicity problems. Advanced cartilage l
oss is best treated by joint
replacement. Hip- and knee-joint replacements with a wide variety of artificial
joints are now common
surgical procedures which greatly improve the mobility of affected individuals.
(See ARTHROPLASTY.) People
with arthritis and their relatives can obtain help and advice from Arthritis Car
e.
Osteoblast A cell responsible for the production of (see OSSIFICATION).
BONE
Osteochondritis Inflammation of both BONE and CARTILAGE. It is a not unc
ommon cause of BACKACHE in
young people, particularly gymnasts.
Osteochondrosis This includes a group of diseases involving degeneration
of the centre of OSSIFICATION
(see also BONE) in the growing bones of children and adolescents. They include K
ohlers disease,
OSGOOD-SCHLATTERS DISEASE, and PERTHES DISEASE.
Osteoclast A cell that resorbs calcified BONE.
due to inadequate mineralisation of osteoid tissue caused by a deficienc
y of vitamin D. This deficiency
may arise because of inadequate intake, or it may be due to impaired absorption
such as occurs in
intestinal malabsorption. It may also be due to renal disease, as the kidney is
responsible for the
hydroxylation of cholecalciferol, which has virtually no metabolic action, to di
hydroxy-cholecalciferol
the metabolically active form of the vitamin. (See APPENDIX 5: VITAMINS.)
Osteomyelitis Inflammation of the BONE as a result of infection (see BON
E, DISEASES OF).
Osteopathy A system of treatment by manipulating bones (see BONE) and ot
her parts with the idea of
thereby restoring functions in the bodily mechanism that have become deranged. P
roperly qualified
osteopaths are included on the General Council and Register of Osteopaths.
Osteophytes Bony spurs or projections. They occur most commonly at the m
argins of areas of bone
affected by OSTEOARTHRITIS.
Osteoporosis
Osteocyte
See under BONE, DISORDERS OF.
A BONE cell formed from an OSTEOBLAST or bone-forming cell that has stop
ped its activity. The cell is
embedded in the matrix of the bone.
Osteosarcoma
Osteogenesis See OSSIFICATION.
Osteogenesis Imperfecta
521
Osteosarcoma, or osteogenic sarcoma, is the most common, and most malign
ant, tumour of bone (see BONE,
DISORDERS OF). It occurs predominantly in older children and young adults; the m
ost common site is at the
ends of the long bones of the body i.e. the femur, tibia and humerus. Treatment
is by CHEMOTHERAPY and
surgical reconstruction or amputation of the affected limb. The five-year surviv
al rate is over 70 per
cent.
A hereditary disease due to an inherited abnormality of COLLAGEN. It is
characterised by extreme
fragility of the skeleton, resulting in fractures and deformities. It may be acc
ompanied by blue sclera
(the outermost, normally white coat of the eyeball), transparent teeth, hypermob
ility (excessive range of
movement) of the joints, deafness, and dwarfism (shortness of stature). The exac
t cause is not known,
although there is some evidence that it may be associated with collagen formatio
n. Parents of affected
children can obtain help and advice from the Brittle Bone Society.
A small accessory BONE behind the ankle-joint which is present in about
7 per cent of the population.
It may be damaged by energetic springing from the toes in ballet, jumping or fas
t 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
Osteotomy The operation of cutting of a BONE.
Os Trigonum
O
522 Otitis
Eustachian tubes between the middle EAR and the PHARYNX as a result of r
apidly changing external air
pressure, such as occurs during descent of an aircraft. VALSALVAS MANOEUVRE pinch
ing the nose with
finger and thumb and attempting to blow hard through the nose will usually relie
ve the blockage. People
prone to this phenomenon may find nasal decongestants helpful.
Otitis Inflammation of the OF.)
EAR.
(See
EAR, DISEASES
Otolaryngology The study, diagnosis and treatment of disorders of the ea
rs, throat and larynx.
Otology Otology is that branch of medical science which is concerned wit
h disorders and diseases of the
organ of hearing one practising this branch being called an otologist.
Otorhinolaryngology The study of diseases of the ear, nose, and throat c
olloquially referred to as
ear, nose and throat (ENT) specialty. The relevant specialist is called an otorh
inolaryngologist (US) or
ENT surgeon (UK).
Otorrhoea O Discharge from the EAR. (See EAR, DISEASES OF.) Otosclerosis
See under EAR, DISEASES OF.
Otoscope See AURISCOPE.
Outpatient A patient attending a hospital clinic who is not admitted to
a bed. Most patients attend an
outpatients department after referral for a specialist opinion by their general p
ractitioner. An
increasing number of investigations and treatments, including surgery, are being
done on an outpatient
basis.
Ovaries The main female reproductive organs which produce the ova (egg c
ells see OVUM) and steroid
HORMONES in a regular cycle (see MENSTRUATION) in response to hormones (see GONA
DOTROPHINS) from the
anterior PITUITARY GLAND. Situated one on each side of the uterus in the lower a
bdomen, each ovary contains
numerous follicles within which the ova
develop. Only a small proportion of these reach maturity, when the ovum
is described as a Graafian
follicle. OVULATION occurs and, if the ovum is fertilised, a pregnancy may devel
op. (See also ENDOCRINE
GLANDS; OESTRADIOL; OESTROGENS; PROGESTERONE.)
Ovaries, Diseases of Ophoritis (infection of the ovaries) rarely occurs a
lone, except in viral
Oximeter 523
having ovarian cancer in England and Wales. Unfortunately it is not read
ily detected in its early
stages; around 85 per cent of women do not see a doctor until after the tumour h
as spread. Early tumours
present with symptoms similar to benign tumours, while late ones present with ab
dominal distension, pain
and vague gastrointestinal symptoms. The disease is most common in menopausal wo
men. Earlier diagnosis and
treatment can be achieved by ULTRASOUND screening. Treatment is surgical, aimed
at totally removing the
tumour mass. Nowadays RADIOTHERAPY is only used for palliation. CHEMOTHERAPY is
often given to patients
with ovarian metastases, or who have residual disease after surgery. The most ac
tive cytotoxic agent is the
taxane, PACLITAXEL especially when it is combined with cisplatin.
Ovariotomy Also called ophorectomy. The operation of removal of an ovary
(see OVARIES) or an ovarian
tumour (see under OVARIES, DISEASES OF).
Overbite A dental term describing the condition where a persons upper INC
ISOR teeth vertically overlap
the lower incisors. If serious, the person may need orthodontic correction and t
his is usually done in
childhood after the permanent teeth have developed.
Over-The-Counter (OTC) A description applied in the UK to MEDICINES and
drugs that can be obtained from
a pharmacist without a doctors or dentists prescription. Some medications may be b
ought from retail
outlets other than pharmacists.
Ovulation The development and release of an OVUM (egg) from the ovary (s
ee OVARIES) into the FALLOPIAN
TUBES. Ovulation is initiated by the secretion of luteinising hormone by the ant
erior PITUITARY GLAND and
occurs half way through the menstrual cycle. If the ovum is not fertilised, it i
s lost during MENSTRUATION.
Ovum The single cell derived from the female, out of which a future indi
vidual arises, after its union
with the SPERMATOZOON derived from the male. It is about 35 micrometres in diame
ter. (See FETUS; OVARIES.)
Oxalic Acid This is an irritant poison that is used domestically for cle
aning purposes. It is also
found in
many plants including rhubarb and sorrel. Oxalic acid, when swallowed, p
roduces burning of the mouth
and throat, vomiting of blood, breathlessness and circulatory collapse. Calcium
salts, lime water or milk
should be given by mouth. An injection of calcium gluconate is an antidote.
Oxaliplatin A platinum-based anticancer drug given intravenously for the
treatment of colorectal cancer
with metastases. It is usually combined with FLUOROURACIL and folinic acid. Side
-effects include toxic
524 Oximetry
safe managament of severe respiratory illness as they provide one measur
e of the lungs ability to
exchange oxygen and carbon dioxide.
Oximetry The measurement by an OXIMETER of the proportion of oxygenated
HAEMOGLOBIN in the blood.
Oxprenolol See ADRENERGIC RECEPTORS.
Oxycephaly A deformity of the skull in which the forehead is high and th
e top of the head pointed.
There is also poor vision and the eyes bulge.
Oxygen
O
A colourless and odourless gas of molecular weight 32. It constitutes ju
st less than 21 per cent of the
earths atmosphere. As a medical gas, it is supplied in the UK compressed at high
pressure (13,600
kilopascals (KPa)) in cylinders which are black with white shoulders. In hospita
ls, oxygen is often stored
as a liquid in insulated tanks and controlled evaporation allows the gas to be s
upplied via a pipeline at a
much lower pressure. Oxygen is essential for life. It is absorbed via the lungs
(see RESPIRATION) and is
transported by HAEMOGLOBIN within the ERYTHROCYTES to the tissues. Within the in
dividual cell it is
involved in the production of adenosine triphosphate (ATP), a compound that stor
es chemical energy for
muscle cells, by the oxidative metabolism of fats and carbohydrates. HYPOXIA cau
ses anaerobic metabolism
with a resulting build-up in LACTIC ACID, the result of muscle cell activity. If
severe enough, the lack of
ATP causes a breakdown in cellular function and the death of the individual. Whe
n hypoxia occurs, it may be
corrected by giving supplemental oxygen. This is usually given via a face mask o
r nasal prongs or, in
severe cases, during ARTIFICIAL VENTILATION OF THE LUNGS. Some indications for o
xygen therapy are high
altitude, ventilatory failure, heart failure, ANAEMIA, PULMONARY HYPERTENSION, C
ARBON MONOXIDE (CO)
poisoning, anaesthesia and post-operative recovery. In some conditions e.g. seve
re infections with
anaerobic bacteria and CO poisoning hyperbaric oxygen therapy has been used.
Oxygen Deficit In a resting individual the potential OXYGEN supply to th
e tissues is greater than its
consumption. During heavy exercise, the energy
required by the tissues is greater than can be supplied by aerobic cellu
lar metabolism and the
additional energy is supplied by a biochemical reaction called anaerobic metabol
ism. There is a build-up of
lactate a product of LACTIC ACID from anaerobic metabolism which is ultimately o
xidised after
conversion to citrate and metabolism via the citric acid cycle. The increased am
Ozone
also to encourage the expelling of the PLACENTA (afterbirth). Sometimes
it is given to a woman who has
had an incomplete miscarriage (see ABORTION). There have been criticisms that ox
ytocin is used too often to
induce labour for social reasons or for the convenience of obstetric departments
. (See also PITUITARY
BODY.)
Oxyuriasis Another name for the threadworm (see ENTEROBIASIS).
Ozaena A chronic disease of the NOSE of an inflammatory nature, combined
with atrophy of the mucous
membrane and the formation of extremely foul-smelling crusts in the interior of
the nose. (See also NOSE,
DISORDERS OF.)
525
Ozone A specially active and poisonous form of OXYGEN in which three vol
umes of the gas are condensed
into the space ordinarily occupied by two. It has a characteristic smell and is
a strong oxidising agent.
Formed when an electrical charge is passed through oxygen or air, it is found at
high altitudes in the
atmosphere where it screens out much of the suns ultraviolet radiation. The ozone
layer, as it is called,
is being damaged by pollutant gases from earth. Unless this damage is reversed,
lethal quantities of
ultraviolet radiation could penetrate to the earths surface, further warming the
worlds climates, with
long-term damage to the environment.
O
P Pacemaker
A cardiac or artificial pacemaker is a device that helps a faulty HEART
to maintain normal rhythm. It
consists of a battery that stimulates the heart by an electric current passed th
rough an insulated wire
which is attached either to the surface of the ventricle (epicardial pacemaker)
or to the heart lining
(endocardial pacemaker). In a normal heart, the regular electrical impulses are
initiated by a special area
of tissue (sinoatrial node). A cardiac pacemaker is used when a persons sinoatria
l node is malfunctioning
or when there is interference with the passage of normal impulses. Some devices
send out signals at a fixed
rate; others monitor the rate and, when it falters in any way, stimulate regular
contractions. Implantation
is carried out under a local anaesthetic, and the lithium batteries can last for
several years. People with
pacemakers should avoid any source of powerful electromagnetic radiation radio o
r radar transmitters or
airport security screens. (See also CARDIAC PACEMAKER.)
Pacinian Corpuscles Pacinian corpuscles, or lamellated corpuscles, are m
inute bulbs at the ends of the
nerves scattered through the SKIN and subcutaneous tissue, and forming one of th
e end-organs for sensation.
Packed Cell Volume That fraction of the bloods total volume made up of re
d cells. The packed cell
volume is found by centrifuging blood in a tube and measuring the depth of the c
olumn of red cells as a
fraction of the whole column of blood. (See also HAEMATOCRIT.)
Paclitaxel A
CYTOTOXIC drug of the taxane group (see TAXANES). Given by intravenous t
ransfusion, it
is used under specialist supervision for the treatment of ovarian cancer
(usually following surgery
see OVARIES, DISEASES OF) with or without CISPLATIN. NATIONAL INSTITUTE FOR CLIN
ICAL EXCELLENCE (NICE)
guidance in 2001 also recommended that the drug could be used to treat advanced
breast cancer (see BREASTS,
DISEASES OF) where initial cytotoxic therapy had failed or could not be used. It
s use
as first-line treatment is limited to clinical trials. Side-effects of p
aclitaxel include
hypersensitivity, MYELOSUPPRESSION, cardiac ARRHYTHMIA and peripheral NEUROPATHY
. Only a minority of
patients respond to the drug, but when it works the results are often long-lasti
ng.
PACS See PICTURE ARCHIVING AND COMMUNICATIONS SYSTEM (PACS).
Paederasty A homosexual act between an adult man and a boy or young man
(see HOMOSEXUALITY).
Paediatrician A medical specialist skilled in the care of childrens healt
h and diseases.
Paediatrics Paediatrics means the branch of medicine dealing with diseas
es of children (see also
NEONATOLOGY).
Paedophilia A perverse sexual attraction to children of either sex. Paed
ophiles are nearly always male
and may have heterosexual, homosexual or bisexual orientation. In England and Wa
les, the age of consent for
heterosexual and homosexual sex is 16 years; in Northern Ireland, 17 years; and
in Scotland the age of
consent for heterosexual sex is 12 for a girl and 14 for a boy. However, girls a
re protected by Section 5
of the Criminal Law (Consolidation) Act 1995 which makes it an offence to have s
exual intercourse with a
girl aged under 16. For girls under 13, the maximum sentence is life-imprisonmen
t, and between 13 and 16,
two years imprisonment. Homosexual consent in Scotland is 16. Paedophiles suffer
from personality problems
rather than overt psychoses (see PSYCHOSIS) and the origins of their behaviour m
ay lie in their own early
sexual experiences. Their behaviour often has features of an addiction. It is of
note that most underaged
sex is between family members such as stepfather and daughter rather than with a
stranger or predatory
paedophile. (See CHILD ABUSE.)
Pagets Disease of Bone Also called osteitis deformans, this is a chronic
disease in which the bones
(see BONE) especially those of the skull, limbs, and spine
Pain
gradually become thick and also soft, causing them to bend. It is said t
o be the most common form of
bone disease in the world, and it is estimated that some 600,000 people in Engla
nd may suffer from it. It
seldom occurs under the age of 40. Pain is its most unpleasant manifestation. Th
e cause is not known, and
there is no known cure, but satisfactory results are being obtained from the use
of CALCITONIN and a group
of drugs known as BISPHOSPHONATES (e.g. etidronate). Those with the disease can
obtain help and advice from
the National Association for the Relief of Pagets Disease.
Pain Pain is an unpleasant sensory and emotional experience associated w
ith actual or potential tissue
damage, or described in terms of such damage (International Association for the
Study of Pain, 1979). Pain
is perceived in the cerebral cortex (see BRAIN) and is always subjective. Someti
mes sensations that would
usually be benign can be perceived as painful for example, allodynia (extreme te
nderness of the skin) or
dysaesthesia (unpleasant skin sensations resulting from partial damage to sensor
y nerve fibres, as in
herpes zoster, or shingles).
Acute pain is caused by internal or external injury or disease. It warns
the individual that harm or
damage is occurring and stimulates them to take avoiding or protective action. W
ith effective treatment of
disease or injury and/or the natural healing process, the pain resolves although
some acute pain
syndromes may develop into chronic pain (see below). Stimuli which are sufficien
tly intense potentially to
damage tissue will cause the stimulation of specific receptors known as NOCICEPT
ORS. Damage to tissues
releases substances which stimulate the nociceptors. On the surface of the body
there is a high density of
nociceptors, and each area of the body is supplied by nerves from a particular s
pinal segment or level:
this allows the brain to localise the source of the pain accurately. Pain from i
nternal structures and
organs is more difficult to localise and is often felt in some more superficial
structure. For example,
irritation of the DIAPHRAGM is often felt as pain in the shoulder, as the nerves
from both structures enter
the SPINAL CORD at the same level (often the structures have developed from the
same parts of the embryo).
This is known as referred pain. The impulses from nociceptors travel along nerve
s to the spinal cord.
Within this there is modulation of the pain messages by other
527
incoming sensory modalities, as well as descending input from the brain
(Melzack and Walls
gate-control theory). This involves morphine-like molecules (the ENDORPHINS and
ENKEPHALINS) amongst many
other paintransmitting and pain-modulating substances. The modified input then p
asses up the spinal cord
through the thalamus to the cerebral cortex. Thus the amount of pain felt may be a
ltered by the emotional
state of the individual and by other incoming sensations. Once pain is perceived
, then action is taken;
this involves withdrawal of the area being damaged, vocalisation, AUTONOMIC NERV
OUS SYSTEM response and
examination of the painful area. Analysis of the event using memory will occur a
nd appropriate action be
taken to reduce pain and treat the damage.
Chronic pain may be defined in several ways: for example, pain resistant
to one months treatment, or
pain persisting one month beyond the usual course of an acute illness or injury.
Some doctors may also
arbitrarily choose the figure of six months. Chronic pain differs from acute pai
n: the physiological
response is different and pain may either be caused by stimuli which do not usua
lly cause the perception of
pain, or may arise within nerves or the central nervous system with no apparent
external stimulation. It
seldom has a physiological protective function in the way acute pain has. Also,
chronic pain may be
selfperpetuating: if individuals gain a psychological advantage from having pain
, they may continue to do
so (e.g. gaining attention from family or health professionals, etc.). The nervo
us system itself alters
when pain is long-standing in such a way that it becomes more sensitive to painf
ul inputs and tends to
perpetuate the pain.
Treatment The treatment of pain depends upon its nature and cause. Acute
pain is generally treated by
curing the underlying complaint and prescribing ANALGESICS or using local anaest
hetic techniques (see
ANAESTHESIA Local anaesthetics). Many hospitals now have acute pain teams for th
e management of
postoperative and other types of acute pain; chronic pain is often treated in pa
in clinics. Those involved
may include doctors (in Britain, usually anaesthetists), nurses, psychologists a
nd psychiatrists,
physiotherapists and complementary therapists. Patients are usually referred fro
m other hospital
specialists (although some may be referred by GPs). They will usually have been
given a diagnosis and
exhausted the
P
528 Palate
P
medical and surgical treatment of their underlying condition. All the us
ual analgesics may be employed,
and opioids are often used in the terminal treatment of cancer pain. ANTICONVULS
ANTS and ANTIDEPRESSANT
DRUGS are also used because they alter the transmission of pain within the centr
al nervous system and may
actually treat the chronic pain syndrome. Many local anaesthetic techniques are
used. Myofascial pain
pain affecting muscles and connective tissues is treated by the injection of loc
al anaesthetic into
tender spots, and nerves may be blocked either as a diagnostic procedure or by w
ay of treatment. Epidural
anaesthetic injections are also used in the same way, and all these treatments m
ay be repeated at intervals
over many months in an attempt to cure or at least reduce the pain. For intracta
ble pain, nerves are
sometimes destroyed using injections of alcohol or PHENOL or by applying CRYOTHE
RAPY or radiofrequency
waves. Intractable or terminal pain may be treated by destroying nerves surgical
ly, and, rarely, the pain
pathways within the spinal cord are severed by cordotomy (though this is general
ly only used in terminal
care). ACUPUNCTURE and TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) are us
ed for a variety of pain
syndromes, particularly myofascial or musculoskeletal pain. It is thought that t
hey work by increasing the
release of endorphins and enkephalins (see above). It is possible to implant ele
ctrodes within the epidural
space to stimulate directly the nerves as they traverse this space before passin
g into the spinal cord.
Physiotherapy is often used, particularly in the treatment of chronic backache,
where pain may be reduced
by improving posture and strengthening muscles with careful exercises. Relaxatio
n techniques and
psychotherapy are also used both to treat chronic pain and to help patients cope
better with their
disability. Some types of chronic pain are caused by injury to sympathetic nerve
s or may be relieved by
interrupting conduction in sympathetic nerves. This may be done in several ways.
The nerves may be blocked
using local anaesthetic or permanently destroyed using alcohol, phenol or by sur
gery. Many of these
techniques may be used in the management of cancer pain. Opioid drugs are often
used by a variety of routes
and methods, and management of these patients concentrates on the control of sym
ptoms and on providing a
good quality of life.
Palate The partition between the cavity of the mouth, below, and that of
the nose, above. It consists
of the hard palate towards the front, which is composed of a bony plate covered
below by the mucous
membrane of the mouth, above by that of the nose; and of the soft palate further
back, in which a muscular
layer, composed of nine small muscles, is similarly covered. The hard palate ext
ends a little further back
than the wisdom teeth, and is formed by the maxillary and palate bones. The soft
palate is concave towards
the mouth and convex towards the nose, and it ends behind in a free border, at t
he centre of which is the
prolongation known as the uvula. When food or air is passing through the mouth,
as in the acts of
swallowing, coughing, or vomiting, the soft palate is drawn upwards so as to tou
ch the back wall of the
throat and shut off the cavity of the nose. Movements of the soft palate, by cha
nging the shape of the
mouth and nose cavities, are important in the production of speech.
Palate, Malformations of The commonest deformity of the PALATE is cleft
palate, which is a result of
faulty embryonic development in which the two sides of the palate fail to fuse o
r only fuse in part. If the
cleft extends the full length with bilateral clefts at the front of the MAXILLA,
it may be accompanied by a
cleft lip (also called hare-lip) and disruption in the development of the front
teeth. About 1 in 500
babies is born with a cleft lip and 1 in 1,000 has a cleft palate. If the parent
s are affected, the risk is
three times that of the normal population; if one child has a deformity, the ris
k for a subsequent child is
higher. Associated abnormalities include tongue tie, malpositioning of the MANDI
BLE and fluid in the middle
EAR. Cleft palate and hare-lip should be rectified by operation, because both ar
e a serious drawback to
feeding in early life while later, harelip is a great disfigurement, and the voi
ce may be affected. The
lip may be dealt with at any time from the neonatal period to a few weeks, depen
ding on the individual
surgeons view of when the best result is likely to be achieved. Prior to operatio
n, special techniques may
be necessary to ensure adequate feeding such as the use of special teats in form
ula-fed babies. The closure
of a large cleft in the palate is a more formidable operation and is better perf
ormed when the face has
grown somewhat, perhaps at 612 months. The operations performed vary greatly in d
etails, but all consist
in paring the edges of the gap and drawing the soft parts together across it.
Palpitation
Further operations may be required over the years to improve the appeara
nce of the nose and lip, to
make sure that teeth are even, and to improve speech. Parents of such children c
an obtain help and advice
from the Cleft Lip and Palate Association (CLAPA).
Palilalia Also called paliphrasia, this means the involuntary repetition
of words or sentences. It is a
symptom of GILLES DE LA TOURETTES SYNDROME.
Palindromic An adjective describing symptoms or diseases that recur. For
example, palindromic
rheumatoid arthritis is a condition in which symptoms wax and wane with periods
of complete remission.
Palliative A term applied to treatment that eases the symptoms of a diso
rder rather than curing the
condition. (See also HOSPICE; PALLIATIVE CARE.)
Palliative Care This is defined as comprehensive care of patients and fa
milies facing terminal illness.
The care focuses primarily on comfort and support. Such care includes: careful c
ontrol of symptoms,
especially PAIN. psychosocial and spiritual care. a personalised management plan
centred on the patients
needs and wishes. care that takes into account the familys needs and that is carr
ied into the bereavement
period. provision of coordinated services in the home, hospital, day-care centre
and other facilities used
by the patient. Palliative care should include: managing chronic cancer pain wit
h planned use of common
ANALGESICS including opioids (see SYRINGE DRIVERS); planning ahead to preserve a
s far as possible the
patients autonomy and choice as death approaches and the ability to make decision
s may decline; and an
understanding and use of artificial feeding and hydration. Palliative care seeks
to improve the
satisfaction of both patient and family, to identify their needs and, if possibl
e, to reduce the overall
cost because the patient can often be looked after at home or in a HOSPICE inste
ad of in hospital. A
well-publicised question that may arise in the context of palliative care is phy
sicianassisted suicide.
This subject is referred to in the entry on ETHICS. A request by a patient for
529
accelerated death may suggest that he or she is depressed a treatable co
ndition or that the
palliative care is inadequate and needs reviewing and, if possible, improving.
Pallidotomy Also known as pallidectomy, this is a neurosurgical procedur
e in which the activities of
the globus pallidus area of the BRAIN are destroyed or modified. The operation i
s sometimes used to relieve
the symptoms of PARKINSONISM and other neurological conditions in which involunt
530 Palsy
including by exercise ECG and treated. The BETA-ADRENOCEPTOR-BLOCKING DR
UGS are the most useful
drugs in controlling the palpitations of anxiety and those due to some cardiac a
rrhythmias. Another name
for PARALYSIS. CEREBRAL PALSY involves total or partial paralysis of a limb or l
imbs due to a perinatal or
early infancy brain lesion.
which digest proteins; AMYLASE, which converts starchy foods into the di
saccharide maltose; and LIPASE,
which breaks up fats. (See also DIGESTION.) Inadequate production of insulin by
the islets of Langerhans
leads to the condition known as DIABETES MELLITUS. In addition to insulin, anoth
er hormone is produced by
the pancreas: this is glucagon which has the opposite effect to insulin and rais
es the blood sugar by
promoting the breakdown of liver glycogen.
PanPancreas, Disorders of
Palsy
A prefix meaning all or completely.
Panacea Panacea is a term applied to a remedy for all diseases, or more
usually to a remedy which
benefits many different diseases.
Pancarditis Inflammation of the pericardium, myocardium, and endocardium
at the same time (see HEART
Structure).
Pancreas
P
A gland situated in the back of the abdomen, at the level of the first a
nd second lumbar vertebrae. It
lies behind the lower part of the stomach, an expanded portion called the head o
f the pancreas
occupying the bend formed by the duodenum or first part of the small intestine,
whilst a long portion
known as the body extends to the left, ending in the tail which rests against th
e spleen. A duct runs
through the whole gland from left to right, joined by many small branches in its
course, and, leaving the
head of the gland, unites with the bile duct from the liver to open into the sid
e of the small intestine
about 7510 cm (34 inches) below the outlet of the stomach. Scattered through the pa
ncreas are
collections of cells known as the ISLETS OF LANGERHANS, of which there are aroun
d a million in a normal
individual. These do not communicate with the duct of the gland, and the interna
l secretion of the pancreas
INSULIN is formed by these cells and absorbed directly into the blood.
Papillitis
identify gall-stones (see under GALL-BLADDER, DISEASES OF). If the patie
nt deteriorates, he or she
should be admitted for intensive care as haemorrhagic pancreatic necrosis may be
developing. LAPAROTOMY and
DEBRIDEMENT may be called for. Mortality is 510%.
Pancreatin Pancreatin preparations (often in the form of a powder) conta
in the four powerful enzymes
(see ENZYME), trypsin, chymotrypsin, lipase, and amylase, which continue the dig
estion of foods started in
the stomach (see PANCREAS Functions; DIGESTION). They are given by mouth for the
relief of pancreatic
deficiency in conditions such as pancreatitis (see PANCREAS, DISORDERS OF) and C
YSTIC FIBROSIS. Pancreatin
is also used for the preparation of pre-digested, or so-called peptonised, foods
, such as milk and some
starchy foods.
Pancreatitis See PANCREAS, DISORDERS OF.
Pancytopenia A fall in the number of red ERYTHROCYTES and white LEUCOCYT
ES, as well as of platelets
(see BLOOD Composition). The condition is found in aplastic ANAEMIA, tumours of
the BONE MARROW, enlarged
SPLEEN, and other disorders.
Pandemic An EPIDEMIC that has spread so widely that very many people in
different countries are
affected. Examples include the Black Death the epidemic PLAGUE, caused by the ba
cterium Yersinia pestis,
that devastated European populations in the Middle Ages, killing more than a thi
rd of the people; and the
INFLUENZA pandemic of 191920 that killed more people than did World War I. AIDS/H
IV is currently pandemic.
Panic Attacks Panic attacks, or panic disorders, are recurrent short epi
sodes of acute distress. Some
sufferers may be mentally confused and fear impending death. Initially these att
acks tend to occur
unexpectedly but, if recurrent, they often become associated with certain places
such as a confined space
(lift) or among crowds. Symptoms include a feeling of breathing difficulties, in
cluding overbreathing,
PALPITATION, dizziness, sweating, faintness and pains in the chest. Attacks are
usually short (a few
minutes) but not often associated with physical illness, although victims may ha
ve an anxiety disorder
531
or PHOBIA. If troublesome or disabling, attacks can be treated symptomat
ically with short-term
ANXIOLYTICS or on a long-term basis with BEHAVIOUR THERAPY.
Panniculitis Inflammation of the subcutaneous fat (see FAT Body fat). It
may occur anywhere on the
body surface.
Pannus 1) Blood vessels growing into the cornea (see EYE) beneath its ep
ithelium. Seen in TRACHOMA and
to a lesser extent in patients who are long-term soft-contact-lens wearers. 2) I
nflammatory tissue which
replaces CARTILAGE in RHEUMATOID ARTHRITIS.
Pantothenic Acid This plays an important part in the transfer of acetyl
groups in the bodys METABOLISM
and is one of the essential constituents of the diet. The daily requirement is p
robably around 10
milligrams. It is widely distributed in food stuffs, both animal and vegetable;
yeast, liver and eggyolk
are particularly rich sources. (See APPENDIX 5: VITAMINS.)
Papanicolaou Test See CERVICAL SMEAR.
Papaveretum The hydrochlorides of ALKALOIDS of OPIUM. Papaveretum relaxe
s smooth MUSCLE and has the
pain-relieving and narcotic effects of MORPHINE, but fewer side-effects. It is l
argely used to prepare
patients for ANAESTHESIA.
Papaverine A smooth-muscle (see MUSCLE) relaxant once used to treat IMPO
TENCE (erectile dysfunction).
The drug is injected directly into the corpora caverosa (spongy, blood-filled er
ectile tissue) of the
PENIS. Men with psychogenic or neurological impotence may respond to this treatm
ent. Its use is less common
since SILDENAFIL (Viagra ) was introduced for the treatment of erectile dysfunctio
n.
Papilla A small projection, such as those with which the corium of the s
kin is covered, and which
project into the epidermis and make its union with the corium more intimate; or
those covering the tongue
and projecting from its surface.
Papillitis Inflammation of any
PAPILLA,
but especially of
P
532 Papilloedema
the prominence formed by the end of the optic nerve in the retina (see E
YE) also known as OPTIC
NEURITIS.
Papilloedema Swelling of the OPTIC DISC of the EYE, specifically due to
raised intracranial pressure.
It can be seen by examining the back of the eye using an OPHTHALMOSCOPE and is a
n important sign in
managing the care of patients with intracerebral disease such as tumours or MENI
NGITIS.
Papilloma Proliferation of epidermis or epithelium (see SKIN) to form a
tumour. Benign papillomas are
common in the skin and are sometimes viral in origin. Papilloma of the urinary b
ladder may cause
HAEMATURIA.
Papova Viruses These include the human papilloma viruses (HPV), of which
nearly a hundred strains have
been identified. HPV cause verrucae (see WARTS) on skin and, less often, on the
mucous membranes of mouth,
larynx, genitalia and the cervix. Some strains may predispose to eventual cancer
.
Papule Small (less than 5 mm) solid elevation of the skin or mucous memb
ranes. A larger lesion is
called a nodule.
P
ParaA prefix meaning near, aside from, or beyond.
Para-Amino Salicylic Acid One of the early antituberculous (see TUBERCUL
OSIS) antibiotics. It tended to
cause DYSPEPSIA and has been replaced by newer antituberculous drugs with fewer
side-effects. The
first-line drugs for tuberculosis are now rifampicin, isoniazid, and ethambutol.
Paracentesis The puncture by hollow needle or TROCAR and CANNULA of any
body cavity (e.g. abdominal,
pleural, pericardial), for tapping or aspirating fluid. (See ASPIRATION.)
Paracetamol (US, acetaminophen.) A non-opioid analgesic (see ANALGESICS)
similar in efficacy to
aspirin, but without any demonstrable antiinflammatory activity. It also has the
advantage over aspirin of
causing less gastric irritation. It is indicated for mild to moderate pain and p
yrexia
in a dose of 0.51g by mouth (maximum 4 doses every 24 hours).
Paracetamol Poisoning Paracetamol is one of the safest drugs when taken
in the correct dosage, but
overdose may occur inadvertently or deliberately. Initially there may be no symp
toms or there may be
nausea, vomiting, abdominal pain and pallor. Then, 1624 hours after ingestion, li
ver damage becomes
evident and by 72120 hours the patient may have JAUNDICE, COAGULATION abnormaliti
Paralysis
Paraganglion One of the small ovoid collections of cells occurring in th
e walls of the ganglia of the
SYMPATHETIC NERVOUS SYSTEM adjacent to the SPINAL CORD. They are CHROMAFFIN cell
s and sometimes secrete
ADRENALINE.
Paragonimiasis A tropical disease found mainly in the Far East. It is ca
used by infections of the lungs
by a parasitic fluke called Paragonimus westermani. The infection is acquired by
eating insufficiently
cooked shellfish. The affected person has symptoms similar to those of chronic B
RONCHITIS; treatment is
with the drugs CHLOROQUINE and bithionol.
Paragraphia Misplacement of words, or of letters in words, or wrong spel
ling, or use of wrong words in
writing as a result of a lesion in the speech region of the BRAIN.
Parainfluenza Viruses These are included in the paramyxoviruses (see MYX
OVIRUSES) and divided into four
types, all of which cause infection of the respiratory system (see RESPIRATION).
Infection with type 3
begins in May, reaches a maximum in July or August and returns to base-line leve
l in October. Types 1 and 2
are predominantly winter viruses. Children are commonly affected and the manifes
tations include CROUP,
fever, and a rash.
Paraldehyde A clear, colourless liquid with a penetrating ethereal (see
ETHER) odour, paraldehyde may
be given by mouth, rectally, or occasionally in intramuscular injection. The dru
gs prime use is as a
hypnotic (see HYPNOTICS) in mentally unstable patients. It is also indicated as
an anticonvulsant in STATUS
EPILEPTICUS (after initial intravenous DIAZEPAM) and in TETANUS. Its unpleasant
taste restricts its use,
but this has the advantage that it usually prevents the patient from becoming an
addict. Caution is needed
when treating patients with bronchopulmonary disease or liver impairment; and in
tramuscular injection near
the sciatic nerve should be avoided, as it may cause severe CAUSALGIA. Adverse e
ffects include rashes; pain
and sterile ABSCESS after intramuscular injection; rectal irritation after ENEMA
.
Paralysis Paralysis, or
PALSY,
is loss of muscular power
533
due to some disorder of the NERVOUS SYSTEM. Weakness rather than total m
ovement loss is sometimes
described as paresis. Paralysis may be temporary or permanent and may be accompa
nied by loss of feeling.
Paralysis due to brain disease The most common form is unilateral palsy,
or HEMIPLEGIA, generally
arising from cerebral HAEMORRHAGE, THROMBOSIS or EMBOLISM affecting the opposite
side of the BRAIN. If all
four limbs and trunk are affected, the paralysis is called quadraplegia; if both
legs and part of the trunk
are affected, it is called paraplegia. Paralysis may also be divided into flacci
d (floppy limbs) or spastic
(rigid). In hemiplegia the cause may be an abscess, haemorrhage, thrombosis or T
UMOUR in the brain.
CEREBRAL PALSY or ENCEPHALITIS are other possible causes. Sometimes damage occur
s in the parts of the
nervous system responsible for the fine control of muscle movements: the cerebel
lum and basal ganglion are
such areas, and lack of DOPAMINE in the latter causes PARKINSONISM.
Damage or injury Damage to or pressure on the SPINAL CORD may paralyse m
uscles supplied by nerves below
the site of damage. A fractured spine or pressure from a tumour may have this ef
fect. Disorders affecting
the cord which can cause paralysis include osteoarthritis of the cervical verteb
rae (see BONE, DISORDERS
OF), MULTIPLE SCLEROSIS (MS), MYELITIS, POLIOMYELITIS and MENINGITIS. Vitamin B1
2 deficiency (see APPENDIX
5: VITAMINS) may also cause deterioration in the spinal cord (see also SPINE AND
SPINAL CORD, DISEASES AND
INJURIES OF).
Neuropathies are a group of disorders, some inherited, that damage the p
eripheral nerves, thus
affecting their ability to conduct electrical impulses. This, in turn, causes mu
scle weakness or paralysis.
Among the causes of neuropathies are cancers, DIABETES MELLITUS, liver disease,
and the toxic consequences
of some drugs or metals lead being one example. Disorders of the muscles themsel
ves for example,
muscular dystrophy (see MUSCLES, DISORDERS OF Myopathy) can disturb their normal
working and so cause
partial or complete paralysis of the part(s) affected.
Treatment The aim of treatment should be to remedy the underlying cause
for example, surgical removal
of a displaced intervertebral
P
534 Paralysis
P
Brain and spinal cord, showing motor paths and positions of injuries cau
sing various forms of
paralysis.
Paraplegia
disc or treating diabetes mellitus. Sometimes the cause cannot be rectif
ied but, whether treatable or
not, physiotherapy is essential to prevent joints from seizing up and to try to
maintain some tone in
muscles that may be only partly affected. With temporary paralysis, such as can
occur after a STROKE,
physiotherapy can retrain the sufferers to use their muscles and joints to ensur
e mobility during and after
recovery. Patients with permanent hemiplegia, paraplegia or quadraplegia need hi
ghly skilled nursing care,
rehabilitative support and resources, and expert help to allow them, if possible
, to live at home.
535
occasionally, infection may spread to produce a cerebral abscess or cere
bral venous sinus thrombosis
(see BRAIN, DISEASES OF).
Paranoia
A generic title for the professions which work closely with or are repon
sible to the medical profession
in caring for patients. A paramedical worker, coloquially called a paramedic, has
skills, experience and
qualifications in certain spheres of health care. Examples are ambulance crew pr
imarily those trained to
deal with emergencies; physiotherapists (see PHYSIOTHERAPY); radiographers (see
RADIOGRAPHER); and
dieticians (see DIETETICS).
A condition whose main characteristic is the delusion (see DELUSIONS) th
at other people are (in an
unclear way) connected to the affected individual. A sufferer from paranoia cons
tructs a complex of beliefs
based on his or her interpretation of chance remarks or events. Persecution, lov
e, jealousy and
self-grandeur are among the emotions evoked. Acute paranoia a history of less th
an six months may be
the result of drastic changes in a persons environment, such as war, imprisonment
, famine or even leaving
home for the first time. Chronic paranoia may be caused by brain damage, substan
ce abuse (including alcohol
and cannbis), SCHIZOPHRENIA or severe DEPRESSION. Those affected may become cons
tantly suspicious and angry
and tend to live an isolated existence, exhibiting difficult and odd behaviour.
Often believing themselves
to be normal, they do not seek treatment. If treated early with antipsychotic dr
ugs, they often recover; if
not, the delusions and accompanying erratic behaviour become entrenched. (See ME
NTAL ILLNESS.)
Parameter
Paraparesis
A measurement of a certain factor for example, pulse rate, blood pressur
e, or haemoglobin
536 Parapsychology
Parapsychology The branch of PSYCHOLOGY that studies extrasensory percep
tion. This includes
precognition (seeing into the future); psychokinesis (a supposed ability of some
people to move or change
the state of objects by thinking); telepathy (communicating thoughts from one pe
rson to another); and
clairvoyance (the ability to visualise events at a distance). These phenomena ha
ve no scientific
explanation and some of these abilities may be manifestations of mental illness su
ch as SCHIZOPHRENIA.
CORD through certain nerve centres in the midbrain, medulla, and lower end of the cord. The nerves
are carried in the third,
seventh, ninth and tenth cranial nerves and the second, third
nerves. The action of the
parasympathetic system is usually antagonistic to that of the
. Thus it inhibits the
action of the HEART and augments the action of the INTESTINE;
hetic augments the action
of the heart and inhibits that of the intestine. (See diagram
parasympathetic nervous
systems under NERVOUS SYSTEM.)
Parkinsonism
resulting bone fragility. This cystic disease of bone is known as OSTEIT
IS FIBROSA CYSTICA. Tumours of
the parathyroid glands result in this overactivity of the parathyroid hormone, a
nd the resulting increase
in the amount of calcium in the blood leads to the formation of stones in the ki
dneys. The only available
treatment is surgical removal of the tumour. Increased activity of the parathyro
id glands, or
hyperparathyroidism, may cause stones in the kidneys. (See KIDNEYS, DISEASES OF.
)
Paratyphoid Fever See ENTERIC FEVER.
Parenchyma A term meaning originally all the soft tissues of internal or
gans except their supporting
structures, although now reserved for the secreting cells of the glandular organ
s.
Parenteral Administration of drugs by any route other than by the mouth
or by the bowel for example,
by intramuscular or intravenous injection or infusion.
Parenteral Nutrition In severely ill patients especially those who have
had major surgery or those
with SEPSIS, burns, acute pancreatitis (see PANCREAS, DISORDERS OF) and renal fa
ilure the bodys reserves
of protein become exhausted. This results in weight loss; reduction in muscle ma
ss; a fall in the serum
albumin (see ALBUMINS) and LYMPHOCYTE count; and an impairment of cellular IMMUN
ITY. Severely ill patients
are unable to take adequate food by mouth to repair the body protein loss so tha
t enteral or parenteral
nutrition is required. Enteral feeding is through the gastrointestinal tract wit
h the aid of a nasogastric
tube; parenteral nutrition involves the provision of carbohydrate, fat and prote
ins by intravenous
administration. The preferred route for the infusion of hyperosmolar solutions i
s via a central venous
catheter (see CATHETERS). If parenteral nutrition is required for more than two
weeks, it is advisable to
use a long-term type of catheter such as the Broviac, Hickman or extra-corporeal
type, which is made of
silastic material and is inserted via a long subcutaneous tunnel; this not only
helps to fix the catheter
but also minimises the risk of ascending infection. Dextrose is considered the b
est source of carbohydrate
and may be used as a 20 per cent or 50 per cent solution. AMINO ACIDS should be
in the laevo form and
should contain the cor537
rect proportion of essential (indispensable) and non-essential amino aci
ds. Preparations are available
with or without electrolytes and with or without fat emulsions. The main hazards
of intravenous feeding are
blood-borne infections made possible by continued direct access to the circulati
on, and biochemical
538 Paronychia
Treatment Several drugs are used to keep the condition under control. No
ne is curative, all have
side-effects, and finding the most suitable one for any individual depends large
ly on understanding
cooperation between family doctor and patient. Dopaminergic and antimuscarinic (
see ANTIMUSCARINE) drugs
are used in treatment. Levodopa, a precursor of dopamine, is a long-used example
of the former; it produces
spectacular improvement in one-fifth and moderate improvement in twofifths of pa
tients. Benzhexol
hydrochloride is one of several antimuscarinic drugs used in Parkinsons disease;
selegiline is a
monoamineoxidase inhibitor used in severe parkinsonism in conjunction with levod
opa to reduce endof-dose
deterioration. Adverse effects include HYPOTENSION, nausea and vomiting, confusi
on, and agitation. Some
drugs used to treat other disorders produce Parkinsonian sideeffects. Patients s
eeking further advice and
help, together with their relatives, are advised to contact the Parkinsons Diseas
e Society of the UK.
Paronychia
P
The term applied to inflammation near the nail (see under SKIN). The inf
ection, usually caused by
Staphyloccous aureus (see STAPHYLOCOCCUS), may affect the tissues around the nai
l, including its root, and
sometimes spreads to the pulp of the affected finger or toe. The tendons that ru
n along the back of the
infected digit may occasionally become infected. Acute paronychia is the most co
mmon type, with local pain
and tenderness and swelling of the nail fold. Treatment is with ANTIBIOTICS or,
if an ABSCESS forms, local
surgery to release any pus. Sometimes infection may be caused by a virus, agains
t which antibiotics are
ineffective. If viral infection persists then antiviral drugs may eradicate it.
Chronic paronychia occurs
with reinfection of the nail bed. This is usually because the persons hands are r
egularly immersed in
water, making the skin vulnerable to infection. The finger should be kept dry an
d a dry dressing applied
accompanied by a course of antibiotics FLUCLOXACILLIN or a cephalosporin.
Parosmia A perverted sense of SMELL; everything may smell unpleasant to
the affected individual. The
most common cause is some septic condition of the nasal passages (see NOSE), but
the condition may
occasionally be due to a lesion in the BRAIN involving the centre responsible fo
r the sense of smell.
Parotid Gland One of the SALIVARY GLANDS. It is situated just in front o
f the ear, and its duct runs
forwards across the cheek to open into the interior of the mouth on a little pro
jection opposite the second
last tooth of the upper row. The parotid gland is generally the first of the sal
ivary glands to become
enlarged in MUMPS.
Parotitis Inflammation of the PAROTID GLAND caused by infection or by ma
ny AUTOIMMUNE DISORDERS.
Epidemic parotitis is another name for MUMPS.
Paroxetine One of the
ANTIDEPRESSANT DRUGS in the SELECTIVE SEROTONIN-REUPTAKE INHIBITORS (SSR
IS) group. (See also MENTAL
ILLNESS.)
Paroxysm A sudden temporary attack that may take the form of a convulsio
n or spasm. It may also occur
when a patient with a disease suddenly deteriorates.
Parrot Disease See PSITTACOSIS.
Parthenogenesis Non-sexual reproduction. In other words, development of
the OVUM into an individual
without fertilisation by a SPERMATOZOON. It is common in plants and has been pro
duced in animals
experimentally.
Partogram A method of recording the degree of dilatation, or opening, of
the cervix (or neck) of the
UTERUS in labour (see PREGNANCY AND LABOUR) to assess how labour is progressing.
Parturition Labour see PREGNANCY AND LABOUR.
Parvoviruses (from parvus, Latin for small) is a group of viruses respon
sible for outbreaks of WINTER
VOMITING DISEASE. One strain is the cause of ERYTHEMA infectiosum (slapped-cheek
syndrome).
PAS A commonly used abbreviation for PARA-AMINO SALICYLIC ACID.
Passive Movement A movement induced by someone other than
Pathogens
the patient. Physiotherapists (see PHYSIOTHERAPY) manipulate joints by p
assive movement in order to
retain and encourage function of a nerve or muscle that is not working normally
because of injury or
disease.
Pastes See OINTMENTS.
Pasteurella A group of bacilli. They are essentially animal parasites (s
ee PARASITE) that under certain
conditions are transmitted to humans, and include the micro-organism responsible
for PLAGUE and TULARAEMIA.
Pasteurisation A method of sterilising milk (see also MILK Preparation o
f milk). In many parts of the
world, pasteurisation has done away with milkborne infections, of which the most
serious is bovine
TUBERCULOSIS, affecting the glands, bones and joints of children. Other infectio
ns conveyed by milk are
SCARLET FEVER, DIPHTHERIA, ENTERIC FEVER (typhoid and paratyphoid), undulant fev
er (BRUCELLOSIS), and food
poisoning (e.g. from CAMPYLOBACTER, or the toxins of the STAPHYLOCOCCUS).
High-temperature short-time (HTST) pasteurisation consists of heating th
e milk at a temperature not
less than 717 C (161 F) for at least 15 seconds, followed by immediate cooling to a
temperature of not
more than 10 C (50 F).
539
shaped somewhat like an oyster-shell, lying in the tendon of the extenso
r muscle of the thigh, and
protecting the knee-joint in front. (See also KNEE.)
Patellar Reflex See REFLEX ACTION.
Patellar Tendinitis Also known as jumpers knee. Inflammation of the tendo
n of the extensor muscle of
the thigh, in which the PATELLA or knee-cap is secured. Usually the result of in
jury or excessive use or
stress for example, in athletic training symptoms include pain, tenderness and s
ometimes restricted
movement of the parent muscle. Treatment may include NON-STEROIDAL ANTIINFLAMMAT
ORY DRUGS (NSAIDS),
ULTRASOUND treatment and PHYSIOTHERAPY, and, if persistent, injection of a corti
costeroid drug (see
CORTICOSTEROIDS) around the tendon.
Patent In the medical context, a term meaning open for example, patent D
UCTUS ARTERIOSUS. The term is
also used for proprietary MEDICINES which, because of the research and cost invo
lved in producing many of
them, are protected by a patent. This means that without an agreement, no compan
y or organisation other
than the patent-holder can produce the substance.
Patent Ductus Arteriosus See DUCTUS ARTERIOSUS.
Low-temperature pasteurisation, or
Pathoholder process, consists in maintaining the milk for at least half an hour
at a temperature between
63 and 65 C (145150 F), followed by immediate cooling to a temperature of not more
that 10 C (50 F).
This has the effect of considerably reducing the number of bacteria contained in
the milk, and of
preventing the diseases conveyed by milk as referred to above.
A prefix indicating relationship to a disease for example, PATHOLOGY, a
study of disease.
Patch Test This is used to identify possible substances that may be caus
ing a patients ALLERGY. Small
amounts of different substances are placed on the skin usually of the back or ar
m. If the patient is
allergic then a red flare and swelling will appear, usually within about 15 minu
tes. Sometimes the reaction
may take longer up to three days to develop.
Patella Also known as the knee-cap, this is a flat bone
Pathogenesis The ways in which a disease or disorder starts and develops
. The term applies in
particular to the physiological and cellular activities that are involved in the
mode of origin and
development of the condition.
Pathogenic This term means disease-producing, and is a term applied, for
example, to bacteria capable
of causing disease.
Pathogens Micro-organisms that cause diseases, parasitising plants, anim
als and humans (see PARASITE).
Some organisms are frequently PATHOGENIC, whereas others rarely cause disease. O
pportunistic pathogens are
those which rarely cause
P
540 Pathognomonic
serious infection in healthy people but can do so in patients with weake
ned immune systems
(immunocompromised see IMMUNITY). Pathogens include BACTERIA, viruses (see VIRUS
), prions (see PRION),
fungi (see FUNGUS), PROTOZOA and metazoa (multicellular microorganisms called HE
LMINTHS or worms). The
pathogenicity of an organism is called its virulence, which is measured by the n
umber of organisms required
to cause disease. The 50 per cent of lethal dose (LD50) is the quantity of a par
ticular pathogen needed to
cause infection in half of the hosts invaded.
Pathognomonic A term applied to signs or symptoms which are especially c
haracteristic of certain
diseases, and on the presence or absence of which the diagnosis depends. Thus th
e discovery of the
Mycobacterium tuberculosis in the sputum is said to be pathognomonic of pulmonar
y tuberculosis.
Pathology The science which deals with the causes of, and changes produc
ed in the body by, disease.
Patient
P
A person with injury, physical or mental disorder or disease, or abnorma
lity who comes into the care of
a health professional or of an institution responsible for providing care to suc
h persons. Professions more
politically correct than medicine have adopted the term client perhaps due to a mi
sunderstanding of the
meaning of the word, patient (I wait upon, i.e. I consult).
Patient Choice See ETHICS.
Patient Consent See ETHICS.
Patient-Controlled Analgesia A technique whereby a patient can deliver a
n analgesic substance (see
ANALGESICS) in amounts related to the extent of the PAIN that he or she is suffe
ring. For example, to
combat post-operative pain, some hospitals use devices which allow patients to g
ive themselves small
intravenous amounts of opiates when they are needed. Pain is more effectively co
ntrolled if it is not
allowed to reach a high level, a situation which tends to happen when patients r
eceive analgesics only on
ward drug rounds or when they ask the nursing staff for them.
Patient Empowerment At a personal level, the engagement of individuals i
n decisions about their health
and about the diagnosis, treatment and after-care of their illness, injuries and
other disorders. At a
public level, the engagement of all members of the public in the planning, provi
sion and performance of
their health-care services. Traditionally, at both personal and public levels, t
he patient has generally
been regarded as naturally subordinate to the politicians and managers who plan
and run the health-care
system(s), and to health professionals and medical institutions who provide pers
onal health care. The
public and patients are increasingly unwilling to accept this traditional model
and are asserting
themselves, for example through patient help groups, complaints, litigation and
local political action with
the aim of securing changes in how health care is organised and a much greater s
ay in their own care.
Paul-Bunnell Test A test for MONONUCLEOSIS which is based upon the fact
that patients with this disease
develop ANTIBODIES which agglutinate sheep red blood cells.
Peak Flow Meter A device that measures the rate at which an individual c
an expel air from the LUNGS.
This is an indication of the reserve in the capacity of the lungs. Narrowed airw
ays (bronchospasm) slow the
rate at which air can be expelled; the peak flow meter can assess the severity o
f the condition. ASTHMA
causes bronchospasm and the device can measure the effectiveness of treatment wi
th BRONCHODILATOR drugs;
this should be done regularly to monitor the progress of the disease.
Pectin A polysaccharide substance allied to STARCH, contained in fruits
and plants, and forming the
basis of vegetable jelly. It has been used as a TRANSFUSION fluid in place of bl
ood in cases of haemorrhage
and shock.
Pectoral Anything pertaining to the chest, or a remedy used in treating
chest troubles.
Pectoriloquy The resonance of the voice, when spoken or whispered words
can be clearly heard through
the stethoscope placed on the chest wall. It is a sign of consolidation, or of a
cavity, in the lung.
Peer Review The procedures used by doctors and scientists to review the
work, decisions and writings of
their professional colleagues peer groups. Reviewers of scientific papers are co
mmonly called referees,
and papers submitted to medical and scientific journals for publication are cust
omarily reviewed by one or
more experts in the subject(s) dealt with in the paper. The aim is to improve th
e quality of the study by
pointing out potential pitfalls or errors to the author(s), or to assist medical
-journal editors in
deciding which papers to prioritise for publication. Evidence that peer review i
s effective is mixed.
Applications for research grants are also usually subjected to peer review. (See
also RESEARCH FRAUD AND
MISCONDUCT.)
Pellagra A potentially fatal nutritional disorder caused by a deficiency
of vitamin B complex (niacin).
The symptoms are DERMATITIS, diarrhoea and DEMENTIA. The deficiency occurs mainl
y in poor people in
developing countries where maize is a prime constituent of the diet. Nicotinic a
cid in maize is in a bound
form that the consumer cannot utilise. Further, maize is deficient in the amino
acid, tryptophan, from
which the human body can make nicotinic acid (see AMINO ACIDS).
Treatment The disease is prevented or cured by adding to the diet, foods
such as fresh meat, eggs,
milk, liver, and yeast extracts, as well as nicotinic acid in addition to improv
ing the general
conditions of life.
Pelvic Inflammatory Disease (PID) An infection of the endometrium (membr
aneous lining) of the UTERUS,
FALLOPIAN TUBES and adjacent structures caused by the ascent of micro-organisms
from the vulva and vagina.
Around 100,000 women develop PID each year in the UK; most of those affected are
under 25 years of age.
Infection is commonly associated with sexual intercourse; Chlamydia trachomatis
(see CHLAMYDIA) and
Neisseria gonorrhoeae (see NEISSERIACEAE) are the most common pathogens. Althoug
h these bacteria initiate
PID, opportunistic bacteria such as STREPTOCOCCUS and bacteroides often replace
them. The infection may be
silent with no obvious symptoms or symptoms may be
P
542 Pelvimetry
troublesome, for example, vaginal discharge and sometimes a palpable mas
s in the lower abdomen. If a
LAPAROSCOPY is done usually by endoscopic examination overt evidence of PID is f
ound in around 65 per
cent of suspected cases. PID may be confused with APPENDICITIS, ECTOPIC PREGNANC
Y and PID is a common
cause of such pregnancies ovarian cyst (see OVARIES, DISEASES OF) and inflammato
ry disorders of the
intestines. Treatment is with a combination of ANTIBIOTICS that are active again
st the likely pathogens,
accompanied by ANALGESICS. Patients may become seriously ill and require hospita
l care, where surgery is
sometimes required if conservative management is unsuccessful. All women who hav
e PID should be screened
for sexually transmitted disease and, if this is present, should be referred wit
h their partner(s) to a
genito-urinary medicine clinic. Up to 20 per cent of women who have PID become i
nfertile, and there is a
sevento ten-fold greater risk of an ectopic pregnancy occurring.
Pelvimetry Measurement of the internal dimensions of the PELVIS. The fou
r diameters measured are:
transverse, anterioposterior, and left and right oblique. These measurements hel
p to establish whether a
fetus can be delivered normally. If the outlet is abnormally small, the mother w
ill have to be delivered by
CAESAREAN SECTION.
P
Pelvis The bony pelvis consists of the two hip bones, one on each side,
with the sacrum and coccyx
behind. It connects the lower limbs with the spine. In the female it is shallowe
r than in the male and the
ilia are more widely separated, giving great breadth to the hips of the woman; t
he inlet is more circular
and the outlet larger; whilst the angle beneath the pubic bones (subpubic angle)
, which is an acute angle
in the male, is obtuse in the female. All these points are of importance in conn
ection with childbearing.
The contents of the pelvis are the urinary bladder and rectum in both sexes; in
addition the male has the
seminal vesicles and the prostate gland surrounding the neck of the bladder, whi
lst the female has the
womb, ovaries, and their appendages. A second meaning is as in renal pelvis that
part of the collecting
system proximal to the URETER which collects urine from the renal pyramids (see
KIDNEYS).
Pemphigoid See PEMPHIGUS.
Pemphigus Autoimmune disease of the SKIN in which the cells of the epide
rmis lose their adhesion to
each other, resulting in blister formation.
Pemphigus vulgaris is a serious form affecting skin and MUCOUS MEMBRANE.
It affects young and
middle-aged people with widespread blistering, erosion and crusting of the skin.
Extensive involvement of
the lips, mouth and throat interfere with nutrition. Untreated, it is eventually
fatal, but the disease can
now be controlled by large doses of oral CORTICOSTEROIDS and other immunosuppres
sive drugs. MORBIDITY from
the adverse effects of steroids is a serious problem, but some patients are even
tually cured.
Pemphigus foliaceus is seen in the elderly; the blistering is more super
ficial in the epidermis. It may
be very widespread, but is not life-threatening because mucous membranes are not
affected. Topical
corticosteroids will sometimes control the eruption, but in severe cases treatme
nt is as for pemphigus
vulgaris.
Pemphigoid is a variant where the blistering occurs because of separatio
n of the epidermis and dermis.
Mucosae are rarely affected and the disease affects mainly the arms and legs in
the elderly. Treatment is
as for pemphigus but smaller doses of corticosteroids usually suffice.
Penicillamine A metabolite of PENICILLIN which is one of the CHELATING A
GENTS. It is sometimes used in
RHEUMATOID ARTHRITIS that has not responded to the first-line remedies and it is
particularly useful when
the disease is complicated by VASCULITIS. Penicillamine is also used as an antid
ote to poisoning by heavy
metals, particularly copper and lead, as it is able to bind these metals and so
remove their toxic effects.
Because of its ability to bind copper it is also used in WILSONS DISEASE where th
ere is a deficiency in
the copper-binding protein so that copper is able to become deposited in the bra
in and liver, damaging
these tissues.
Penicillin The name given by Sir Alexander Fleming, in 1929, to an antib
acterial substance produced by
the mould Penicillium notatum. The story of penicillin is one of the most dramat
ic in the history of
medicine, and its introduction into
Penis
medicine initiated a new era in therapeutics comparable only to the intr
oduction of ANAESTHESIA by
Morton and Simpson and of ANTISEPTICS by Pasteur and Lister. The two great advan
tages of penicillin are
that it is active against a large range of bacteria and that, even in large dose
s, it is non-toxic.
Penicillin diffuses well into body tissues and fluids and is excreted in the uri
ne, but it penetrates
poorly into the cerebrospinal fluid. Penicillin is a beta-lactam antibiotic, one
of a group of drugs that
also includes CEPHALOSPORINS. Drugs of this group have a fourpart beta-lactam ri
ng in their molecular
structure and they act by interfering with the cellwall growth of mutliplying ba
cteria. Among the organisms
to which it has been, and often still is, active are: streptococcus, pneumococcu
s, meningococcus,
gonococcus, and the organisms responsible for syphilis and for gas gangrene (for
more information on these
organisms and the diseases they cause, refer to the separate dictionary entries)
. Most bacteria of the
genus staphylococcus are now resistant because they produce an enzyme called PEN
ICILLINASE that destroys
the antibiotic. A particular problem has been the evolution of strains resistant
to methicillin a
derivative originally designed to conquer the resistance problem. These bacteria
, known as
METHICILLINRESISTANT STAPHYLOCOCCUS AUREUS (MRSA), are an increasing problem, es
pecially after major
surgery. Some are also resistant to other antibiotics such as vancomycin. An imp
ortant side-effect of
penicillins is hypersensitivity which causes rashes and sometimes ANAPHYLAXIS, w
hich can be fatal.
Forms of penicillin These include the following broad groups: benzylpeni
cillin and
phenoxymethyl-penicillin; penicillinaseresistant penicillins; broad-spectrum pen
icillins; antipseudomonal
penicillins; and mecillinams. BENZYLPENICILLIN is given intramuscularly, and is
the form that is used when
a rapid action is required. PHENOXYMETHYLPENICILLIN (also called penicillin V) i
s given by mouth and used
in treating such disorders as TONSILLITIS. AMPICILLIN, a broad-spectrum antibiot
ic, is another of the
penicillins derived by semisynthesis from the penicillin nucleus. It, too, is ac
tive when taken by mouth,
but its special feature is that it is active against gram-negative (see GRAMS STA
IN) micro-organisms such
as E. coli and the salmonellae. It has been superceded by amoxicillin to the ext
ent that prescriptions for
ampicillin written by GPs in the UK to be dis543
pensed to children have fallen by 95 per cent in the last ten years. CAR
BENICILLIN, a semi-synthetic
penicillin, this must be given by injection, which may be painful. Its main use
is in dealing with
infections due to Pseudomonas pyocanea. It is the only penicillin active against
544 Pentamidine
This makes the penis erect and ready for insertion into the womans vagina
in sexual intercourse. The
end of the penis, the glans, is covered by a loose fold of skin the foreskin or
PREPUCE which retracts
when the organ is erect. The foreskin is sometimes removed for cultural or medic
al reasons. A common
congenital disorder of the penis is HYPOSPADIAS, in which the urethra opens some
where along the under side;
it can be repaired surgically. BALANITIS is inflammation of the glans and foresk
in. (See also REPRODUCTIVE
SYSTEM; EJACULATION; IMPOTENCE; PRIAPISM.)
Pentamidine A drug that is used in the prevention and treatment of Afric
an trypanosomiasis (see
SLEEPING SICKNESS), and in the treatment of LEISHMANIASIS.
Pepsin
P
next to one another. Still more valuable evidence is given by AUSCULTATI
ON.
Percutaneous Any method of administering remedies by passing them throug
h the SKIN, as by rubbing in an
ointment or applying a patch containing a drug.
Percutaneous Transhepatic Cholangiopancreatography (PTC) A technique for
displaying the bile ducts (see
BILE DUCT) and pancreatic ducts (see PANCREAS) with radio-opaque dyes. These are
introduced via a catheter
(see CATHETERS) inserted into the ducts through an incision in the skin. An X-ra
y is then taken of the
area.
Percutaneous Transluminal Coronary Angioplasty
An ENZYME found in the gastric juice which digests proteins, converting
them into peptides (see
PEPTIDE) and AMINO ACIDS. It is used in the preparation of predigested foods (PE
PTONISED FOODS), or, more
frequently, taken orally after meals. Available as a white powder or liquid, it
is prepared from the mucous
membrane of cow, sheep, or pig stomachs.
A treatment for a stenosed (restricted) coronary artery (see ARTERIES).
A balloon-tipped catheter (see
CATHETERS) is passed through an incision in the skin of the chest into the arter
y of the HEART that has
developed stenosis (narrowing). The balloon is aligned with the stenosed section
and then inflated to
dilate the coronary artery and allow the blood to flow more freely.
Peptic Ulcer
Perforation
The term commonly applied to ulcers in the stomach and duodenum. (See DU
Periosteum
545
Perfusion
Perinatal Mortality
The transfer of fluid through a tissue. For example, when blood passes t
hrough the lung tissue,
dissolved oxygen perfuses from the moist air in the alveoli to the blood. Fluid
may also be deliberately
introduced into a tissue by injecting it into the blood vessels supplying the ti
ssue. It is used as a sign
of how adequate the circulation is at the time of illness. Poor peripheral perfu
sion, a sign of circulatory
collapse or shock, is recognised by pressing on the skin to force blood from cap
illaries. The time it takes
for them to refill and the skin to become pink is noted: more than 5 seconds, an
d the circulation is likely
to be compromised.
Perinatal mortality consists of deaths of the FETUS after the 28th week
of pregnancy and deaths of the
newborn child during the first week of life. Today, more individuals die within
a few hours of birth than
during the following 40 years. It is therefore not surprising that the perinatal
mortality rate, which is
the number of such deaths per 1,000 total births, is a valuable indicator of the
quality of care provided
for the mother and her newborn baby. In 2002, the perinatal mortality rate was 7
.87 in the United Kingdom
compared with 11.4 in 1982 and over 30 in the early 1960s. The causes of perinat
al mortality include
extreme prematurity, intrapartum anoxia (that is, difficulty in the birth of the
baby, resulting in lack of
oxygen), congenital abnormalities of the baby, and antepartum anoxia (that is, c
onditions in the terminal
stages of pregnancy preventing the fetus from getting sufficient oxygen). The mo
st common cause of
perinatal death is some complication of placenta, cord or membranes. The next mo
st common is congenital
abnormality. Intrauterine hypoxia and birth asphyxia comprise the third most com
mon cause.
PeriA prefix meaning around.
Periarteritis Nodosa See POLYARTERITIS NODOSA.
Pericarditis Acute or chronic inflammation of the PERICARDIUM, the membr
anous sac that surrounds the
HEART. It may occur on its own or as part of PANCARDITIS, when inflammation also
affects the MYOCARDIUM and
ENDOCARDIUM (membranous lining of the inside of the heart). Various causes inclu
de virus infection, cancer
and URAEMIA. (See also HEART, DISEASES OF.)
Pericardium The smooth membrane that surrounds the
Perineum Popularly called the crotch, or crutch, this is the region situ
546 Periostitis
place beneath it; if it is destroyed, the bone may cease to grow and a p
ortion may die and separate as
a sequestrum.
Periostitis Periostitis means inflammation on the surface of a BONE, aff
ecting the PERIOSTEUM. (See
BONE, DISORDERS OF.)
Peripheral-Blood Stem-Cell Transplants
P
These have almost completely replaced BONE MARROW TRANSPLANT, used to tr
eat malignancies such as
LEUKAEMIA and LYMPHOMA for the past 20 years. The high doses of CHEMOTHERAPY or
RADIOTHERAPY used to treat
these diseases destroy the bone marrow which contains stem cells from which all
the blood cells derive. In
1989 stem cells were found in the blood during recovery from chemotherapy. By gi
ving growth factors
(cytokines), the number of stem cells in the blood increased for about three to
four days. In a
peripheral-blood stemcell transplant, these cells can be separated from the peri
pheral blood, without a
general anaesthetic. The cells taken by either method are then frozen and return
ed intravenously after the
chemotherapy or radiotherapy is completed. Once transplanted, the stem cells usu
ally take less than three
weeks to repopulate the blood, compared to a month or more for a bone marrow tra
nsplant. This means that
there is less risk of infection or bleeding during the recovery from the transpl
ant. The whole procedure
has a mortality risk of less than 5 per cent half the risk of a bone marrow tran
splant.
Peripheral Nervous System See NERVOUS SYSTEM.
Peripheral Neuritis Inflammation of the nerves (see NERVE) in the outlyi
ng parts of the body. (See
NEURITIS.)
Peripheral Vascular Disease The narrowing of the blood vessels in the le
gs and, less commonly, in the
arms. Blood flow is restricted, with pain occurring in the affected area. If the
blood supply is seriously
reduced, GANGRENE of the tissues supplied by the affected vessel(s) may occur an
d the limb may need to be
amputated. The common cause is ATHEROSCLEROSIS which may be brought on by HYPERT
ENSION, excessively fatty
diet, poorly controlled DIABETES MELLITUS or smoking the latter being the bigges
t risk factor, with 90
per cent of affected patients having been moderate to heavy smokers. Stopping sm
oking is essential;
adequate exercise and a low-fat diet
are important measures. Surgery may be required.
Peristalsis The worm-like movement by which the stomach and bowels prope
Personality Disorder
treatment, together with strong analgesics is usually successful if star
ted soon enough.
Peritonsillar Abscess The term applied to a collection of pus or an ABSC
ESS which occurs complicating
an attack of TONSILLITIS. The collection of pus forms between the tonsil and the
superior constrictor
muscle of the pharynx. This condition is also known as quinsy; treatment drainag
e of the abscess and the
administration of appropriate antibiotics.
Permethrin Along with phenothrin, this is a largely nontoxic pyrethroid
insecticide, effective in
SCABIES and lice infestations. Resistance may develop to these insecticides and
also to MALATHION and
CARBARYL, in which case topical treatment should be alternated among the differe
nt varieties.
Pernicious Anaemia An autoimmune disease in which sensitised lymphocytes
(see LYMPHOCYTE) destroy the
parietal cells of the STOMACH. These cells normally produce intrinsic factor, wh
ich is the carrier protein
for vitamin B12 that permits its absorption in the terminal ileum. Without intri
nsic factor, vitamin B12
cannot be absorbed and this gives rise to a macrocytic ANAEMIA. The skin and muc
osa become pale and the
tongue smooth and atrophic. A peripheral NEUROPATHY is often present, causing pa
raesthesiae (see under
TOUCH), numbness and even ATAXIA. The more severe neurological complication of s
ub-acute combined
degeneration of the cord is fortunately more rare. The anaemia gets its name fro
m the fact that before the
discovery of vitamin B12 it was uniformly fatal. Now a monthly injection of vita
min B12 is all that is
required to keep the patient healthy.
Peroneal The name given to structures, such as the muscles, and nerves,
on the outer or fibular side of
the leg.
Perphenazine See PHENOTHIAZINES.
Perseveration Perseveration is the senseless repetition of words or deed
s by a person with a disordered
mind.
Persistent Vegetative State (PVS) PVS may occur in patients with severe
brain
547
damage from HYPOXIA or injury. Patients do not display any
their surroundings, and are
unable to communicate. Sleep alternates with apparent wakefulness,
lexes (see REFLEX ACTION)
may be present: for example, patients eyes may reflexly follow or
d, their limbs can
reflexly withdraw from pain, and their hands can reflexly grope or
awareness of
when some ref
respond to soun
grasp. Patien
ts can breathe
spontaneously, and retain normal heart and kidney function, although they are do
ubly incontinent (see
INCONTINENCE). For a diagnosis of PVS to be made, the state should have continue
d for more than a
predefined period, usually one month. Half of patients die within 26 months, but
some can survive for
longer with artificial feeding. To assess a persons level of consciousness, a num
erical marking system
rated according to various functions eye opening, motor and verbal responses has
been established
called the GLASGOW COMA SCALE. The ETHICS of keeping patients alive with artific
ial support are
controversial. In the UK, a legal ruling is usually needed for artificial suppor
t to be withdrawn after a
diagnosis of PVS has been made. The chances of regaining consciousness after one
year are slim and, even if
patients do recover, they are usually left with severe neurological disability.
PVS must be distinguished
from conditions which appear similar. These include the LOCKED-IN SYNDROME which i
s the result of damage
to the brain stem (see BRAIN). Patients with this syndrome are conscious but una
ble to speak or move except
for certain eye movements and blinking. The psychiatric state of CATATONIA is an
other condition in which
the patient retains consciousness and will usually recover.
Personality Disorder Condition in which the individual fails to learn fr
om experience or to adapt to
changes. The outcome is impaired social functioning and personal distress. There
are three broad
overlapping groups. One group is characterised by eccentric behaviour with paran
oid or schizoid overtones.
The second group shows dramatic and emotional behaviour with self-centredness an
d antisocial behaviour as
typical components of the disorder. In the third group, anxiety and fear are the
main characteristics,
which are accompanied by dependency and compulsive behaviour. These disorders ar
e not classed as illnesses
but psychotherapy and behavioural therapy may help. The individuals affected are
notoriously resistant to
any help that is offered,
P
548 Perspiration
tending to blame other people, circumstances or bad luck for their persi
stent difficulties. (See MENTAL
ILLNESS; MULTIPLE PERSONALITY DISORDER; MUNCHAUSENS SYNDROME.)
Perspiration Commonly called sweat, it is an excretion from the SKIN, pr
oduced by microscopic
sweatglands, of which there are around 25 million, scattered over the surface. Th
ere are two different
types of sweat-glands, known as eccrine and apocrine. Insensible (that is unnoti
ced) perspiration takes
place constantly by evaporation from the openings of the sweat-glands, well over
a litre a day being
produced. Sensible perspiration (that is, obvious) to which the term sweat is usua
lly confined occurs
with physical exertion and raised body temperature: up to 3 litres an hour may b
e produced for short
periods. Normal sweating maintains the body within its customary temperature ran
ge and ensures that the
skin is kept adequately hydrated for example, properly hydrated skin of the palm
helps the effectiveness
of a persons normal grip. The chief object of perspiration is to maintain an even
body temperature by
regulating the heat lost from the body surface. Sweating is therefore increased
by internally produced
heat, such as muscular activity, or external heat. It is controlled by two types
of nerves: vasomotor,
which regulate the local blood flow, and secretory (part of the sympathetic nerv
ous system) which directly
influence secretion.
P
Eccrine sweat is a faintly acid, watery fluid containing less than 2 per
cent of solids. The eccrine
sweat-glands in humans are situated in greatest numbers on the soles of the feet
and palms of the hands,
and with a magnifying glass their minute openings or pores can be seen in rows o
ccupying the summit of each
ridge in the skin. Perspiration is most abundant in these regions, although it a
lso occurs all over the
body. Apocrine sweat-glands These start functioning at puberty and are found in
the armpits, the eyelids,
around the anus in association with the external genitalia, and in the areola an
d nipple of the breast.
(The glands that produce wax in the ear are modified apocrine glands.) The flow
of apocrine sweat is evoked
by emotional stimuli such as fear, anger, or sexual excitement.
Abnormalities of perspiration
Decreased sweating may occur in the early stages
of fever, in diabetes, and in some forms of glomerulonephritis (see KIDN
EYS, DISEASES OF). Some people
are unable to sweat copiously, and are prone to HEAT STROKE. EXCESSIVE SWEATING,
OR HYPERIDROSIS, may be
caused by fever, hyperthyroidism (see THYROID GLAND, DISEASES OF), obesity, diab
etes mellitus, or an
Phaeochromocytoma
Pes cavus may be present at birth or it can be caused by disruption of o
r damage to the blood and nerve
supplies to the foot muscles. The use of a specially made insole in the shoe may
help, but surgery is
sometimes needed.
Pes Planus The technical name for FLAT-FOOT.
Pessaries (1) A plastic device placed in the VAGINA designed to support
a displaced UTERUS. (2) A
suppository suitably shaped for insertion into the vagina. Made of oil of theobr
omine or a glycerin basis,
they are used for applying local treatment to the vagina.
Pesticides Any substance or mixture of substances intended for preventin
g or controlling unwanted
species of plants and animals. This includes any substances intended for use as
plant-growth regulators,
defoliants or desiccants. The main groups of pesticides are: herbicides to contr
ol weeds; insecticides to
control insects; and fungicides to control or prevent fungal disease.
Petechiae Small red MACULES due to haemorrhage in the skin. They may be
caused by trauma such as by
tight pressure, as in strangulation or even by the effect of violent coughing. B
leeding and clotting
disorders may provoke petechiae, and they are a feature of many childhood viral
infections. Most
importantly they may be a sign of SEPTICAEMIA due to a meningococcus (see NEISSE
RIACEAE).
Pethidine Hydrochloride A synthetic analgesic and antispasmodic drug, wh
ich is used in the treatment of
painful and spasmodic conditions in place of morphine and atropine. A prompt but
short-lasting analgesic,
it has less of a constipating effect than morphine but is less potent. Useful fo
r analgesia during
childbirth because it produces less respiratory depression in the baby than othe
r opioids. Pethidine is one
of the CONTROLLED DRUGS.
Petit Mal An out-of-date term for less severe type of epileptic seizure
(see EPILEPSY) that occurs
usually in children or adolescents but less often in adults. The type of seizure
is now referred to as an
absence attack.
549
Petri Dishes Shallow, circular glass dishes, usually 10 cm in diameter,
which are used in bacteriology
laboratories for the growth of micro-organisms.
PET Scanning Positron-emission tomography is a NUCLEAR MEDICINE diagnost
ic technique that works by
identifying positrons positively charged electrons given off by substances label
led with radioactive
varieties of elements. The result is three-dimensional images that identify meta
550 Phagocyte
pressure (HYPERTENSION), raised heart rate, and headache. Surgery to rem
ove the tumour may be possible;
if not, drug treatment may help.
Phagocyte Cells including monocytes (a variety of LEUCOCYTES) in the blo
od and macrophages (see
MACROPHAGE) in the tissues that envelop and digest BACTERIA cells, cell debris a
nd other small particles.
Phagocytes are an essential part of the bodys defence mechanisms.
Phagocytosis A process by which BACTERIA and other foreign particles in
the body are ingested by
monocytes in the blood and macrophages in the tissues (see under PHAGOCYTE) that
envelop and digest
bacteria, cells, cell debris and other small particles. Phagocytes are an essent
ial part of the bodys
defence mechanisms.
Phalanx (Plural: phalanges.) The name given to any one of the small bone
s of the fingers and toes. The
phalanges are 14 in number in each hand and foot the thumb and great toe possess
ing only two each, whilst
each of the other fingers and toes has three.
Phallus
P
An alternative name for the PENIS, this word may also be used to describ
e a penis-like object. In
embryology the phallus is the rudimentary penis before the urethral duct has com
pletely developed.
Phantasy The term applied to an imaginary appearance or daydream.
Phantom Limb Following the AMPUTATION of a limb, it is usual for the pat
ient to experience sensations
as if the limb were still present. This condition is referred to as a phantom li
mb. In most patients the
sensation passes off in time.
Pharmacists Health professionals trained in the preparation and dispensi
ng of medicines; in England,
Scotland and Wales they are registered (after acquiring the relevant professiona
l qualifications) by the
Royal Pharmaceutical Society. Northern Ireland has its own registration body. Re
gistered pharmacists are a
vital branch of health care. They dispense P (pharmacy-only) and POM (prescripti
on-only medicines)
products; those working in community (retail) pharmacies also
sell over-the-counter (OTC) drugs, providing, where appropriate, advice
on their use. (See also
MEDICINES.) Pharmacists work in hospitals (NHS and private) and in community pha
rmacies, as well as in the
pharmaceutical industry where they conduct research and prepare and test pharmac
eutical products. They have
particular expertise on the use of drugs: for instance, the way in which one med
Phenindione
should benefit patients by ensuring a more accurately targeted drug and
by reducing the risks to a
person of side-effects from taking a drug that would not work. There would also
be substantial economic
savings.
Pharmacokinetics The way in which the body deals with a drug. This inclu
des the drugs absorption,
distribution in the tissues, METABOLISM, and excretion.
Pharmacology The branch of science that deals with the discovery and dev
elopment of drugs. Those
working in it (pharmacologists, doctors, scientists and laboratory technicians)
determine the chemical
structure and composition of drugs and how these act in the body. They assess th
e use of drugs in the
prevention and treatment of diseases, their side-effects and likely toxicity. Th
is work takes place in
universities, hospitals and, in particular, the pharmaceutical industry. The lat
ter has expanded
tremendously during the 20th century and in Britain it is now one of the largest
business sectors, not only
providing the NHS with most of its pharmaceutical requirements but also exportin
g many medicines to other
countries. Pharmacologists not only research for new drugs, but also look for wa
ys of synthesising them on
a large scale. Most importantly, they organise with clinicians the thorough test
ing of drugs to ensure that
these are safe to use, additionally helping to monitor the effects of drugs in r
egular use so as to
identify unforeseen sideeffects. Doctors and hospital pharmacists have a special
reporting system (Yellow
Cards) under which they notify the governments MEDICINES CONTROL AGENCY of any unt
oward consequences of
drug treatments on their patients (see also MEDICINES).
551
Pharmacy The term applied to the practice of preparing and compounding m
edicines, or to a place where
this is carried out.
Pharyngitis An inflammatory condition affecting the wall of the PHARYNX
or the throat proper. It is
most commonly due to a viral upper respiratory tract infection, and may be confi
ned to the pharynx or may
also involve the rest of the upper respiratory tract i.e. the nose and the laryn
x. The mucous membrane is
red and glazed with enlarged lymph-follicles scattered over it. The patients thro
at feels sore and
swallowing may be uncomfortable. Only symptomatic treatment, such as the use of
analgesic drugs or lozenges
and gargles, is necessary for viral pharyngitis, which usually is a stage in the
development of a cold, or
(less often, but more seriously) INFLUENZA. MONONUCLEOSIS may also start with ph
aryngitis. Streptococcal
bacteria linked to SCARLET FEVER also cause the condition.
Pharynx Another name for the throat. The term throat is popularly applie
d to the region about the front
of the neck generally, but in its strict sense it means the irregular cavity int
o which the nose and mouth
open above, from which the larynx and gullet open below, and in which the channe
l for the air and that for
the food cross one another. In its upper part, the EUSTACHIAN TUBES open one on
either side, and between
them on the back wall grows a mass of glandular tissue adenoids (see NOSE, DISOR
DERS OF).
Phenazocine Hydrobromide A powerful analgesic which can be given under t
he tongue if nausea and
vomiting are a problem.
Pharmacopoeia
Phenelzine
An official publication dealing with the recognised drugs and giving the
ir doses, preparations,
sources, and tests. Most countries have a pharmacopoeia of their own. That for G
reat Britain and Ireland is
prepared by the British Pharmacopoeia Commission under the direction of the Medi
cines Commission. Many
hospitals and medical schools have a small pharmacopoeia of their own, giving th
e prescriptions most
commonly dispensed in that particular hospital or school. The British National F
ormulary is a compact
authoritative volume for those concerned with the prescribing or dispensing of m
edicines.
An example of the widely used ANTIDEPRESSANT DRUGS which are classified
as MONOAMINE OXIDASE INHIBITORS
(MAOIS). The drug is particularly useful because its stimulant effect is less th
an that of most other
MAOIs.
Phenindione A synthetic anticoagulant (see ANTICOAGULANTS). Given by mou
th, it is used to prevent the
formation of clots in the blood in rheumatic heart disease and atrial fibrillati
on (see HEART, DISEASES
OF); as prophylaxis after insertion of a prosthetic heart valve; and as prophyla
xis and treatment of venous
thrombosis and pulmonary
P
552 Phenobarbitone
embolism. It is slower in action than WARFARIN, not achieving its full a
nticoagulant effect until up to
48 hours after the initial dose. The drug should be avoided in patients with ren
al or hepatic impairment,
and whenever severe hypersensitivity reactions have previously occurred. Adverse
effects include rashes,
fever, LEUCOPENIA, AGRANULOCYTOSIS, diarrhoea and pink urine; breast feeding sho
uld be avoided.
Phenobarbitone The British Pharmacopoeia name for one of the most widely
used of all the group of drugs
called BARBITURATES. It was mainly used in combination with PHENYTOIN SODIUM as
an anticonvulsant drug in
the control of EPILEPSY, but has been superceded largely by newer and safer anti
-epileptic drugs.
See PERMETHRIN.
Phenotype An individuals characteristics as determined by the interaction
between his or her genotype
quota of GENES and the environment.
Phenoxybenzamine An alpha-adrenoceptor blocking drug (see ADRENERGIC REC
EPTORS) used in the treatment
of HYPERTENSION caused by PHAEOCHROMOCYTOMA.
Phenoxymethylpenicillin See under PENICILLIN.
Phenylalanine
Another name for CARBOLIC ACID.
A natural amino acid (see AMINO ACIDS) essential for growth in infants,
and for nitrogen metabolism in
adults.
Phenothiazines
Phenylketonuria
A group of major antipsychotic drugs, colloquially called TRANQUILLISERS,
widely used to treat
psychoses (see PSYCHOSIS). They can be divided into three main groups. Chlorprom
azine, methotrimeprazine
and promazine are examples of group 1, usually characterised by their sedative e
ffects and moderate
antimuscarinic and extrapyramidal side-effects. Group 2 includes pericyazine, pi
pothiazine and
thioridazine, which have moderate sedative effects but significant antimuscarini
c action and modest
extrapyramidal side-effects. Fluphenazine, perphenazine, prochlorperazine and tr
ifluoperazine comprise
group 3. Their sedative effects are less than for the other groups and they have
little antimuscarinic
action; they have marked extrapyramidal side-effects.
Commonly referred to as PKU, this is one of the less common, but very se
vere, forms of mental
Phospholipid
there is growing evidence of the part they play in the animal kingdom. T
hus, if a strange male rat is
put into a group of female rats, this may cause death of the fetus in any pregna
nt rats, and this is
attributed to the pheromones emitted by the male rat.
Phimosis Tightness of the foreskin (PREPUCE) which prevents it from bein
g pulled back over the
underlying head (glans) of the PENIS. Some phimosis is normal in uncircumcised m
ales until they are six
months old. The condition may, however, persist, eventually causing problems wit
h urination. BALANITIS may
occur because the inside of the foreskin cannot be properly washed. There may be
an increased risk of
cancer of the penis. In adolescents and adults with phimosis, erection of the pe
nis is painful.
CIRCUMCISION is the treatment.
Phlebitis Inflammation of a vein. (See EASES OF.)
553
phobophobia (fear of phobias) and triskaidekaphobia (fear of having 13 s
itting at table). Phobia is a
form of obsession, and not uncommonly one of the features of anxiety. Treatment
is behavioural therapy
complemented in some patients with ANTIDEPRESSANT DRUGS. Care is needed, as some
sufferers can become
psychologically dependent on the drugs used to treat them (see DEPENDENCE). Thos
e who suffer from what can
be a most distressing condition can obtain help and advice from the Phobics Soci
ety. (See also MENTAL
ILLNESS.)
Phocomelia This is a great reduction in the size of the proximal parts o
f the limbs. In extreme cases
the hands and feet may spring directly from the trunk. A rare condition, it occu
rred most commonly in
children whose mothers took THALIDOMIDE in early pregnancy.
Pholcodine VEINS; VEINS, DISPhlebography
An
OPIOID cough suppressant similar CODEINE; it is not, however, potent eno
ugh
to to suppress severe coughs and is also constipating.
The study of the VEINS, particularly by means of X-rays after the veins
have been injected with a
radio-opaque substance.
Phonation
Phlebolith
Phonocardiograph
The term applied to a small stone formed in a vein (see VEINS) as a resu
lt of calcification of a
An instrument for the graphic recording of heart sounds and murmurs.
THROMBUS.
Phlebotomy A traditional name for the operation of bloodletting by openi
ng a vein. (See VEINS;
VENESECTION.)
Phlegm A popular name for MUCUS, particularly that secreted in the air p
assages. (See BRONCHITIS;
EXPECTORANTS.)
Phlyctenule A HYPERSENSITIVITY reaction of the conjunctiva (see EYE). At
the turn of the century the
most common cause was TUBERCULOSIS; nowadays it is most commonly due to hypersen
sitivity to staphylococci
(see STAPHYLOCOCCUS).
Phobia An irrational fear of particular objects or situations. A well-kn
own American medical dictionary
lists more than 200 examples of phobias, ranging, alphabetically, from fear of air
to fear of writing.
Included in the list are
The production of vocal sounds in particular, speech.
Phosphates Salts of phosphoric acid. As this substance is contained in m
any articles of food as well as
in bone, the nuclei of cells, and the nervous system, phosphates are constantly
excreted in the URINE. The
continued use of an excess of food containing alkalis, such as green vegetables,
and still more the
presence in the urine of bacteria which lead to its decomposition, produce the n
ecessary change from the
natural mild acidity to alkalinity, and lead to the deposit of phosphates and to
their collection into
stones.
Phosphaturia The presence in the URINE of a large amount of PHOSPHATES.
Phospholipid A LIPID, the molecule of which contains a chemical derivati
ve of PHOSPHORUS called
phosphate. This type of lipid, which includes cephalins, lecithins and plasmalog
ens, is found in all
tissues and organs, especially the BRAIN. Phospholipids are produced in the LIVE
R and
P
554 Phosphorus
and take part in many of the bodys metabolic activities (see METABOLISM).
Phosphorus A non-metallic element whose compounds are widely found in pl
ant and animal tissues. In
humans, this element is largely concentrated in BONE. Some phosphorus-containing
compounds such as
ADENOSINE TRIPHOSPHATE (ATP) and creatine phosphate are essential participants i
n the conversion and
storage of energy that are part of the bodys METABOLISM. Pure phosphorus is toxic
.
Phosphorus Burns Phosphorus compounds are used in chemical laboratories,
some industrial processes,
matches, fireworks and in certain types of aerial bombs and artillery shells. If
particles of phosphorus
settle on or become embedded in the skin, the resulting burn should be treated w
ith a 2 per cent solution
of sodium bicarbonate, followed by application of a 1 per cent solution of coppe
r sulphate.
Photochemotherapy A form of treatment in which deliberate exposure to a
photosensitising drug and
ultraviolet light benefits certain skin diseases, particularly PSORIASIS and T-c
ell LYMPHOMA. A psoralen is
the photoactive agent which reacts with long-wave ultraviolet light (UVA), givin
g the acronym, PUVA
therapy.
P
Photocoagulation Coagulation of the tissues of the retina (see EYE) by l
aser, for treatment of diseases
of the retina such as diabetic retinopathy (see under EYE, DISORDERS OF Retina,
disorders of ).
Photodermatoses Diseases of the SKIN for which sunlight is partially or
wholly responsible. In
sufficient dosage, short-wave ultraviolet light (UVB see ULTRAVIOLET RAYS (UVR))
always causes ERYTHEMA.
Higher doses progressively cause OEDEMA and blistering; this is acute sunburn. G
raduated exposure to UVB
causes pigmentation (tanning). Prolonged chronic exposure to sunlight eventually
accelerates ageing of the
exposed skin with LENTIGO formation and loss of COLLAGEN and elastic tissue. Aft
er decades of such
exposure, epidermal DYSPLASIA and CANCER may supervene. Drugs given orally or to
pically may induce
phototoxic reactions of various types. Thus, TETRACYCLINES exaggerate sunburn re
actions. and the diuretic
FRUSEMIDE may cause blistering reactions. Psoralens induce erythema and pigmentation. AMIODARONE al
so induces pigmentation. (See
also PHOTOCHEMOTHERAPY.)
Phytophotodermatitis is a streaky, blistering photodermatosis typically
seen on the limbs of children
playing in grassy meadows in summer. The phototoxic reaction is caused by psoral
ens in weeds.
Berlocque dermatitis
is a pattern of streaky pigmentation usually seen on womens necks, caused
by a reaction to psoralens
in perfumes. Certain rare metabolic diseases may lead to photosensitisation. The
y include the PORPHYRIAS
and PELLAGRA. Other skin diseases such as lupus erythematosus (see under LUPUS)
and ROSACEA may be
aggravated by light exposure. Sometimes, in the absence of any of these factors,
some people spontaneously
develop a sensitivity to light causing various patterns of DERMATITIS or URTICAR
IA. The most common pattern
is polymorphic light eruption which typically appears within a day or two of arriv
al at a sunny holiday
destination and persists until departure. Continuously exposed areas, such as th
e hands and face, may be
hardened and unaffected.
Treatment Appropriate clothing and headgear, sunscreen creams and lotion
s are the main preventative
measures.
Photodynamic Therapy This comprises a photosensitising agent (one activa
ted by light), which
accumulates in malignant tissue, and a source of light that activates the photos
ensitiser, triggering it to
generate highly reactive oxygen compounds that destroy malignant cells. One such
photosensitiser is
temoporfin. Photodynamic therapy is used to treat various types of malignancy; a
recognised complication is
photosensitivity, when a patient may suffer burns after transient exposure to su
nlight. Photodynamic
therapy is increasingly used and photosensitivity reactions may also become more
common.
Photophobia Sensitivity to light. It can occur in MIGRAINE, disorders of
the eye, or in MENINGITIS.
Photopsia This is a description of the flashing lights which are a not u
ncommon AURA preceding an
attack of MIGRAINE.
Physostigmine
555
Photosensitivity
Physical Examination
Abnormal reaction to sunlight. The condition usually occurs as a skin ra
sh appearing in response to
light falling on the skin, and it may be caused by substances that have been eat
en or applied to the skin.
These are called photosensitisers and may be dyes, chemicals in soaps, or drugs.
Sometimes plants act as
photosensitisers for example, buttercups and mustard. The condition may occur in
some illnesses such as
lupus erythematosus (see under LUPUS).
That part of a patients consultation with a doctor in which the doctor lo
oks, feels (palpates) and
listens to (auscultates) various parts of the patients body. Along with the histo
ry of the patients
symptoms, this enables the doctor to assess the patients condition and decide whe
ther an immediate
diagnosis is possible or whether laboratory or imaging investigations are needed
to reach a diagnosis. A
full physical examination may take 30 minutes or more. Physical examination, alo
ng with certain standard
investigations, is done when a person attends for a preventive check-up of his or
her state of health.
Photosynthesis The method by which green plants and some bacteria produc
e CARBOHYDRATE from water and
carbon dioxide. They use energy absorbed from the suns rays by a green pigment in
the organism called
chlorophyll. Photosynthesis is one of the earths fundamental biological processes
. As well as converting
the carbon dioxide into the essential biological compound carbohydrate, the proc
ess removes the gas from
the atmosphere where, if it builds to excess, the atmospheric temperature rises,
thus contributing to
global warming.
Physical Medicine A medical specialty founded in 1931 and recognised by
the Royal College of Physicians
of London in 1972. Physical-medicine specialists started by treating rheumatic d
iseases; subsequently their
work developed to include the diagnosis and rehabilitation of people with physic
al handicaps. The specialty
has now been combined with that of RHEUMATOLOGY. (See also PHYSIOTHERAPY.)
Phrenic Nerve
Physician-Assisted Suicide
The
NERVE which chiefly supplies the DIAPHRAGM. A phrenic nerve arises on ea
ch side of the SPINAL CORD from
the third, fourth and
See SUICIDE.
fifth cervical spinal nerves; both follow a long course down the neck, a
nd through the chest to the
diaphragm. They play a key part in RESPIRATION through control of the diaphragm.
Injury to one nerve
paralyses one half of the diaphragm. Occasionally the phrenic nerve may be surgi
cally crushed as part of
the treatment to repair a HIATUS HERNIA or, rarely, to stop intractable hiccups.
Physiology is the branch of medical science that deals with the healthy
functions of different organs,
and the changes that the whole body undergoes in the course of its activities. T
he teaching of physiology
is a basic part of the medical students initial education.
Phrenology A quack method, common in the Victorian era, allegedly to stu
dy the mind and character of
individuals from the shape of the head. As the shape of the head has been shown
to depend chiefly upon
accidental characteristics, such as the size of the air spaces in the bones, and
not upon development of
special areas in the contained brain, there is no scientific basis for the pract
ice.
Phthisis A historical term means wasting, and was applied to that progre
ssive enfeeblement and loss of
weight that arose from tuberculous disease of all kinds, but especially from the
disease as it affected the
lungs (see TUBERCULOSIS).
Physiology
Physiotherapy An important treatment involving the use of physical measu
res, such as exercise, heat,
manipulation and remedial exercises in the treatment of disease. An alternative
name is PHYSICAL MEDICINE.
It is an essential part of the rehabilitation of convalescent or disabled patien
ts. Those who practise
physiotherapy physiotherapists have a recognised training and, on successful com
pletion of this, are
placed on the professions official register (see APPENDIX 8: PROFESSIONAL ORGANIS
ATIONS.)
Physostigmine Also known as eserine. An alkaloid (see ALKALobtained from
Calabar bean, the seed of
Physostigma venenosum, a climbing plant of West Africa. Its action depends on th
e presence of two
alkaloids, the one known as physostigmine or eserine, the other as calabarine, t
he OIDS)
P
556 Phytomenadione
former of these being much the more important.
Action Physostigmine produces the same effect as stimulation of the PARA
SYMPATHETIC NERVOUS SYSTEM:
i.e. it constricts the pupil of the eye, stimulates the gut, increases the secre
tion of saliva, stimulates
the bladder, and increases the irritability of voluntary muscle. In poisonous do
ses it brings on a general
paralysis.
Uses It is used in medicine in the form of eye drops or ointment to trea
t GLAUCOMA.
Phytomenadione The British Pharmacopoeia name for vitamin K. (See APPEND
IX 5: VITAMINS.)
Pia Mater The membrane closely investing the BRAIN and SPINAL CORD, in w
hich run blood vessels for the
nourishment of these organs.
Pica
P
This is the Latin for magpie and is used to describe an abnormal craving
for unusual foods. It is not
uncommon in pregnancy. Among the unusual substances for which pregnant women hav
e developed a craving are
soap, clay pipes, bed linen, charcoal, ashes and almost every imaginable food st
uff taken in excess. In
primitive races, the presence of pica is taken as an indication that the growing
fetus requires such food.
It is also not uncommon in children in whom, previously, it was an important cau
se of LEAD POISONING due to
ingestion of paint flakes. (See also APPETITE.)
Picorna Viruses These infectious agents derive their name from pico (sma
ll) and from RNA (because they
contain ribonuleic acid). They are a group of viruses which includes the ENTEROV
IRUSES and the
RHINOVIRUSES.
Picric Acid A yellow crystalline solid substance which is used as a fixa
tive for tissues being prepared
for examination under a microscope; it is also used as a dye.
Picture Archiving and Communications System (PACS) The use of digital im
aging systems to replace
conventional X-ray pictures and other imaging techniques. Though expensive to op
erate, digital imaging and
storage systems offer promising possibilities for transmission of clinical
images within and between hospitals and community health-care units, pro
viding fast access and remote
working that will benefit patients and health-care staff alike. When security an
d confidentiality are
assured, images could be transferred via the Internet and teleradiology. In futu
re, hospitals might be able
to eliminate the costly physical transfer and storage of X-ray films. The integr
ation of PACS with hospital
information systems in the NHS will (hopefully) facilitate the introduction of e
lectronic radiology.
Pigeon Breast See CHEST, DEFORMITIES OF.
Pigment The term applied to the colouring matter of various secretions,
blood, etc.; also to any
medicinal preparation of thick consistency intended for painting on the skin or
mucous membranes.
Piles See HAEMORRHOIDS.
Pills Small round masses containing active drugs held together by syrup,
gum, glycerin, or adhesive
vegetable extracts. They are sometimes without coating, being merely rolled in F
rench chalk, but often they
are covered with sugar or gelatin. Many people use the term interchangeably with
tablets, and the pill
has come to represent oral contraceptives.
Pilocarpine An alkaloid (see ALKALOIDS) derived from the leaves of Piloc
arpus microphyllus (jaborandi).
It produces the same effects as stimulation of the PARASYMPATHETIC NERVOUS SYSTE
M: i.e. it has exactly the
opposite effect to ATROPINE, but cannot be used in the treatment of atropine poi
soning as it does not
antagonise the action of poisonous doses of atropine on the brain. Its main use
today is in the form of eye
drops to decrease the pressure inside the eyeball in GLAUCOMA.
Pilonoidal Sinus A SINUS that contains hairs, usually occurring in the c
left between the buttocks. It
may get infected and cause considerable pain. Treatment is by antibiotics and, i
f necessary, surgical
removal.
Pimples Technically known as papules, these are small, raised and inflam
ed areas on the SKIN. On the
Pituitary Gland
face, the most common cause is ACNE. BOILS (FURUNCULOSIS) start as hard
pimples. The eruption of
SMALLPOX and that of CHICKENPOX begin also with pimples. (See also SKIN, DISEASE
S OF.)
Pineal Gland A small reddish structure, 10 mm in length and shaped somew
hat like a pine cone (hence its
name), situated on the upper part of the midbrain (see BRAIN). Many theories hav
e been expounded as to its
function, but there is increasing evidence that, in some animals at least, it is
affected by light and
plays a part in hibernation and in controlling sexual activity and the colour of
the skin. This it seems to
do by means of a substance it produces known as MELATONIN. There is also growing
evidence that it may play
a part in controlling the circadian rhythms of the body the natural variations i
n physiological
activities throughout the 24-hour day.
Pinna The part of the EAR, formed of cartilage and skin, that is externa
l to the head. In animals it is
an important element in detecting the direction of sound.
Pins and Needles A form of PARAESTHESIA, or disturbed sensation, such as
may occur, for example, in
NEURITIS or POLYNEURITIS.
Pint A measure of quantity containing 16 fluid ounces (wine measure) or
20 fluid ounces (Imperial
measure). The metric equivalent is 568 millilitres. (See APPENDIX 6: MEASUREMENT
S IN MEDICINE.)
557
Pinworm See ENTEROBIASIS.
Piperacillin A ureidopenicillin with a broad spectrum of antibacterial a
ctivity. The drug is active
against the serious infective agent Pseudomonas aeruginosa. (See PENICILLIN.)
Piperazine A drug used for the treatment of threadworms (see ENTEROBIASI
S) and ASCARIASIS.
Pipothiazine An antipsychotic drug for maintenance treatment of SCHIZOPH
RENIA. It is given as a depot
injection that lasts four weeks. (See NEUROLEPTICS; MENTAL ILLNESS.)
Piroxicam An intermediate risk, oral non-steroidal antiinflammatory drug
(see NON-STEROIDAL
ANTIINFLAMMATORY DRUGS (NSAIDS)) with prolonged action. Used to treat pain and i
nflammation in RHEUMATOID
ARTHRITIS, other musculoskeletal disorders, and acute GOUT.
Pituitary Gland Also known as the pituitary body and the hypophysis, thi
s is an ovoid structure,
weighing around 05 gram in the adult. It is attached to the base of the BRAIN, an
d lies in the depression
in the base of the skull known as the sella turcica. The anterior part is called
THYROID GLAND, DISEASES OF). Fortunately the ACTH-producing cells are the most r
esistant to extrinsic
pressure and this is teleologically sound as ACTH is the one pituitary hormone t
hat is essential to life.
However, these cells can suffer damage from intracellular tumours, and adrenocor
tical insufficiency is not
uncommon. Information about these disorders may be obtained from the Pituitary F
oundation.
Pityriasis A skin disorder typified by a bran-like desquamation (flaking
). There are several varieties
including P. alba, rosea, versicolor (fungal caused) and rubra (exfoliative derm
atitis).
Pityriasis alba is a mild form of chronic eczema (see DERMATITIS) occurr
ing mainly in children on the
face and in young adults on the upper arms. It is characterised by round or oval
flaky patches which are
paler than the surrounding skin due to partial loss of MELANIN pigment. The appe
arance is more dramatic in
dark-skinned or suntanned subjects. Moisturising cream often suffices, but 1 per
cent HYDROCORTISONE cream
is more effective.
Pityriasis rosea is a common self-limiting eruption seen mainly in young
adults. It usually begins as a
solitary red flaky patch (often misdiagnosed as ringworm). Within a week this her
ald patch is followed by
a profuse symmetrical eruption of smaller rose-pink, flaky, oval lesions on the
trunk and neck but largely
sparing the limbs and face. Itching is variable. The eruption usually peaks with
in 3 weeks and fades away
leaving collarettes of scale, disappearing within 67 weeks. It rarely recurs and
a viral cause is
suspected but not proved. It is not contagious and there is no specific treatmen
t, but crotamiton cream
(Eurax) may relieve discomfort.
PKU See PHENYLKETONURIA.
Placebo Placebo is the Latin for I will please and
Plague
implies giving an inactive treatment. Traditionally, placebos were used
to pacify without actually
benefiting the patient. They were inactive, often highly coloured, substances fo
rmerly given to please or
gratify the patient but without pharmacological benefit. Nowadays they are used
in controlled studies,
approved by ETHICS COMMITTEES and with patient consent, to determine the efficac
y of drugs. However,
pharmacologically inert compounds can relieve symptoms, and this is called the p
lacebo effect. The
reassurance that is associated with placebo administration is accompanied by mea
surable changes in body
function which are affected through autonomic pathways and humoral mechanisms. A
lterations in blood
pressure and pulse frequency are especially common. Placebos have the ability to
relieve a variety of
symptoms in a consistent proportion of the population in some studies in as many
as 30 per cent. Some
patients with symptoms such as pain or cough will respond to placebo medications
, and an even higher
proportion of patients with psychological symptoms such as anxiety or insomnia m
ay benefit. In judging the
effectiveness of a drug, the comparison must be with a placebo rather than with
no treatment at all.
Placenta The thick, spongy, disc-like mass of tissue which connects the
EMBRYO with the inner surface
of the UTERUS, the embryo otherwise lying free in the amniotic fluid (see AMNION
). The placenta is mainly a
new structure growing with the embryo, but, when it separates, a portion of the
inner surface of the womb
called the maternal placenta comes away with it. It is mainly composed of loops
of veins belonging to the
embryo, lying in blood-sinuses, in which circulates maternal blood. Thus, althou
gh no mixing of the blood
of embryo and mother takes place, there is ample opportunity for the exchange of
fluids, gases, and the
nutrients brought by the mothers blood. The width of the full-sized placenta is a
bout 20 cm (8 inches),
its thickness 25 cm (1 inch). One surface is rough and studded with villi, which
consist of the loops of
fetal veins; the other is smooth, and has implanted in its centre the umbilical
cord, or navel string,
which is about as thick as a finger and 50 cm (20 inches) long. It contains two
arteries and a vein, enters
the fetus at the navel, and forms the sole connection between the bodies of moth
er and fetus. The name
afterbirth is given to the structure because it is expelled from the womb in the
third stage of labour (see
559
PREGNANCY AND
LABOUR).
Placenta Praevia Implantation of the PLACENTA in the bottom part of the
560 Plantar
(septicaemic plague), haematogenous transmission produces mortality in a
high percentage of cases.
Pneumonic plague is associated with pneumonic consolidation (person-to-person tr
ansmission) and death often
ensues on the fourth or fifth day. (The nursery rhyme Ringo-ring o roses, a pocket
ful o posies, atishoo!
atishoo!, we all fall down is considered to have originated in the 17th century a
nd refers to this form of
the disease.) In addition, meningitic and pharyngeal forms of the disease can oc
cur; these are unusual.
Diagnosis consists of demonstration of the causative organism. Treatment is with
tetracycline or
doxycycline; a range of other antibiotics is also effective. Plague remains (tog
ether with CHOLERA and
YELLOW FEVER) a quarantinable disease. Contacts should be disinfected with insec
ticide powder; clothes,
skins, soft merchandise, etc. which have been in contact with the infection can
remain infectious for
several months; suspect items should be destroyed or disinfected with an insecti
cide. Ships must be
carefully checked for presence of rats; the rationale of anchoring a distance fr
om the quay prevents access
of vermin. (See also EPIDEMIC; PANDEMIC; NOTIFIABLE DISEASES.)
Plantar Describing anything related to the sole of the foot.
Plantar Dermatosis P
A common form of eczema (see DERMATITIS) of the soles of the feet typica
lly seen in boys with an atopic
(see ATOPY) background who constantly wear trainers.
Plantar Fasciitis See FASCIITIS.
Plaque (1) A coating of the TEETH which forms as a result of poor mouth
and dental hygiene. It consists
of food debris and bacteria; later, calcium salts will be deposited in it to for
m calculus. It is therefore
associated with both caries and periodontal disease (see TEETH, DISORDERS OF Car
ies of the teeth). (2)
Raised patch on the skin resulting from the merging or enlargement of papules (s
ee PAPULE; PIMPLES).
Plasma The name applied to the straw-coloured fluid portion of the BLOOD
composed of a solution of
various inorganic salts of sodium, potassium, calcium, etc., as well as SERUM an
d fibrinogen,
the material which produces clotting (see When the plasma is clotted, th
e thinner fluid separating from
the clot is the serum.
COAGULATION).
Plasma Cells These are cells that produce ANTIBODIES and occur in bone-f
orming tissue as well as the
lining of the gastrointestinal tract and the lungs. The cells develop in LYMPH N
ODES, SPLEEN and BONE
MARROW when T-lymphocytes (see IMMUNITY) are stimulated by antigens (see ANTIGEN
) to produce the precursor
cells from which plasma cells originate.
Plasma Exchange Also known as plasmapheresis. The removal of the circula
ting PLASMA from the patient.
It is done by removing blood from a patient and returning the red cells with a p
lasma expander. The plasma
exchange is carried out through an in-dwelling CANNULA in the femoral vein, and
the red cells and plasma
are separated by a hemonetics separator. Usually a sequence of three or four ses
sions is undertaken, at
each of which 23 litres of plasma are removed. The lost plasma can either be repl
aced by human serum
albumin (see ALBUMINS) or a plasma expander. In autoimmune disorders, disease is
due to damage wrought by
circulating ANTIBODIES or sensitised lymphocytes (see LYMPHOCYTE). If the diseas
e is due to circulating
humoral antibodies, removal of these antibodies from the body should theoretical
ly relieve the disorder.
This is the principle on which plasma exchange was used in the management of aut
oimmune diseases due to
circulating antibodies. Such disorders include Goodpastures syndrome, SYSTEMIC LU
PUS ERYTHEMATOSUS (SLE)
and MYASTHENIA GRAVIS. One of the problems in the use of plasma exchange in the
treatment of such diseases
is that the body responds to the removal of an antibody from the circulation by
enhanced production of that
antibody by the immune system. It is therefore necessary to suppress this homeos
tatic response with
cytotoxic drugs such as AZATHIOPRINE. Nevertheless, remissions can be achieved i
n autoimmune diseases due
to circulating antibodies by the process of plasma exchange.
Plasmapheresis See PLASMA EXCHANGE.
Plasma Transfusion This procedure is sometimes used instead of blood TRA
NSFUSION. PLASMA the fluid
part of
Pleurisy
561
Plethora
blood from which the cells have been separated may be dried and in powde
r form kept almost
indefinitely; when wanted it is reconstituted by adding sterile distilled water.
In powder form it can be
transported easily and over long distances. Transfusion of plasma is especially
useful in the treatment of
SHOCK. One advantage of plasma transfusion is that it is not necessary to carry
out testing of blood groups
before using it.
A condition of fullness of the blood vessels in a particular part or in
the whole body. This results in
a florid, red appearance of the affected area, particularly the face. The volume
of blood may be increased
(POLYCYTHAEMIA) or the blood vessels beneath the skin may be dilated. Plethoric
lung fields are seen on
X-rays of patients with left-to-right shunts through the heart wall (see SEPTAL
DEFECT).
Plasmids
Plethysmograph
A generic description of any discrete agents in cells that have genetic
functions. They include
plasmagenes (self-reproducing copies of a nuclear gene existing outside the cell
nucleus) and viruses.
Plasmin Also called fibrinolysin, this is an ENZYME that digests the pro
tein FIBRIN. It dissolves blood
clots (see COAGULATION) and so is present in the blood in the form of PLASMINOGE
N, an inactive precursor.
Plasminogen A precursor of PLASMIN, an ENZYME that digests the protein F
IBRIN the main constituent of
blood clots (see COAGULATION). When tissue is damaged, activators are released w
hich provoke the conversion
of plasminogen into plasmin.
Plasmodium The general term applied to minute protoplasmic cells, and pa
rticularly to those which cause
MALARIA and allied diseases.
Plaster of Paris A form of calcium sulphate, which, after soaking in wat
er, sets firmly. For this
reason it is widely used as a form of splinting in the treatment of fractures, f
or producing casts to
immobilise parts of the body, and for dental models. Splints are made with banda
ges impregnated with
plaster and a suitable adhesive. Its great advantage, compared with an ordinary
splint, is that it can be
moulded to the shape of the limb.
Plastic Surgery See RECONSTRUCTIVE (PLASTIC) SURGERY.
562 Pleurodynia
Symptoms The symptoms of pleurisy vary, being generally well marked, but
sometimes obscure. DRY
PLEURISY In the case of dry pleurisy, which is, on the whole, the milder form, t
he chief symptom is a sharp
pain in the side, felt especially on breathing. Fever may or may not be present.
There is a slight, dry
cough, and breathing is quicker than normal and shallow. PLEURISY WITH EFFUSION
is usually more severe than
dry pleurisy, and, although it may in some cases develop insidiously, it is in g
eneral ushered in sharply
by shivering and fever, like other acute inflammatory diseases. Pain is felt in
the side or breast, of a
severe cutting or stabbing character. A dry cough usually occurs and breathing i
s painful and difficult.
Treatment The treatment varies greatly with the form and severity of the
attack. Bed rest, antibiotics,
analgesics and antipyretics are advisable. A large pleural effusion may need to
be drained via an
aspiration needle.
Pleurodynia Also known as BORNHOLM DISEASE. A painful condition of the c
hest wall, it is usually the
result of an infection of coxsackie virus B (see COXSACKIE VIRUSES) and may occu
r in epidemics (see
EPIDEMIC). Fever, sore throat, headache and malaise are typical but the conditio
n is self-limiting,
subsiding within a few days.
P
Plexus A network of nerves or vessels: for example, the brachial and sac
ral plexuses of nerves and the
choroid plexus of veins within the brain.
Plumbism Another name for LEAD POISONING.
Plummer-Vinson Syndrome Hypochromic ANAEMIA and difficulty in swallowing
due to an oesophageal web.
PneumoA prefix relating to the Examples are PNEUMONIA, and PNEUMOPERITON
EUM.
LUNGS or to air. PNEUMONECTOMY
Pneumococcus A
type of streptococcal bacterium (see STREPTOCOCCUS) which can cause otit
is media (see EAR, DISEASES OF
Diseases of the middle ear), TONSILLITIS, PNEUMONIA, MENINGITIS and SEPTICAEMIA.
It is usually sensitive
to PENICILLIN.
Pneumoconiosis The general name applied to a chronic form of inflammatio
n of the LUNGS which is liable
to affect people who constantly inhale irritating particles at work. It has been
defined by the Industrial
Injuries Advisory Council as: Permanent alteration of lung structure due to the i
Podophyllin 563
gram-negative bacteria (see GRAMS STAIN), is commonly the terminal event.
In patients with an immune
system suppressed by pregnancy and labour, infection with HIV, CHEMOTHERAPY or i
mmunosuppressive drugs
after organ transplantation, a wider range of opportunistic organisms needs to b
e considered. Some of these
organisms such as CYTOMEGALOVIRUS (CMV) or the fungus Pneumocystis carinii rarel
y cause disease in
immunocompetent individuals those whose bodys immune (defence) system is effectiv
e. TUBERCULOSIS is
another cause of pneumonia, although the pattern of lung involvement and the mor
e chronic course usually
differentiate it from other causes of pneumonia.
Symptoms
The common symptoms of pneumonia are cough, fever (sometimes with RIGOR)
, pleuritic chest pain (see
PLEURISY) and shortness of breath. SPUTUM may not be present at first but later
may be purulent or reddish
(rusty). Examination of the chest may show the typical signs of consolidation of
an area of lung. The solid
lung in which the alveoli are filled with inflammatory exudate is dull to percus
sion but transmits sounds
better than air-containing lung, giving rise to the signs of bronchial breathing
and increased conduction
of voice sounds to the stethoscope or palpating hand. The chest X-ray in pneumon
ia shows opacities
corresponding to the consolidated lung. This may have a lobar distribution fitti
ng with limitation to one
area of the lung, or have a less confluent scattered distribution in bronchopneu
monia. Blood tests usually
show a raised white cell (LEUCOCYTES) count. The organism responsible for the pn
eumonia can often be
identified from culture of the sputum or the blood, or from blood tests for the
specific ANTIBODIES
produced in response to the infection.
Treatment The treatment of pneumonia involves appropriate antibiotics to
gether with oxygen, pain relief
and management of any complications that may arise. When treatment is started, t
he causative organism has
often not been identified so that the antibiotic choice is made on the basis of
the clinical features,
prevalent organisms and their sensitivities. In severe cases of community-acquir
ed pneumonia (see above),
this will often be a PENICILLIN or one of the CEPHALOSPORINS to cover Strep. pne
umoniae together with a
macrolide such as ERYTHROMYCIN. Pleuritic pain will need analgesia to allow deep
breathing and coughing;
oxygen
may be needed as judged by the oxygen saturation or blood gas measuremen
t. Possible complications of
pneumonia are local changes such as lung abscess, pleural effusion or EMPYEMA an
d general problems such as
cardiovascular collapse and abnormalities of kidney or liver function. Appropria
te treatment should result
in complete resolution of the lung changes but some FIBROSIS in the lung may rem
ain. Pneumonia can be a
severe illness in previously fit people and it may take some months to return to
full fitness.
Pneumonitis An inflammation of the lung (see LUNGS) due to chemical or p
hysical agents.
Pneumoperitoneum A collection of air in the peritoneal cavity (see PERIT
ONEUM). Air introduced into the
peritoneal cavity collects under the diaphragm which is thus raised and collapse
s the lungs. This procedure
was sometimes carried out in the treatment of pulmonary tuberculosis in the prea
ntibiotic days as an
alternative to artificial PNEUMOTHORAX.
Pneumothorax A collection of air in the pleural cavity, into which it ha
s gained entrance by a defect
in the lung or a wound in the chest wall. When air enters the chest, the lung im
mediately collapses towards
the centre of the chest; but, air being absorbed from the pleural cavity, the lu
ng expands again within a
short time. (See LUNGS, DISEASES OF.) Tension pneumothorax is a life-threatening
condition in which the air
in the hemithorax is under such pressure that it forces the heart to the other s
ide and compresses the
still-inflated lung on the other side. It must be promptly relieved by inserting
a hollow tube into the
pleural cavity a chest drain. Artificial pneumothorax was an operation often per
formed in the
pre-antibiotic days to treat pulmonary tuberculosis. Air was run into the pleura
l cavity to cause collapse
of one lung, which rested it and allowed cavities in it to heal.
Podagra Another name for GOUT affecting the foot.
Podophyllin A resin derived from podophyllum plants, its active agent, p
odophyllotoxin, in alcoholic
solution is used to treat genital WARTS. Paints, creams and impregnated plasters
are used for calluses and
warts elsewhere.
P
564 Poikilocytosis
Poikilocytosis This is a term used to describe the variation seen in the
shape of red blood cells in
some disorders of the BONE MARROW.
Poisons
P
A poison is any substance which, if absorbed by, introduced into or appl
ied to a living organism, may
cause illness or death. The term toxin is often used to refer to a poison of biolo
gical origin. Toxins
are therefore a subgroup of poisons, but often little distinction is made betwee
n the terms. The study of
the effects of poisons is toxicology and the effects of toxins, toxinology. The
concept of the
dose-response is important for understanding the risk of exposure to a particula
r substance. This is
embodied in a statement by Paracelsus (c.14931541): All substances are poisons; th
ere is none which is
not a poison. The right dose differentiates a poison and a remedy. Poisoning may
occur in a variety of
ways: deliberate SUICIDE, substance abuse or murder; accidental including accide
ntal overdose of
medicines; occupational; and environmental including exposure during fire. Inges
tion is the most common
route of exposure, but poisoning may also occur through inhalation, absorption t
hrough the skin, by
injection and through bites and stings of venomous animals. Poisoning may be des
cribed as acute, where a
single exposure produces clinical effects with a relatively rapid onset; or chro
nic, where prolonged or
repeated exposures may produce clinical effects which may be insidious in onset,
cumulative and in some
cases permanent. Diagnosis of poisoning is usually by circumstantial evidence or
elimination of other
causes of the clinical condition of the patient. Some substances (e.g. opioids)
produce a characteristic
clinical picture in overdose that can help with diagnosis. In some patients labo
ratory analysis of body
fluids or the substance taken may be useful to determine or confirm the offendin
g agent. Routine assays are
not necessary. For a very small number of poisons, such as paracetamol, aspirin,
iron and lead, the
management of the patient may depend on measuring the amount of poison in the bl
oodstream. Accurate
statistics on the incidence of poisoning in the UK are lacking. Mortality figure
s are more reliable than
morbidity statistics; annually, well over 100,000 cases of poisoning are admitte
d to hospital. The annual
number of deaths from poisoning is relatively small about 300 and in most cases
patients die before
reaching hospital. Currently, CARis by far the most common cause of death due to poisoning. The most comm
on agents involved in
intentional or accidental poisoning are drugs, particularly ANALGESICS, ANTIDEPR
ESSANT DRUGS and SEDATIVES.
Alcohol is also commonly taken by adults, usually in combination with drugs. Chi
ldren frequently swallow
household cleaners, white spirit, plant material such as belladonna (deadly nigh
tshade) and certain
mushrooms; for example, death cap and fly agaric aftershave and perfume as well
as drugs. If possible,
the suspect container, drug or plant should be taken with the victim to the hosp
ital or doctor. The use of
child-resistant containers has reduced the number of admissions of children to h
ospital for treatment.
Bixtrex is an intensely bitter-tasting agent which is often added to products to
discourage ingestion;
however, not everybody is able to taste it, nor has any beneficial effect been p
roven. BON MONOXIDE (CO)
Treatment of poisoning usually begins with decontamination procedures. F
or ingested substances this may
involve making the patient sick or washing the stomach out (GASTRIC LAVAGE): thi
s is usually only
worthwhile if performed soon after ingestion. It should be emphasised that salt
(sodium chloride) water
must never be given to induce vomiting, since this procedure is dangerous and ha
s caused death. For
substances spilt on the skin, the affected area should immediately be thoroughly
washed and all
contaminated clothing removed. Following eye exposure, the affected eye/s should
be thoroughly irrigated
with saline or water. Treatment thereafter is generally symptomatic and supporti
ve, with maintenance of the
victims respiratory, neurological and cardiovascular systems and, where appropria
te, monitoring of their
fluid and electrolyte balance and hepatic and renal function. There are specific
antidotes for a few
substances: the most important of these are PARACETAMOL, iron, cyanide (see CYAN
IDE POISONING), opioids
(see OPIOID), DIGOXIN, insecticides and some heavy metals. Heavy-metal poisoning
is treated with CHELATING
AGENTS chemical compounds that form complexes by binding metal ions: desferrioxa
mine and pencillinamine
are two such agents. The number of people presenting with paracetamol overdose a
common drug used for
attempted suicide has fallen sharply since restrictions were placed on its overthecounter sales. When a
patient presents with an illness thought to be caused by exposure to substances
at work, further exposure
should be limited or
Symptoms The incubation period is around 714 days, the onset being marked
by a mild fever and headache
which improves after a few days. In around 85 per cent of infected children ther
e is no further
progression, but in some after approximately one week the symptoms recur, togeth
er with neck stiffness
and signs of meningeal irritation (see MENINGES). Weakness of individual muscle
groups is common, and may
progress to a variable extent, depending on the distribution of the virus to wid
espread PARALYSIS.
Involvement of the diaphragm and intercostal muscles may lead to respiratory fai
lure and rapid death unless
artificial respiration is provided. Involvement of the cranial nerves and brain
may lead to nystagmus (see
under EYE, DISORDERS OF), hoarseness and difficulty in swallowing, and CONVULSIO
NS may occur in young
children. The CEREBROSPINAL FLUID shows an early increase in lymphocytes, follow
ed by a rise in protein
concentration.
Treatment There is no effective drug treatment for the infection. Treatm
ent involves early bed rest,
followed by PHYSIOTHERAPY and orthopaedic measures as required. At the onset of
respiratory difficulties a
TRACHEOSTOMY and artificial ventilation should be started. (In the 1950s, when p
olio epidemics were
occurring, respiratory difficulties were treated by placing patients in an iron l
ung a large, airtight,
cylindrical container in which the air pressure was raised and lowered to simula
te normal breathing.) In
cases of severe paralysis with persistent wasting of the limbs, surgery may be n
ecessary to minimise the
resulting disability.
Pollex A Latin term for thumb.
Polyarteritis Nodosa Also known as periarteritis nodosa. A rare but pote
ntially serious disease,
probably caused by a disturbance of the immune system (see IMMUNITY). Prolonged
fever and obscure symptoms
P
566 Polyarthritis
referable to any system of the body are associated with local areas of i
nflammation along the arteries,
giving rise to nodules in their walls. Large doses of CORTICOSTEROIDS, coupled w
ith IMMUNOSUPPRESSANT
treatment, usually curtail the disorder. Recovery occurs in about 50 per cent of
cases.
Polyarthritis A rheumatic disorder usually caused by RHEUMATOID ARTHRITI
S that affects several
joints in the body. The joints are stiff, painful and swollen. Different joints
may be affected at the same
time or in various sequences.
Polychromasia Also polychromatophilia; terms applied to an abnormal reac
tion of the red blood cells in
severe ANAEMIA. They have a bluish tinge instead of the normal red colour in a b
lood film stained by the
usual method. It is a sign that the cell is not fully developed.
Polychromatophilia See POLYCHROMASIA.
Polycystic Disease of the Kidney
P
An inherited disease in which the KIDNEYS contain many cysts. These grow
in size until normal kidney
tissue is largely destroyed. Cysts may also occur in other organs such as the li
ver. In adults, the disease
will cause HYPERTENSION and kidney failure. There is also a juvenile form. There
is no effective treatment,
although symptoms can be alleviated by DIALYSIS and sometimes kidney transplant
(see TRANSPLANTATION).
Polycythaemia A rise in the amount of HAEMOGLOBIN in the blood. This may
be caused by an excess in the
number of ERYTHROCYTES produced in the BONE MARROW or to a fall in the total vol
ume of PLASMA in the
circulatory system. It may also be a response to reduced oxygen levels for examp
le, among people living
at high altitudes or to liver or kidney disease: this type is called secondary p
olycythaemia. The
disorder may, however, occur for no obvious reason and is then called polycythae
mia vera. This type
develops mainly in people over 40 and about 400 people develop the disorder ever
y year in the United
Kingdom. The blood thickens, the sufferer may develop high blood pressure, flush
ing, headaches, itching and
an enlarged spleen. A stroke may occur later in the disease process. Treatment o
f polycythaemia vera is by
regular removal of blood by VENESECTION, sometimes in combination with an antica
ncer drug. Secondary
polycythaemia is treated by remedying the underlying cause.
Polycythaemia rubra vera A disorder in which the red blood cells increas
e in number along with an
increase in the number of white blood cells and platelets. The cause is unknown.
Severe cases may require
Polysaccharide
the blood which have a nucleus of irregular and varied shape. These form
between 70 and 75 per cent of
all the white corpuscles. (See BLOOD.)
Polymyalgia Rheumatica A form of rheumatism characterised by gross early
-morning stiffness, which tends
to ease off during the day, and pain in the shoulders and sometimes around the h
ips. It affects women more
than men, and is rare under the age of 60. The cause is still obscure. It respon
ds well to PREDNISOLONE,
but treatment may need to be long continued. On the other hand the condition is
not progressive and does
not lead to disability.
Polymyositis A connective-tissue disease affecting the muscles throughou
t the body. This rare disorder,
which is associated with DERMATOMYOSITIS, may be acute or chronic but it usually
affects the muscles of the
shoulders or hip areas. The muscles weaken and are tender to the touch. Diffuse
inflammatory changes occur
and symptomatic relief may be obtained with
567
Polypill A suggestion by two epidemiologists, made in the British Medica
l Journal in 2003, that many
lives could be saved if all persons aged over 55 took a daily combination pill t
hey termed the polypill.
Its components would be ASPIRIN, a CHOLESTEROL-lowering agent, FOLIC ACID and tw
o blood-pressure-lowering
agents. The suggestion caused a massive correspondence as it implied treating a
whole population rather
than individuals considered to be at special risk.
Polyposis The presence of a crop, or large number, of polypi (see POLYPU
S). The most important form of
polyposis is that known as familial polyposis coli. This is a hereditary disease
characterised by the
presence of large numbers of polypoid tumours in the large bowel. Every child bo
rn to an affected parent
stands a fifty-fifty chance of developing the disease. Its importance is that so
oner or later one or more
of these tumours undergoes cancerous change. If the affected gut is removed surg
ically before this occurs,
and preferably before the age of 20, the results are excellent.
CORTICOSTEROIDS.
Polypus Polymyxin A group of antibiotics derived from various species of
Bacillus polymyxa. One
variety, colistin, is used to sterilise the bowels before surgery as it is not a
bsorbed when given by
mouth. The drugs are sometimes used in topical applications for infections of th
e skin, eye and ear.
Polyneuritis An inflammatory condition of nerves in various parts of the
body. (See NEURITIS.)
568 Polyuria
structural parts of plants (as cellulose) and animals (as mucopolysaccha
rides).
Polyuria The production of excessive amounts of URINE (1,500 ml or there
about is the usual daily
quantity). It is a symptom of DIABETES MELLITUS, DIABETES INSIPIDUS and chronic
renal failure.
Porphyrins
See DERMATITIS.
Complex organic compounds which are sensitive to light and form the basi
s of respiratory pigments for
example, haemoglobin and myoglobin. Porphyrins are crucial to many metabolic oxi
dation/reduction reactions
in animals, plants, and micro-organisms.
Popliteal Space
Portal Hypertension
The name given to the region behind the knee. The muscles attached to th
e bones immediately above and
below the knee bound a diamondshaped space through which pass the main artery an
d vein of the limb (known
in this part of their course as the popliteal artery and vein); the tibial and c
ommon peroneal nerves
(which continue the sciatic nerve from the thigh down to the leg); the external
saphenous vein; and several
small nerves and lymphatic vessels. The muscles which bound the upper angle of t
he space and which are
attached to the leg bones by strong prominent tendons are known as the hamstring
s. The lower angle of the
space lies between the two heads of the gastrocnemius muscle, which makes up the
main bulk of the calf of
the leg.
Raised blood pressure in the PORTAL VEIN entering the LIVER. This result
s in increased pressure in the
veins of the oesophagus and upper stomach and these grow in size to form varices
dilated tortuous veins.
Sometimes these varices rupture, causing bleeding into the oesophagus. The raise
d pressure also causes
fluid to collect in the abdomen and form ASCITES. The commonest reason for porta
l hypertension is cirrhosis
(fibrosis) of the liver (see LIVER, DISEASES OF). THROMBOSIS in the portal vein
may also be a cause.
Treatment requires the cause to be tackled, but bleeding from ruptured vessels m
ay be stopped by injecting
a sclerosant or hardening solution into and around the veins. Sometimes a surgic
al shunt may be done to
divert blood from the portal vein to another blood vessel.
Pompholyx
Poppy P
5,000 people in some countries. The British king, George III, suffered f
rom porphyria, a disorder
unrecognised in the 18th century.
Two species are used in medicine: Papaver somniferum, the white opium-po
ppy (see OPIUM), and Papaver
rhoeas, the red corn-poppy. The corn-poppy is chiefly used as a colouring agent,
its syrup being a
brilliant crimson colour.
Pore A small opening. The word is usually used to describe an opening in
the skin that releases sweat
or sebum, a waxy material secreted by the sebaceous glands in the SKIN.
Porphyrias A group of rare inherited ENZYME diseases in which disorders
of the metabolic pathways
leading to the synthesis of HAEM cause excessive production of haem precursors c
alled PORPHYRINS by the
bone marrow or liver. The excess porphyrins in the blood mainly affect the skin,
causing PHOTOSENSITIVITY,
or the central nervous system, causing various neuro-psychiatric disorders. Exce
ss porphyrins can be
detected in blood, urine and faeces. Usually porphyrias are genetically determin
ed, but one form is due to
alcoholic liver disease. The commonest form, porphyria cutanea tarda, affects up
to 1 in
Portal System A vein or collection of veins which finish at both ends in
a bed of capillary blood
vessels. An important example is the hepatic portal system, comprising the porta
l vein and its tributaries.
Blood from the stomach, pancreas, spleen and intestines drains into the veins th
at join up to comprise the
portal vein into the liver, where it branches into sinusoids.
Portal Vein The vein which carries to the LIVER, blood that has been cir
culating in many of the
abdominal organs. It is peculiar among the veins of the body in that it ends by
breaking up into a
capillary network instead of carrying the blood directly to the heart a peculiar
ity which it shares only
with certain small vessels in the kidneys. The PORTAL SYSTEM begins below in the
haemorrhoidal plexus of
veins around the lower end of the rectum; from this point, along the whole lengt
h of the intestines, the
blood is collected into an inferior mesenteric vein upon the left, and a superio
r mesenteric vein upon the
right side. The inferior mesenteric vein empties into the splenic vein, and the
latter, uniting with the
Post-Partum
superior mesenteric vein immediately above the pancreas, forms the porta
l vein. The portal vein is
joined by veins from the stomach and gallbladder, and finally divides into two b
ranches which sink into the
right and left lobes of the liver. (For their further course, see LIVER). The or
gans from which the portal
vein collects the blood are the large and small intestines, the stomach, spleen,
pancreas, and
gall-bladder.
Port Wine Stain See NAEVUS.
Positron-Emission Tomography (PET) See PET SCANNING.
Possetting The technical term used to describe the quite common habit of
healthy babies to regurgitate,
or bring up, small amounts of the meal they have just taken. Its name derives fr
om possett, an 18th century
drink made from porridge and sherry.
PostA prefix signifying after or behind.
Post-Coital Contraception Action taken to prevent CONCEPTION after sexua
l intercourse. The type of
contraception may be hormonal, or it may be an intrauterine device (see below, a
nd under CONTRACEPTION).
Pregnancy after intercourse without contraception or where contraception has fai
led as a result, for
example, of a leaking condom may be avoided with a course of morning-after contrac
eptive pills. Such
preparations usually contain an oestrogen (see OESTROGENS) and a PROGESTOGEN. Tw
o doses should be taken
within 72 hours of unprotected intercourse. An alternative for the woman is to tak
e a high dose of
oestrogen on its own. The aim is to postpone OVULATION and to affect the lining
of the UTERUS so that the
egg is unable to implant itself.
Intrauterine contraceptive device (IUCD) This, in effect, is a form of p
ost-coital contraception. The
IUCD is a plastic shape up to 3 cm long around which copper wire is wound, carry
ing plastic thread from its
tail. Colloquially known as a coil, it acts by inhibiting implantation and may a
lso impair migration of
sperm. Devices need changing every 35 years. Coils have generally replaced the la
rger, non-copper-bearing
inert types of IUCD, which caused more complications but did not
569
need changing (so are sometimes still found in situ). They tend to be ch
osen as a method of
contraception (6 per cent) by older, parous women in stable relationships, with
a generally low problem
rate. Nevertheless, certain problems do occur with IUCDs, the following being th
e most common: They tend to
be expelled by the uterus in women who have never conceived, or by a uterus dist
orted by, say, fibroids.
ECTOPIC PREGNANCY is more likely. They are associated with pelvic infection and
INFERTILITY, following
SEXUALLY TRANSMITTED DISEASES (STDS) or possibly introduced during insertion. Th
ey often produce heavy,
painful periods (see MENSTRUATION), and women at high risk of these problems (e.
g. women who are HIV
positive [see AIDS/HIV], or with WILSONS DISEASE or cardiac lesions) should gener
ally be excluded unless
the IUCD is inserted under antibiotic cover.
Post-Coital Test A test for INFERTILITY. A specimen of cervical mucus, t
aken up to 24 hours after
coitus (during the post-ovulatory phase of the menstrual cycle), is examined mic
roscopically to assess the
motility of the sperms. If motility is above a certain level, then sperms and mu
cus are not interacting
abnormally thus eliminating one cause of sterility.
Post-Mortem Examination Also called an autopsy (and less commonly, necro
psy), this is an examination of
a body to discover the causes of death. Such an examination is sometimes require
d by law. An unnatural
death; a death occurring in suspicious circumstances; or a death when a doctor f
eels unable to complete a
certificate about the cause all must be reported to the CORONER (in Scotland, to
the procurator fiscal).
He or she may order an autopsy to be carried out as part of the inquiry into cau
se of death. Sometimes
doctors may request the permission of relatives to perform a post-mortem so that
they may discover
something of value for the improvement of medical care. Relatives may refuse con
sent. (See also DEATH,
CAUSES OF.)
Post-Operative The period after an operation, the patients condition afte
r operation, or any
investigations or treatment during this time.
Post-Partum The term applied to anything happening
P
Percivall Pott, an English surgeon (171488), who first described the condition.
Potts Fracture A variety of fractures around the ankle, accompanied by a
varying degree of dislocation
of the ankle. In all cases the fibula is fractured. Named after Percivall Pott,
who suffered from this
fracture and was the first to describe it (see BONE, DISORDERS OF), it is often
mistaken for a simple
sprain of the ankle.
Pouchitis A rare chronic inflammatory disease in the ileal pouch, which
remains after a patient has had
intestinal resection because of INFLAMMATORY BOWEL DISEASE (IBD). Metronidazole
and oral PROBIOTICS are
effective treatments.
Poultices (See also FOMENTATION.) Soft, moist applications to the surfac
e of the body, generally used
hot to soothe pain due to inflammation and to 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 the
anterior abdominal wall and the front of the thigh.
Potassium A metal which, on account of its great affinity for other subs
tances, is not found in a pure
state in nature. Its salts are widely used in medicine but, as their action depe
nds in general not on their
metallic radical but upon the acid with which it is combined, their uses vary gr
eatly and are described
elsewhere. All salts of potassium depress the hearts action as a result of action
by the potassium ion.
Praziquantel An effective drug against all human schistosomes which has
a broad spectrum of activity
and low toxicity (see SCHISTOSOMIASIS).
PreA prefix meaning before.
Potassium-Channel Activators
Precipitin
Drugs that have the ability to dilate
An antibody (see
ARTERIES
ANTIBODIES)
that combines
as 30 days from the last menstrual period. The estimated date of delivery can be
accurately estimated from
the size of the developing fetus measured by ULTRASOUND (see also below) between
seven and 24 weeks. Term
refers to the time that the baby is due; this can range from 38 weeks to 41 comp
leted weeks. Physical
changes occur in early pregnancy periods stop and the abdomen enlarges. The brea
sts swell, with the veins
becoming prominent and the nipples darkening. About two in three women will have
nausea with a few
experiencing such severe vomiting as to require hospital admission for rehydrati
on.
Antenatal care The aim of antenatal care is to ensure a safe outcome for
both mother and child; it is
provided by midwives (see MIDWIFE) and doctors. Formal antenatal care began in E
dinburgh in the 1930s with
the recognition that all aspects of pregnancy normal and abnormal warranted surv
eillance. Cooperation
between general practitioners, midwives and obstetricians is now established, wi
th pregnancies that are
likely to progress normally being cared for in the community and only those need
ing special intervention
being cared for in a hospital setting. The initial visit (or booking) in the fir
st half of pregnancy will
record the history of past events and the results of tests, with the aim of cate
gorising the patients into
normal or not. Screening tests including blood checks and ultrasound scans are a
routine part of antenatal
care. The first ultrasound scan is done at about 11 weeks to date the pregnancy,
with a further one done at
20 weeks the anomaly scan to assess the babys structure. Some obstetric units wil
l check the growth of
the baby with one further scan later in the pregnancy or, in the case of twin pr
egnancies (see below), many
scans throughout. The routine blood tests include checks for ANAEMIA, DIABETES M
ELLITUS, sickle-cell
disease and THALASSAEMIA, as well as for the blood group. Evidence of past infec
tions is also looked for;
tests for RUBELLA (German measles) and SYPHILIS are routine, whereas tests for h
uman immunodeficiency virus
(see AIDS/
P
573
birth using ultrasound. Some of these defects are obvious, such as the a
bsence of kidneys, a condition
incompatible with life outside the womb. These women can be offered a terminatio
n of their pregnancy.
However, more commonly, the pattern of problems can only hint at an abnormality
and closer examination is
needed, particularly in the diagnosis of chromosomal deformities such as DOWNS (D
OWN) SYNDROME (trisomy 21
or presence of three 21 chromosomes instead of two). Chromosomal abnormalities c
an be definitively
diagnosed only by cell sampling such as amniocentesis (obtaining amniotic fluid
see AMNION from around
the baby) done at 15 weeks onwards, and chorionic villus sampling (sampling a sm
all part of the placenta)
another technique which can be done from 12 weeks onwards. Both have a small ris
k of miscarriage associated
with them; consequently, they are confined to women at higher risk of having an
abnormal fetus. Biochemical
markers present in the pregnant womans blood at different stages of pregnancy may
have undergone changes
in those carrying an abnormal fetus. The first such marker to be routinely used
was a high concentration of
alpha-fetol protein in babies with SPINA BIFIDA (defects in the covering of the
spinal cord). Fuller
research has identified a range of diagnostic markers which are useful, and, in
conjunction with other
factors such as age, ethnic group and ultrasound findings, can provide a predict
ive guide to the
obstetrician in consultation with the woman as to whether or not to proceed to a
n invasive test. These
tests include pregnancy-associated plasma protein assessed from a blood sample t
aken at 12 weeks and four
blood tests at 1522 weeks alphafetol protein, beta human chorionic gonadotrophin,
unconjugated oestriol
and inhibin A. Ultrasound itself can reveal physical findings in the fetus, whic
h can be more common in
certain abnormalities. Swelling in the neck region of an embryo in early pregnan
cy (increased nuchal
thickness) has good predictive value on its own, although its accuracy is improv
ed in combination with the
biochemical markers. The effectiveness of prenatal diagnosis is rapidly evolving
, the aim being to make the
diagnosis as early in the pregnancy as possible to help the parents make more in
formed choices. MULTIPLE
PREGNANCIES In the UK, one in 95 deliveries is of twins, while the prevalence of
triplets is one in 10,000
and quadruplets around one in 500,000. Racial variations occur, with African wom
en having a prevalence rate
of one in 30 deliveries for twins and Japanese
P
presenting to the neck of the womb. Some malpositions will correct naturally; ot
hers can be manipulated
abdominally during pregnancy to a better position. If, however, the mother start
s labour with the babys
head badly positioned or with the buttocks instead of the head presenting (breec
h position), the labour
will usually be longer and more difficult and may require intervention using spe
cial obstetric forceps to
assist in extracting the baby. If progress is poor and the fetus distressed, cae
sarean section may be
necessary. HIV INFECTION Pregnant women who are HIV positive (see HIV; AIDS/HIV)
should be taking antiviral
drugs in the final four to five months of pregnancy, so as to reduce the risk of
infecting the baby in
utero and during birth by around 50 per cent. Additional antiviral treatment is
given before delivery; the
infection risk to the baby can be further reduced by about 40 per cent if delive
ry is by caesarean
section. The mother may prefer to have the baby normally, in which case great ca
re should be taken not to
damage the babys skin during delivery. The infection risk to the baby is even fur
ther reduced if it is not
breast fed. If all preventive precautions are taken, the overall risk of the inf
ant becoming infected is
cut to under 5 per cent.
Premature birth This is a birth that takes place before the end of the n
ormal period of gestation,
usually before 37 weeks. In practice, however, it is defined as a birth that tak
es place when the baby
weighs less than 25 kilograms (5 pounds). Between 5 and 10 per cent of babies are
born prematurely, and
in around 40 per cent of premature births the cause is unknown. Pre-eclampsia is
the most common known
cause; others include hypertension, chronic kidney disease, heart disease and di
abetes mellitus. Multiple
pregnancy is another cause. In the vast majority of cases the aim of management
is to prolong the pregnancy
and so improve the outlook for the unborn child. This consists essentially of re
st in bed and sedation, but
there are now several drugs, such as RITODRINE, that may be used to suppress the
activity of the uterus and
so help to delay premature labour. Prematurity was once a prime cause of infant
mortality but modern
medical care has
elective caesarean section: for example, if the placenta is low in the uterus ca
lled placenta praevia
making a vaginal delivery dangerous. The third stage occurs when the placenta (o
r afterbirth) is delivered,
which is usually about 1020 minutes after the baby. An injection of ergometrine a
nd oxytocin is often
given to women to prevent bleeding. Pain relief in labour varies according to th
e mothers needs. For
uncomplicated labours, massage, reassurance by a birth attendant, and a warm bat
h and mobilisation may be
enough for some women. However, some labours are painful, particularly if the wo
man is tired or anxious or
is having her first baby. In these cases other forms of analgesia are available,
ranging from inhalation of
NITROUS OXIDE GAS, injection of PETHIDINE HYDROCHLORIDE or similar narcotic, and
regional local anaesthetic
(see ANAESTHESIA). Once a woman has delivered, care continues to ensure her and
the babys safety. The
midwives are involved in checking that the uterus returns to its normal size and
that there is no infection
or heavy bleeding, as well as caring for stitches if needed. The normal blood lo
ss after birth is called
lochia and generally is light, lasting up to six weeks. Midwives offer support w
ith breast feeding and care
of the infant and will visit the parents at home routinely for up to two weeks.
Some complications of labour
All operative deliveries in the UK are now done in hospitals, and are pe
rformed if a spontaneous birth
is expected to pose a bigger risk to the mother or her child than a specialist-a
ssisted one. Operative
deliveries include caesarean section, forceps-assisted deliveries and those in w
hich vacuum extraction
(ventouse) is used. CAESAREAN SECTION Absolute indications for this procedure, w
hich is used to deliver
over 15 per cent of babies in Britain, are cephalopelvic disproportion and exten
sive placenta praevia, both
discussed above. Otherwise the decision to undertake caesarean section depends o
n the clinical judgement of
the specialist and the views of the mother. The rise in the proportion of this t
ype of intervention (from 5
per cent in the 1930s to its present level of over 23 per cent
P
risk of causing damage to the babys scalp and brain than vacuum extraction, altho
ugh properly used, both
types should not cause any serious damage to the baby.
Episiotomy Normal and assisted deliveries put the tissues of the genital
tract under strain. The
PERINEUM is less elastic than the vagina and, if it seems to be splitting as the
babys head
Cephalic (left) and breech (right) presentation of fetus in maternal pel
vis at term.
Premedication
moves down the birth canal, it may be necessary to cut the perineal tiss
ue a procedure called an
episiotomy to limit damage. This is a simple operation done under local anaesthe
tic. It should be done
only if there is a specific indication; these include: to hasten the second stag
e of labour if the fetus is
distressed. to facilitate the use of forceps or vacuum extractor. to enlarge a p
erineum that is restricted
because of unyielding tissue, perhaps because of a scar from a previous labour.
Midwives as well as
obstetricians are trained to undertake and repair (with sutures) episiotomies. (
For organisations which
offer advice and information on various aspects of childbirth, including eclamps
ia, breast feeding and
multiple births, see APPENDIX 2: ADDRESSES:
SOURCES OF INFORMATION, ADVICE, SUPPORT AND SELF-HELP.)
Psychological and social problems Any previously existing mental-health
problems may worsen under the
stress of pregnancy and childbirth, and a womans socio-economic circumstances may
be an influential
factor. Mood swings are common in pregnant women and mothers of new babies; symp
athetic support from staff
and relations will usually remedy the situation. If postnatal depression lasts f
or more than a week or two
the use of mild ANTIDEPRESSANT DRUGS may be justified. If depression persists, r
eferral to a psychiatrist
may be advisable. Rarely, severe psychiatric problems puerperal psychosis may de
velop during or after
pregnancy and referral to an appropriate psychiatric unit is then essential. If
the mothers social
circumstances are unsatisfactory, advice should be sought from social services d
epartments. Mothers may
also need advice on benefits to which they are entitled and how to claim them. B
enefits Agency offices or
Citizens Advice Bureaux as well as antenatal clinics are useful sources of inform
ation.
Pregnancy Tests There are several tests for pregnancy (see PREGin its ea
rly stages, and these can be
done on blood or urine; some of the urine tests may be carried out at home. Most
tests are based on the
detection of HUMAN CHORIONIC GONADOTROPHIN (HCG) in the womans urine. They are ne
arly 100 per cent
accurate and may show positive as early as 30 days after the first day of the la
st normal period. NANCY AND
LABOUR)
577
The haemagglutination inhibition test This, and the subsequent tests to
be mentioned, are known as
immunological tests. They are based upon the effect of the urine from a pregnant
woman upon the interaction
of red blood cells, which have been sensitised to human gonadotrophin, and antig
e fetal abnormalities.
Alphafetoprotein (AFP) is produced by babies and leaks into the AMNIOTIC FLUID and
is absorbed by the
mother. In spina bifida and other neural-tube defects there is increased leakage
of AFP, and a blood test
at 16 weeks gestation can detect a raised level which suggests the presence of th
ese abnormalities. The
triple test, also performed at 16 weeks, measures AFP and two hormones HUMAN CHO
RIONIC GONADOTROPHIN and
unconjugated OESTRADIOL and is used in diagnosing DOWNS (DOWN) SYNDROME. Amniocen
tesis involves
inserting a needle through the mothers abdominal wall into the uterus to remove a
sample of amniotic fluid
at 1618 weeks. Examination of the fluid and the cells it contains is used in the
diagnosis of Downs
syndrome and other inherited disorders. The test carries a small risk of miscarr
iage. Chorionic villus
sampling may be used to diagnose various inherited conditions. A small amount of
tissue from the developing
PLACENTA is removed for analysis: this test has the advantages of having a lower
incidence of miscarriage
than amniocentesis and is carried out at an earlier stage (913 weeks). Analysis o
f a blood sample removed
from the umbilical cord (cordocentesis) may diagnose infections in the uterus, b
lood disorders or inherited
conditions. Direct observation of the fetus via a viewing instrument called a fe
toscope is also used
diagnostically and will detect structural abnormalities. Most tests have a recog
nised incidence of false
positive and negative results and are therefore usually cross-checked with anoth
er test. Counselling of the
parents about prenatal tests is important. This allows them to make an informed
choice which may not
necessarily involve terminating the pregnancy if an abnormality is found. (See P
REGNANCY AND LABOUR.)
Prepuce Also known as the foreskin, this is the free fold of skin that o
verlaps the glans PENIS and
retracts when the penis becomes erect. It is the part that is removed at CIRCUMC
ISION.
Preventive Medicine
579
DEAFNESS
Computer-generated prescriptions The Royal College of General Practition
ers
Presbyopia
has issued guidelines on the use of computergenerated prescriptions for
drugs other than controlled
drugs. The guidelines include rules on giving the patients name, address and date
of birth with the
responsible prescribing doctors name at the bottom, along with his or her surgery
address and telephone
number. The prescription has to be signed by the doctor. Several other requireme
nts are included to
minimise the risk of prescription-tampering, fraud or the inclusion of identifia
ble confidential
information. Full details of the guidelines appear in the British National Formu
lary, published every six
months.
Presbyacusis that comes on with increasing years. It is caused by increa
sing loss of elasticity in the
hearing mechanism, combined with the slowing-down of the mental processes that a
ccompanies old age. It is
characterised by particular difficulty in hearing high notes such as the telepho
ne and the voices of women
and children. Hearing in a background of noise is also affected. Modern, miniatu
rised, transistor
within-the-ear hearing aids are now available that are proving helpful in making l
ife more bearable for
the elderly in this respect. (See also AGEING; HEARING AIDS.)
See ACCOMMODATION; EYE, DISORDERS OF.
Prescribed Diseases A collection of industrial diseases which provide th
ose with a disease legal
entitlement to welfare benefits. Examples are DEAFNESS from excessive noise in t
he workplace; ANTHRAX from
farming; PNEUMOCONIOSIS from industrially generated dust (coal mining); and LEAD
POISONING from the
handling of chemicals. (See also OCCUPATIONAL HEALTH, MEDICINE AND DISEASES.)
Prescription The written direction for drugs for medicinal use, given by
the doctor, dentist and (for
some drugs) nurse to the patient, for dispensation by the pharmacist. Drugs shou
ld only be prescribed when
essential for treatment, and when any possible risks involved to the patient (an
d fetus in cases of
pregnancy) are outweighed by the potential benefits of giving the drug. When pos
sible, non-proprietary, or
generic, titles should be prescribed; by allowing the pharmacist to dispense any
equivalent drug this
avoids delay for the patient, as well as reducing the cost to the Health Service
. Dosage is generally
stated in metric units, and both the amount and frequency should be carefully ex
Prion
carried out. Inevitably, some of the screening tests proposed can be exp
ensive (particularly if used in
large populations), painful or inaccurate and may not improve the results of tre
atment. Screening can also
provoke considerable anxiety in those waiting for tests or results. Therefore, o
ver the years considerable
research has been carried out into the appropriateness and ethics of screening,
and the World Health
Organisation in 1968 identified a set of rules for evaluating screening tests: T
he condition sought should
be an important health problem, for which there should be an accepted treatment
for patients with
recognised disease. Facilities for diagnosis and treatment should be available i
f a case is found. The
screening test or examination must be suitable and valid. A false positive test
will cause massive anxiety
and also considerable expense in proving that there is no disease. Similarly, fa
lse negatives can lead
people to be reassured and to ignore serious symptoms until too late. If large n
umbers of positive tests or
false positives occur during a screening programme, health services can be swamp
ed. The test, and any
treatment as a possible result, should be acceptable. For example, there is litt
le point in screening for a
fetal abnormality which, if found, would lead to a recommendation for terminatio
n if the mother will refuse
it on religious or moral grounds. Screening tests also need to be considered fro
m an economic perspective
and the cost of case-finding (including diagnosis and treatment of patients diag
nosed) balanced in relation
to possible expenditure on medical care as a whole. Finally the programme should
reflect the natural
history of the disease, and casefinding should normally be a continuing process
and not a once for all
project. If these rules are followed, considerable benefits can result from well
-planned and wellmanaged
screening programmes, and they form an important part of any health-care system.
The extent to which
manipulation of genetic material will be added to more traditional approaches su
ch as counselling,
immunisation and drug treatment cannot yet be predicted but, as time goes by, it
is often likely to be
ethical and social controls which limit developments rather than technical and s
cientific limits.
PENIS
581
occurring without sexual stimulation. It is a rare but acute condition t
hat requires immediate
treatment. The cause is the failure of blood to drain from the spongy corpus cav
ersonum tissues of the
penis, thus maintaining an erection. This may happen because of infection, damag
e to the nerves controlling
the blood vessels, or a clotting defect in the blood.
Prickly Heat See MILIARIA.
Primary Care Trust See GENERAL PRACTITIONER (GP)
Primary Health Care Sometimes called primary medical care, this is the c
are provided by a GENERAL
PRACTITIONER (GP) traditionally entitled the family doctor or other health profe
ssionals who have first
contact with a patient needing or wanting medical attention. In the NHS, the pri
mary health-care services
include those provided by the general, dental, ophthalmic and pharmaceutical ser
vices as well as the family
doctor service. Community health services provided outside the hospitals also of
fer some primary health
care.
Primidone A barbiturate-related drug (see BARBITURATES) used to treat al
l forms of EPILEPSY, except in
sufferers who do not have seizures.
Primigravida A woman who is undergoing her first pregnancy (see PREGNANC
Y AND LABOUR).
Primipara The term applied to a woman who has given birth, or is giving
birth, to her first child (see
PREGNANCY AND LABOUR).
Prion An aberrant variety of one of the proteins, called PrP, in a brain
cell. The result of a gene
mutation (see GENES), prions are stable, resistant to radiation and impervious t
o the normal cellular
processes of degradation. They seem to react with normal PrP, turning it into an
abnormal type that then
accumulates in brain tissue. Prions are believed to be the infectious agents tha
t cause a group of serious
neurological disorders called spongiform encephalopathies. CREUTZFELDT-JAKOB DIS
EASE (CJD), the new variant
of CJD linked with BOVINE SPONGIFORM ENCEPHALOPATHY (BSE), and KURU a neurologic
al disorder found in a
cannibal tribe
P
Prolactin
Prochlorperazine
583
Prognathism
Prochlorperazine is an antipsychotic phenothiazine drug (see NEUROLEPTIC
S). It is also an effective
drug for the prevention or treatment of vomiting, and has therefore been used in
the treatment of MENIRES
DISEASE.
Abnormal protusion of the lower JAW, or sometimes of both jaws. The cond
ition may make biting and
chewing difficult, in which case corrective surgery is necessary.
Procidentia
The term applied to a forecast as to the probable result of an illness o
r disease, particularly with
regard to the prospect of recovery.
Another term for PROLAPSE.
Proctalgia
Nerve pain in the ANUS or RECTUM, without any local disease to account for
it. Proctalgia fugax is a
condition more common in men, characterised by cramp-like pains in the rectum an
d occasionally accompanied
by a feeling of faintness. Occurring at night and lasting up to 15 minutes, the
cause is unknown, but is
probably due to muscle spasm. Rapid relief may be achieved by taking food or dri
nk, exerting perineal
pressure (including inserting a finger into the rectum), or sucking a 1 mg table
t of GLYCERYL TRINITRATE.
Proctitis
Inflammation situated about the
RECTUM
or
ANUS.
Prodromata
A term applied to the earliest symptoms of a disease, or those which giv
e warning of its presence.
Progeria
Premature old age (see also AGEING).
Progesterone
The hormone of the CORPUS LUTEUM of the ovary (see OVARIES). After the e
scape of the OVUM from the
ruptured follicle, the corpus luteum secretes progesterone, which stimulates the
growth and secretion of
the endometrial glands of the UTERUS during the 14 days before MENSTRUATION. In
the event of pregnancy, the
secretion of progesterone continues until the babys birth. (See also NORETHISTERO
NE; PREGNANDIOL;
CONTRACEPTION.)
Progestogen
One of a naturally occurring or synthetically produced group of steroid
HORMONES, including
PROGESTERONE, that help to maintain normal pregnancy. Progestogens are used in c
ontraceptives (see
CONTRACEPTION) and are useful in treating AMENORRHOEA, premenstrual tension, and
abnormal uterine bleeding.
Prognosis
Proguanil Hydrochloride
A synthetic antimalarial drug usually used with CHLOROQUINE to prevent i
nfection with MALARIA.
Occasionally the drug is used to treat uncomplicated falciparum malaria in combi
nation with atovaquone.
Prolactin
Prolactin is the pituitary hormone (see PITUITwhich initiates lactation.
The development of the breasts
during pregnancy is ascribed to the action of OESTROGENS; prolactin starts them
secreting. If lactation
does not occur or fails, it may be started by injection of prolactin. The secret
ion of prolactin is
normally kept under tonic inhibition by the secretion of DOPAMINE which inhibits
prolactin. This is formed
in the HYPOTHALAMUS and secreted into the portal capillaries of the pituitary st
alk to reach the anterior
pituitary cells. Drugs that deplete the brain stores of dopamine or antagonise d
opamine at receptor level
will cause HYPERPROLACTINAEMIA and hence the secretion of milk from the breast a
nd AMENORRHOEA. METHYLDOPA
and RESERPINE deplete brain stores of dopamine and the PHENOTHIAZINES act as dop
amine antagonists at
receptor level. Other causes of excess secretion of prolactin are pituitary tumo
urs, which may be minute
and are then called microadenomas, or may actually enlarge the pituitary fossa a
nd are then called
macroadenomas. The most common cause of hyperprolactinaemia is a pituitary tumou
r. The patient may present
with infertility because patients with hyperprolactinaemia do not ovulate or wit
h amenorrhea and even
GALACTORRHOEA. BROMOCRIPTINE is a dopamine agonist. Treatment with bromocriptine
will therefore control
hyperprolactinaemia, restoring normal menstruation and ovulation and suppressing
galactorrhoea. If the
cause of hyperprolactinaemia is an adenomatous growth in the pituitary gland, su
rgical treatment should be
584 Prolapse
P
Prolapse
Promazine
Displacement of an organ or structure from its normal position. The term
is applied chiefly to downward
displacements of the RECTUM and
A phenothiazine drug used to tranquillise disturbed patients (see NEUROL
EPTICS).
UTERUS.
Promethazine Hydrochloride
Prolapsed Intervertebral Disc
A widely used antihistamine drug with a prolonged action and a pronounce
d sedative effect. (See
ANTIHISTAMINE DRUGS.)
The SPINAL COLUMN is built up of a series of bones, known as vertebrae,
placed one upon the other.
Between these vertebrae lies a series of thick discs of fibro-cartilage known as
intervertebral discs. Each
disc consists of an outer portion known as the anulus fibrosus, and an inner cor
e known as the nucleus
pulposus. The function of these discs is to give flexibility and resiliency to t
he spinal column and to act
as buffers against undue jarring. In other words, they are most efficient shocka
bsorbers. They may,
however, PROLAPSE, or protrude, between the two adjacent vertebrae. If this shou
ld happen they press on the
neighbouring spinal nerve and cause pain. As the most common sites of protrusion
are between the last two
lumbar vertebrae and between the last lumbar vertebra and the sacrum, this means
that the pain occurs in
the back, causing LUMBAGO, or down the course of the sciatic nerve causing SCIAT
ICA. The prolapse is most
likely to occur in middle age, which suggests that it may be associated with deg
eneration of the disc
involved, but it can occur in early adult life as well. It usually occurs when t
he individual is performing
some form of exercise which involves bending or twisting, as in gardening. The o
nset of pain may be acute
and sudden, or gradual and more chronic in intensity. (See also INTERVERTEBRAL D
ISC.)
Treatment
varies, depending (amongst other things) on the severity of the conditio
n. In the acute phase, rest in
bed is advisable, along with ANALGESICS. Later, exercise and physiotherapy are h
elpful, and in some cases
manipulation of the spine brings relief by allowing the herniated, or prolapsed,
disc to slip back into
position. The injection of a local anaesthetic into the spine (epidural ANAESTHE
SIA) is yet another measure
that often helps the more chronic cases. If those measures fail, surgery to remo
ve the prolapsed disc may
be necessary, but the patients condition should be carefully reviewed before surg
ery is considered since
success is not certain. An alternative form of treatment is the injection into t
he disc of chymopapain, an
ENZYME obtained from the paw-paw, which dissolves the disc.
Promethazine Theoclate A drug that is widely used in the alleviation or
prevention of sea-sickness (see
MOTION (TRAVEL) SICKNESS).
Pronation The movement whereby the bones of the forearm are crossed and
the palm of the hand faces
downwards.
Prone Lying with the face down, or positioning the arm and hand so that
the palm faces downwards.
Prophylaxis Treatment or action adopted with the view of warding off dis
ease.
Propofol A drug used intravenously to induce general ANAESTHESIA. Propof
ol may be used by intravenous
infusion to maintain anaesthesia; it is also useful for sedating patients in int
ensive care.
Propranolol Hydrochloride One of the BETA-ADRENOCEPTOR-BLOCKING DRUGS, p
ropranolol hydrochloride is
used in the treatment of ANGINA PECTORIS, myocardial infarction (see under HEART
, DISEASES OF), certain
abnormal rhythms of the heart, and high blood pressure (HYPERTENSION). It also p
revents attacks of
MIGRAINE, and is used for certain anxiety states particularly those associated w
ith unpleasant bodily
sensations, such as palpitations. (See also ADRENERGIC RECEPTORS.)
Proprietary Name The trade name of a drug registered by the pharmaceutic
al company which has developed
and patented it. This protects the name, ingredients and manufacturing technique
for a set period of time,
and helps the company to recoup the often costly research and development needed
to produce and test the
drug. Doctors may prescribe a drug by its trade name or by its official, approve
d name, although the
Symptoms These are similar to those resulting from benign prostatic hype
rtrophy (see Spread of the
cancer to bones can cause pain. The use of a blood test measuring the amount of
an ANTIGEN, PROSTATE
SPECIFIC ANTIGEN (PSA), can be helpful in making the diagnosis as can an ULTRASO
UND scan of the prostate.
above).
Treatment This could be surgical, with removal of the prostate (either v
ia an abdominal incision, total
prostatectomy, or transurethrally), or could be by radiotherapy. In more advance
d cancers, treatment with
antiandrogen drugs, such as cyprotexone acetate or certain oestrogens, is used t
o inhibit the growth of the
cancer.
Prostate Specific Antigen (PSA) An ENZYME produced by glandular tissue i
n the PROSTATE GLAND. When the
gland enlarges (see PROSTATE, DISEASES OF), greater amounts of PSA are secreted,
raising the concentration
of the enzyme in the blood. This is especially so in cancer of the prostate, and
testing the level of PSA
is an indicator that the disease may be present. There is much controversy about
the use of PSA as a
screening test. Its proponents claim that its use reduces deaths from prostate c
ancer; its opponents
suggest that it does this only by bringing to light many cases that needed no tr
eatment and would not have
caused death in any case. Further, if the level of PSA is very high, the disease
is already advanced; where
the result is equivocal it is uncertain whether the benefits of treatment outwei
gh the risks.
Prostatectomy An operation to remove part or all of the PROSTATE GLAND.
The most common method is
transurethral prostatectomy (TURP) carried out during cytoscopy. A very enlarged
prostate may need to be
removed by a retropubic prostatectomy. After several weeks, most patients are ab
le to resume normal
activity including sexual intercourse.
Prostatis See under PROSTATE GLAND, DISEASES OF.
Prostatism The condition induced by benign enlargement of the PROSTATE G
LAND.
Prosthesis
Prosthesis An artificial replacement of a missing or malfunctioning body
part. Examples include false
legs or arms fitted after AMPUTATION (see below); artificial heart valves; artif
icial heart devices;
COCHLEAR IMPLANTS to improve hearing; a bio-artificial PANCREAS (containing live
pancreatic cells from
pigs) now under development to treat DIABETES MELLITUS; artificial bone; and (un
der development) artifical
lungs. Cosmetic prostheses such as artifical eyes, teeth, noses and breasts are
in widespread use.
Development of such mechanical and biomechanical devices points the way to a muc
h wider use of effective
prostheses, enabling people who would previously have died or been severely hand
icapped to lead normal or
near normal lives. The technical hazards that have already been overcome provide
a sound foundation for
future successes. Progress so far in producing prostheses should also ensure tha
t organ replacement is free
from the serious ethical problems that surround the use of genetic manipulation
to cure or prevent serious
diseases (see ETHICS).
Limbs These are best made to meet the individuals requirements but can be
obtained off the shelf .
Artificial joints normally comprise complex mechanisms to stimulate flexion and
rotation movements. Leg
prostheses are generally more useful than those for arms, because leg movements
are easier to duplicate
than those of the arm. Modern electronic circuitry that enables nerve impulses t
o be picked up and
converted into appropriate movements is greatly improving the effectiveness of l
imb prostheses.
Eyes Artificial eyes are worn both for appearance and for psychological
reasons. They are made of glass
or plastic, and are thin shells of a boat-shape, representing the front half of
the eye which has been
removed. The stump which is left has still the eye-muscles in it, and so the art
ificial eye still has the
power of moving with the other. A glass eye has to be replaced by a new one ever
y year. Plastic eyes have
the advantage of being more comfortable to wear, being more durable, and being u
nbreakable. Research is
taking place aimed at creating a silicon chip that stimulates the visual cortex
and thus helps to restore
sight to the blind. Dental prostheses
is any artificial replacement of a tooth. There are three main types: a
crown, a bridge and a denture.
A crown
587
is the replacement of the part of a tooth which sticks through the gum.
It is fixed to the remaining
part of the tooth and may be made of metal, porcelain, plastic or a combination
of these. A bridge is the
replacement of two or three missing teeth and is usually fixed in place. The rep
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 records of such operations dat
ing back to 1,000 BC. Loss of a
nose may be due to eroding disease, war wounds, gun-shot wounds or dog bites. In
essence the operation is
the same as that practised a thousand years before Christ: namely the use of a s
kin graft, brought down
from the forehead. Alternative sources of the skin graft today are skin from the
arm, chest or abdomen. As
a means of support, the new nose is built round a graft of bone or of cartilage
from the ear.
symptom of serious heart or kidney disease, although some normal people
have mild and transient
proteinuria after exercise.
Protease A digestive ENZYME also known as a proteolytic enzyme that brea
ks down PROTEIN in food as
part of the digestive process. The complex protein molecules are reduced to thei
r constituent AMINO ACIDS.
Protease Inhibitors A new group of drugs which, in combination with anti
viral agents, are used to treat
AIDS (see AIDS/HIV). They inhibit the activity of PROTEASE, an enzyme produced b
y HIV, and which breaks
down proteins. The drugs have recently been introduced: those in use are indinav
ir, nelfinavir, ritonavir
and saquinavir.
Protein
P
The term applies to members of a group of non-crystallisable nitrogenous
substances widely distributed
in the animal and vegetable kingdoms, and forming the characteristic materials o
f their tissues and fluids.
They are essentially combinations of AMINO ACIDS. They mostly dissolve in water
and are coagulated by heat
and various chemical substances. Typical examples of protein substances are whit
e of egg and gelatin.
Proteins constitute an essential part of the diet as a source of energy, and for
the replacement of protein
lost in the wear and tear of daily life. Their essential constituent from this p
oint of view is the
nitrogen which they contain. To be absorbed, or digested, proteins have to be br
oken down into their
constituent amino acids. The adult human body can maintain nitrogenous equilibri
um on a mixture of eight
amino acids, which are therefore known as the essential (or indispensable) amino
acids. They are
isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan an
d valine. In addition,
infants require histidine.
Pseudocyst
589
Proteolysis
Proximal
The mechanism by which complex PROTEIN molecules are broken down by dige
stive enzymes (see PROTEASE) in
the stomach and small intestine. The constituent AMINO ACIDS are then absorbed i
nto the bloodstream.
A term of comparison applied to structures which are nearer the centre o
f the body or the median line
as opposed to more distal, or distant, structures.
Prothrombin
See FLUOXETINE.
An inactive substance in the blood PLASMA that is the precursor of the E
NZYME, thrombin, which clots
the blood. The conversion occurs when a blood vessel is damaged and the process
of blood COAGULATION
occurs.
Prozac Prurigo An intensely itching form of eczema (see DERMATITIS) in w
hich LICHEN takes a nodular
form.
Proton Pump
Pruritus
A key enzyme system in the parietal cells of the mucosal lining of the s
tomach: hydrogen ions are
produced which acidify the stomachs secretions and convert pepsinogen to PEPSIN,
an active participant in
the digestion of food.
Another name for itching, it is a common symptom with many causes. It ma
y accompany obvious skin
disease such as URTICARIA, eczema (see DERMATITIS) or SCABIES. Pruritus may be s
ystemic in origin and can
be caused by advanced hepatic (liver) or renal (kidney) failure, uncontrolled DI
ABETES MELLITUS, or
HYPERTHYROIDISM. It may be due to drugs and certain forms of malignancy for exam
ple, Hodgkins disease
(see LYMPHOMA). Anxiety or depression may also cause pruritus. Pruritus ani, itc
hing round the ANUS, is a
common troublesome condition: it may be caused by obsessive efforts to keep this
area clean; soft toilet
paper and gentle cleansing once daily should be sufficient. A weak anal sphincte
r, skin tags, and
HAEMORRHOIDS may also cause itching, and these conditions should be treated.
Proton-Pump Inhibitors These are drugs that inhibit the production of ac
id in the stomach by blocking a
key enzyme system, known as the PROTON PUMP, of the parietal cells of the stomac
590 Pseudohermaphrodite
lining and which contains fluid. Patients with chronic pancreatitis (see
PANCREAS, DISORDERS OF)
sometimes develop these pseudocysts which fill with pancreatic juice containing
enzymes produced by the
gland. Abdominal pain usually results; treatment is by surgical draining.
accomplished by the contraction of this muscle. Disease of the spine in
the lumbar region may produce
an ABSCESS which lies within the sheath of this muscle and makes its way down to
the front of the thigh.
Such an abscess is known as a psoas abscess.
Pseudohermaphrodite
Psoralens
A person in whom the gonads (testes or ovaries see GONAD) of only one se
x are present in the body but
in whom the external GENITALIA may not be obviously male or female. The conditio
n is a result of a hormonal
imbalance and can normally be treated by appropriate surgery and hormone drugs.
(See also HERMAPHRODITE.)
See PHOTOCHEMOTHERAPY; TOSES.
Psoriasis
Also called parrot disease. An infectious disease of parrots and other e
xotic birds which may be
transmitted to humans and is caused by the micro-organism Chlamydia psittaci. It
presents as PNEUMONIA or a
systemic illness in which the patient has an enlarged spleen and liver and PNEUM
ONITIS. Tetracycline is an
effective treatment, but relapses may occur.
This chronic, relapsing inflammatory skin disease is extremely common, a
ffecting about 2 per cent of
the UK population. Frequently it is mild and trivial, affecting only the points
of the elbows or knees and
the scalp, but in a substantial minority of sufferers the disease is much more w
idespread and causes
considerable discomfort and social embarrassment. Rarely, it can be universal an
d even life-threatening.
The predisposition to psoriasis is genetic, multiple genes being involved, but p
ostnatal factors such as
acute infection, hormonal disturbance, pregnancy and drugs can influence or prov
oke it. The sexes are
equally affected and onset is most common in the second or third decade of life.
The psoriatic lesion is
dull red, scaly and well defined. Scale is shed constantly, either in tiny piece
s or as large plaques. The
scalp is usually affected but the disease does not cause significant hair loss.
The fingernails may be
pitted or ridged and the toenails grossly thickened. Several clinical patterns o
ccur: in guttate psoriasis,
a sudden explosion of multiple tiny lesions may follow a streptococcal throat in
fection, especially in
children. Larger lesions are characteristic of discoid (plaque) psoriasis, the u
Psychologist
psoriasis. METHOTREXATE, CICLOSPORIN A and oral RETINOIDS are the most e
ffective drugs, but they are
potentially dangerous and require expert monitoring. Patient information may be
obtained through the
Psoriasis Association.
Psyche The mind or soul of an individual and his or her mental in contra
st to the physical
functioning.
Psychedelic Drugs Drugs, such as CANNABIS and LYSERGIC ACID DIETHYLAMIDE
(LSD), that expand
consciousness and perception. (See DEPENDENCE.)
591
Psychogeriatrics The branch of PSYCHIATRY that investigates, diagnoses a
nd treats the mental-health
problems of old people. Psychogeriatricians work in close co-operation with phys
icians for the care of the
elderly, and with other health professionals and social workers in this branch o
f medicine.
Psychologist Psychologists have a graduate degree in PSYCHOLOGY, followe
d by an accredited postgraduate
training leading to chartered status. There are a number of different branches r
elated to the various
applications psychology has to different fields of work.
Psychiatry
Types of psychologist
That branch of medical science which treats mental disorder and disease
and also helps with the
management of people with learning disabilities (see LEARNING DISABILITY; MENTAL
ILLNESS).
Working in schools and in local education authorities, they are concerne
d with childrens learning and
development. They carry out tasks aimed at improving childrens learning and helpi
ng teachers to become
more aware of social factors that affect teaching and learning. Chartered educat
ional psychlogists have a
graduate degree in psychology and also a teaching qualification, with experience
; in addition they have
completed a one-year postgraduate course in educational psychology with supervis
ed experience. COUNSELLING
PSYCHOLOGISTS apply psychology to working in collaboration with people across a
range of human problems.
For example, helping people to manage difficult life events, relationship issues
, BEREAVEMENT and issues
raised by mental-health problems. Their usual route to qualify is completing a t
hree-year postgraduate
training in counselling psychotherapy. CLINICAL PSYCHOLOGISTS have completed a t
hree-year doctorate
training course as well as having their first degree in psychology. They work in
health and care settings.
Their aim is to reduce psychological distress and to promote psychological wellbeing. They work with
individuals, families, groups and organisations: the individuals are people who
have problems such as
anxiety, DEPRESSION, serious and enduring MENTAL ILLNESS, brain injuries, addict
ion, child and family
problems, LEARNING DISABILITY and the after-effects of trauma. They provide vari
ous types of treatment, for
example COGNITIVE BEHAVIOUR THERAPY and family therapy, based on psychological t
heories and research. They
also carry out research, training, consultation with other professionals involve
d with clients, and
supervision of colleagues. (See also NEUROSIS; PSYCHOTHERAPY.) FORENSIC PSYCHOLO
GISTS work in the
Psychoanalysis The term applied to the theories and practice of the scho
ol of psychology originating
with Freud and developed by Jung and other psychotherapists (see PSYCHOLOGY). It
depends upon the theory
that states of disordered mental health have been produced by a repression in th
e subconscious of painful
memories or of conflicting instincts, thus absorbing the individuals mental energ
y and diverting attention
from normal mental activities. Psychoanalysis aims at discovering these represse
d memories, which are
responsible for the diversion of mental power and of which the affected person u
sually is only dimly aware
or quite unaware. The fundamental method of psychoanalytical treatment is the fr
ee expression of thoughts,
ideas and fantasies on the part of the patient. To facilitate this, the analyst
uses techniques to relax
the patient and maintains a neutral attitude to his or her problems. In the cour
se of analysis the patient
will re-explore his or her early emotional attitudes and tensions. The fundament
al conception of
psychoanalysis, although hard to prove by orthodox scientific methods and theref
ore challenged by some
psychiatrists, has been widely adopted and developed by other schools of psychol
ogy. Freuds work changed
the attitudes of the scientific community and the public to the problems of the
neurotic, the morbidly
anxious, the fearful and to the mental and emotional develoment of the child.
EDUCATIONAL PSYCHOLOGISTS
P
592 Psychology
criminal and justice fields, applying psychological theory to aspects of
legal processes in courts,
criminal investigation, and understanding and treating psychological problems as
sociated with criminal
behaviour. They will have completed an accredited training course in forensic ps
ychology. HEALTH
PSYCHOLOGISTS apply psychological methods to studying behaviour relevant to heal
th, illness and care
including health promotion and education. OCCUPATIONAL PSYCHOLOGISTS are concern
ed with how people perform
at work and how organisations function. They work in management, personnel, sele
ction and careers advice.
They have a postgraduate degee in occupational psychology and will have had to u
ndertake three years
supervised practice.
Psychology
P
The scientific study of people: how they think, and how and why they act
, react and interact as they
do. It covers such matters as memory, rational and irrational thought, intellige
nce, learning, personality,
perceptions and emotions. There are different schools of psychology, varying bot
h in attitude and in
methods of working. The main groups consist of the introspectionist Freudian, Ju
ngian and Adlerian schools,
and the gestaltist, behaviourist and cognitive schools. Although many practical
psychologists deny
belonging to any specific school, contemporary psychology in general favours the
cognitive schools,
although many are sub-specialities based on practical considerations. (See also
FREUDIAN THEORY; JUNGIAN
ANALYSIS; ADLER; GESTALTISM; PSYCHOLOGIST.)
Psychometrics The use of standardised psychological tests to measure dif
ferences in functions for
example, intelligence and personality in individuals.
Psychoneurosis A general term applied to various functional disorders of
the nervous system. (See
NEUROSIS.)
Psychopathic Psychopathic disorder is defined by the Mental Health Act 1
983 as a persistent disorder or
disability of mind (whether or not including significant impairment of intellige
nce) which results in
abnormally aggressive or seriously irresponsible conduct. The cardinal features
are as follows: (1) Absence
of normal feelings for other people such as love, affection, sympathy and condol
ence. (2) A tendency to
antisocial impulsive acts with no forethought of the consequences. (3) A failure to learn by experience and to be deterred from
crime by punishment. (4)
Absence of any other form of mental disorder that would explain the unusual beha
viour. The corresponding
Psychotherapy
symptoms instead and that they are also at greater risk of physical dise
ase. The trouble with this
view is that medical advances repeatedly show that it goes too far. Stress certa
inly causes physical
symptoms for example, DYSPEPSIA but the belief that it caused peptic ulcers vani
shed with the discovery
of the true cause: colonisation of the stomach by the bacterium, Helicobacter py
lori. Of course, stress and
social adversity affect the risk of many diseases. For example, the incidence of
heart disease among UK
government employees (civil servants) has been shown to be influenced by their s
ocial class and their
degree of job satisfaction. But we do not know how this works. Some argue that s
ocial adversity and stress
influence how the heart functions (He died of a broken heart). Stress can also aff
ect IMMUNITY but it
cannot cause AIDS/HIV and we do not know if there is a link running from stress
to abnormal immune function
to actual illness. We can say that psychological factors provoke physical sympto
ms, and often even explain
how this can happen. For example, when you are anxious you produce more epinephr
ine (adrenaline), which
gives rise to chest pain, butterflies in the stomach and PALPITATION. These sympto
ms are not all in the
mind, even if the trigger is a psychological one. People who are depressed are mo
re likely to experience
nearly every physical symptom there is, but especially pain and fatigue. Taken a
s a whole, psychologically
induced symptoms are an enormous burden on the NHS and probably responsible for
more doctor visits and
sickness absence than any other single cause. Also we can be confident that soci
al adversity and stress
powerfully influence the outcome of many illnesses; likewise, a vast range of un
healthy activities and
behaviours such as smoking, excessive alcohol intake, excessive eating, and so o
n. But we must be careful
not to assume that our emotions directly cause our illnesses.
Psychosurgery This was introduced in 1936 by Egas Moniz, Professor of Me
dicine in Lisbon University,
for the surgical treatment of certain psychoses (see PSYCHOSIS). For his work in
this field he shared the
Nobel prize in 1949. The original operation, known as leucotomy, consisted of cu
tting white fibres in the
frontal lobe of the BRAIN. It was accompanied by certain hazards such as persist
ent EPILEPSY and
undesirable changes in personality; pre-frontal leucotomy is now regarded as obs
olete. Modern stereotactic
surgery may be indicated in certain intractable psychiatric illnesses in which t
he patient is
593
chronically incapacitated, especially where there is a high suicide risk
. Patients are only considered
for psychosurgery when they have failed to respond to routine therapies. One con
traindication is marked
histrionic or antisocial personality. The conditions in which a favourable respo
594 Psychotic
therapy is drama therapy. Large group therapy also exists.
Education and employment may be important factors psychotherapy.
in
rehabilitative
Supportive therapy consists of sympaPtosis
thetically reviewing the patients situation with him or her, and encourag
ing the patient to identify
and solve problems.
See EYE, DISORDERS OF.
Short-term supportive psychotherapy is aimed at stabilising and strength
ening the psychological defence
mechanisms of those patients who are confronted by a crisis which threatens to o
verwhelm their ability to
cope, or who are struggling with the aftermath of major life events.
Ptyalin The name of the ENZYME contained in the SALIVA, by which starchy
materials are changed into
sugar, and so prepared for absorption. It is identical to the AMYLASE of pancrea
tic juice. (See DIGESTION;
PANCREAS.)
Puberty
See PERCUTANEOUS TRANSHEPATIC CHOLANGIOPANCREATOGRAPHY (PTC).
The change that takes place when childhood passes into manhood or womanh
ood. This change is generally a
very definite one, occurring at about the age of 14 years, although it is modifi
ed by race, climate, and
bodily health so that it may appear a year or two earlier or several years later
. At this time, the sexual
functions attain their full development; the contour of the body changes from a
childish to a more rounded
womanly, or sturdy manly, form; and great changes take place in the mode of thou
ght and feeling. In girls,
puberty is marked by the onset of MENSTRUATION and development of the BREASTS. T
he latter is usually the
first sign of puberty to appear, and may occur from nine years onwards; most gir
ls show signs of breast
development by the age of 13. The time from the beginning of breast development
to the onset of
menstruation is usually around two years but may range from six months to five y
ears. The first sign of
puberty in boys is an increase in testicular and penile size (see TESTICLE; PENI
S) between the age of ten
and 14. The LARYNX enlarges in boys, so that the voice after going through a per
iod of breaking
finally assumes the deep manly pitch. Hair appears on the pubis and later in the
armpits in both boys and
girls, whilst in the former it also begins to grow on the upper lip, and skin er
uptions are not uncommon on
the face (see ACNE). The period is one of transition from a physical and mental
point of view. Puberty is
not to be regarded as a physiological coming of age, for full development is usual
ly achieved in the
early 20s.
Pterygium
Pubis
A degenerative disorder of the conjunctiva (see EYE) which grows over th
e cornea medially and
Pubis is the bone that forms the front part of the pelvis. The pubic bon
es of opposite sides
Long-term supportive psychotherapy is needed for patients with personali
ty disorders or recurrent
psychotic states, where the aim of treatment is to prevent deterioration and hel
p the patient to achieve an
optimal adaptation, making the most of his or her psychological assets. Such pat
ients may find more
profound and unstructured forms of therapy distressing.
Behavioural therapy and cognitive therapy, often carried out by psycholo
gists,
P
laterally. The overgrowths look like wings. They are commonly seen in pe
ople who live in areas of
bright sunlight, particularly when reflected from deserts or snowfields. Treatme
nt involves excision of the
overgrowth. (See also EYE, DISORDERS OF.)
attempt to clarify with the patient specific features of behaviour or me
ntal outlook respectively, and
to identify step-by-step methods that the patient can use for controlling the di
sorder. Behaviour therapy
is commonly used for AGORAPHOBIA and other phobias, and cognitive therapy has be
en used for depression and
anxiety. (See MENTAL ILLNESS.)
Psychotic Adjective describing PSYCHOSIS or noun referring to someone wi
th a psychosis.
Psychotropic Affecting the mind. Psychotropic drugs include HALLUCINOGEN
S, HYPNOTICS or sleeping drugs,
sedatives, TRANQUILLISERS and NEUROLEPTICS (antipsychotic drugs).
PTC
Public Health
meet in the symphysis and protect the bladder from the front.
Public Health Individuals with health problems go to their doctor, are d
iagnosed and prescribed
treatment. Public-health doctors use epidemiological studies (see EPIDEMIOLOGY,
and below) to diagnose the
causes of health problems in populations and to plan services to treat the healt
h and disease problems
identified. Their concern is often focused particularly on those who are disadva
ntaged or marginalised, and
on the delivery of safe, effective and accessible health care: however, to achie
ve their goal of better
health and well-being for everybody, they must also influence decision-makers ac
ross the whole community.
Central to an understanding of public health is recognition that public-health p
ractitioners are concerned
not just with individuals, but also with whole populations and that improving he
alth care plays only a
part of public-health improvement. The health of populations (public health) is
also dependent on many
factors such as the social, economic and physical environment in which the peopl
e live and the nutrition
and health care available to them. For thousands of years, a fundamental feature
of civilisations has been
to seek to improve the health of the population and protect it from disease. Thi
s has led to the
development of legal frameworks which differ widely from country to country, dep
ending on their social and
political development. All are concerned to stop the spread of infectious diseas
es, and to maintain the
safety of urban food and water supplies and waste disposal. Most are also associ
ated with housing
standards, some form of poverty relief, and basic health care. Some trading stan
dards are often covered, at
least in relation to the sale and distribution of poisons and drugs, and to cont
rols on industrial and
transport safety for example, in relation to drinking and driving and car design
. Although these varied
functions protect the public health and were often originally developed to impro
ve it, most are
managerially and professionally separated from todays public-health departments.
So publichealth
professionals in the NHS, armed with evidence of the cause of a disease problem,
must frequently act as
advocates for health across many agencies where they play no formal management p
art. They must also seek to
build alliances and add a health perspective to the policies of other services w
herever possible.
Epidemiology is the principal diagnostic
595
method of public health. It is defined as the study of the distribution
and determinants of
health-related states in specified populations, and the application of this stud
y to the control of health
problems. Public-health practitioners also draw on many other skills, such as th
ose of statisticians,
sociologists, anthropologists, economists and policy analysts in identifying and
trying to resolve the
health problems of the societies they serve. Treatments proposed are likely to e
xtend well beyond the
clinic or hospital and may include recommendations for measures to resolve pover
ty, improve sanitation or
housing, control pollution, change lifestyles such as smoking, improve nutrition
, or change health
services. At times of acute EPIDEMIC, public-health doctors have considerable le
gal powers granted to
enable them to prevent infection from spreading. At other times their work may b
e more concerned with
monitoring, reporting, planning and managing services, and advocating policy cha
nges to politicians so that
health is promoted. The term the public health can relate to the state of health o
f the population, and
be represented by measures such as MORTALITY indices (e.g. perinatal or infant m
ortality and standardised
mortality rates), life expectancy, or measures of MORBIDITY (illness). These can
be compared across areas
and even countries. Sometimes people refer to a pubic health-care system; this i
s a publicly funded
service, the primary aim of which is to improve health by the use of populationbased measures. They may
include or be separate from private healthcare services for which individuals pa
y. The structure of these
systems varies from country to country, reflecting different social composition
and political priorities.
There are, however, some general elements that can be identified:
Surveillance The collection, collation and analysis of data to provide u
seful information about the
distribution and causes of health and disease and related factors in populations
. These activities form the
basis of epidemiology, which is the diagnostic backbone of publichealth practice
.
Intervention The design, advocacy and implementation of policies to impr
ove health. This may be through
the provison of PREVENTIVE MEDICINE, environmental measures, influencing the beh
aviour of individuals, or
the provision of appropriate services to limit disability and handicap. It will
lead to advocacy for
health, promoting change in many areas of
P
SPONGIFORM ENCEPHALOPATHY
(BSE) have again showed the importance of prevention and a broader approach to h
ealth. With it has come
recognition that, while disease may be the justification for action, a narrow di
seasetreatment-based
approach is not always the most effective or economic solution. The role of the
director of public health
(the successor to the medical officer of health) is again being expanded, and in
1997 for the first time
in the UK a government Minister for Public Health was appointed. This reflects n
ot only a greater
priority for public health, but also a concern that the health effects of policy
should be considered
across all parts of government. (See also ENVIRONMENT AND HEALTH.)
Public Health Laboratory Service (PHLS) A statutory organisation that is
part of the NHS. It comprises
ten laboratory groups and two centres in the UK, with central coordination from
PHLS headquarters. The
service provides diagnostic-testing facilities for cases of suspected infectious
disease. The remit of the
PHLS (which was set up during World War II and then absorbed into the NHS) is no
w based on legislation
approved in 1977 and 1979. Its overall purpose was to protect the population fro
m infection by maintaining
a national capability of high quality for the detection, diagnosis, surveillance
, protection and control of
infections and communicable diseases. It provided microbiology services to hospi
tals, family doctors and
local authorities as well as providing national reference facilities. In 2001 it
was incorporated into the
newly established NATIONAL INFECTION CONTROL AND HEALTH PROTECTION AGENCY.
Pudendal Nerve The nerve that operates the lowest muscles of the floor o
f the PELVIS and also the anal
SPHINCTER muscle. It may be damaged in childbirth, resulting in INCONTINENCE.
Pudendum The external genital organs. The term is usually used to descri
be those of the female (see
VULVA).
Pulmonary Embolism
Puerperal Depression Also called postnatal DEPRESSION, this is the state
of depression that may affect
women soon after they have given birth. The condition often occurs suddenly a da
y or so after the birth.
Many women suffer from it and usually they can be managed with sympathetic suppo
rt. If, however, the
depression sometimes called maternal blues persists for ten days or more, mild ANT
IDEPRESSANT DRUGS
are usually effective. If not, psychiatric advice is recommended. (See PREGNANCY
AND LABOUR.)
Puerperal Sepsis An infection, once called puerperal fever, that starts
in the genital tract within ten
days after childbirth, miscarriage or abortion (see PREGNANCY AND LABOUR). Once
a scourge of childbirth,
with many women dying from the infection, the past 50 years have seen a dramatic
decline in its incidence
in developed countries, with only 13 per cent of women having babies now being af
fected. This decline is
due to much better maternity care and the advent of ANTIBIOTICS. Infection usual
ly starts in the VAGINA and
is caused by the bacteria that normally live in it: they can cause harm because
of the mothers lowered
resistance, or when part of the PLACENTA has been retained in the genital tract.
The infection usually
spreads to the UTERUS and sometimes to the FALLOPIAN TUBES. Sometimes bacteria m
ay enter the vagina from
other parts of the body. Fever, an offensive-smelling post-partum vaginal discha
rge (lochia) and pain in
the lower abdomen are the main features. Untreated, the women may develop SALPIN
GITIS, PERITONITIS and
septicaemia. Antibiotics are used to treat the infection and any retained placen
tal tissue must be removed.
Puerperium The period which elapses after the birth of a child until the
mother is again restored to
her ordinary health. It is generally regarded as lasting for a month. One of the
main changes to occur is
the enormous decrease in size that takes place in the muscular wall of the womb.
There are often AFTERPAINS
during the first day in women who have borne several children, less often after
a first child. The
discharge is bloodstained for the first two or three days, then clearer till the
end of the first week,
before stopping within two or three weeks. The breasts, which have already enlar
ged before the birth of the
child, secrete milk more copiously, and there should be a plentiful supply on th
e third
day of the puerperium. (See
597
also PREGNANCY
AND LABOUR.)
Management The mother should start practising exercises to help ensure t
Purpura
Pulse
Pulse Oximetry
If the tip of one finger is laid on the front of the forearm, about 25 cm
(one inch) above the wrist,
and about 1 cm (half an inch) from the outer edge, the pulsations of the radial
artery can be felt. This is
known as the pulse, but a pulse can be felt wherever an artery of large or mediu
m size lies near the
surface. The cause of the pulsation lies in the fact that, at each heartbeat, 809
0 millilitres of blood
are driven into the AORTA, and a fluid wave, distending the vessels as it passes
, is transmitted along the
ARTERIES all over the body. This pulsation falls away as the arteries grow small
er, and is finally lost in
the minute capillaries, where a steady pressure is maintained. For this reason,
the blood in the veins
flows steadily on without any pulsation. Immediately after the wave has passed,
the artery, by virtue of
its great elasticity, regains its former size. The nature of this wave helps the
doctor to assess the state
of the artery and the action of the heart. The pulse rate is usually about 70 pe
r minute, but it may vary
in health from 50 to 100, and is quicker in childhood and slower in old age than
in middle life; it is low
(at rest) in physically fit athletes or other sports people. Fever causes the ra
te to rise, sometimes to
120 beats a minute or more. In childhood and youth the vessel wall is so thin th
at, when sufficient
pressure is made to expel the blood from it, the artery can no longer be felt. I
n old age, however, and in
some degenerative diseases, the vessel wall becomes so thick that it may be felt
like a piece of whipcord
rolling beneath the finger. Different types of heart disease have special featur
es of the pulse associated
with them. In atrial FIBRILLATION the great character is irregularity. In patien
ts with an incompetent
AORTIC VALVE the pulse is characterised by a sharp rise and sudden collapse. (Se
e HEART, DISEASES OF.) An
instrument known as the SPHYGMOGRAPH registers the arterial waves and a polygrap
h (an instrument that
obtains simultaneous tracings from several different sources such as radial and
jugular pulse, apex beat of
the heart and ELECTROCARDIOGRAM (ECG)) enables tracings to be taken from the pul
se at the wrist and from
the veins in the neck and simultaneous events in the two compared. The pressure
of the blood in various
arteries is estimated by a SPHYGMOMANOMETER. (See BLOOD PRESSURE.)
Measurement
599
of OXYGEN saturation of in a blood sample using a noninvasive device cal
led a spectrophotometer.
HAEMOGLOBIN
600 Purulent
may be caused by capillary defects (nonthrombocytopenic purpura) or be d
ue to a deficiency of PLATELETS
in the blood (thrombocytopenic purpura). Most worryingly, the rash may be due to
a fulminant form of
meningococcal SEPTICAEMIA called purpura fulminans. (See also HENOCH-SCHNLEIN PUR
PURA;
Pyelitis
IDIOPATHIC THROMBOCYTOPENIC (ITP); THROMBOCYTOPENIA.).
See INTRAVENOUS PYELOGRAM (UROGRAM).
PURPURA
Containing, comprising or forming PUS.
Pus Pus is a thick, white, yellow or greenish fluid, found in abscesses
(see ABSCESS), ulcers, and on
inflamed and discharging surfaces generally. Its colour and consistency are due
to the presence of white
blood corpuscles, and superficial cells of granulation tissue or of a mucous mem
brane which die and are
shed off in consequence of the inflammatory process (see PHAGOCYTOSIS). Bacteria
that normally produce pus
are STREPTOCOCCUS, PNEUMOCOCCUS and ESCHERICHIA coli.
Pustule A small collection of PUS. Malignant pustule is one of the forms
of ANTHRAX.
Putrefaction The change that takes place in the bodies of plants and ani
mals after death, whereby they
are ultimately reduced to carbonic acid gas, ammonia, and other simple substance
s. The change is almost
entirely due to the action of bacteria, and, in the course of the process, vario
us offensive and poisonous
intermediate substances are formed. In the case of the human body, putrescine, c
adaverine, and other
alkaloids are among these intermediate products.
Putrid Fever An old name for typhus fever (see
Pyelogram Pyelography
Purulent
P
A term describing inflammation of the pelvis of the kidney. In fact, the
inflammation usually affects
the whole kidney tissue and the description should be PYELONEPHRITIS.
ENTERIC
FEVER).
PUVA See PHOTOCHEMOTHERAPY; PSORIASIS.
from the STOMACH. It is usually the result of a pyloric ulcer or cancer near the
exit of the stomach.
Food is delayed when passing from the stomach to the duodenum and vomiting occur
s. The stomach may become
distended and peristalsis (muscular movement) may be seen through the abdominal
wall. Unless surgically
treated the patient will steadily deteriorate, losing weight, becoming dehydrate
d and developing
Q QALY
This is an outcome measure of health care devised by health economists i
n the 1980s, and stands for
Quality Adjusted Life Year. It takes a year of healthy life expectancy to be wor
th a grade of 1, and a year
of unhealthy life expectancy to be worth less than 1. The worse the forecast of
an unhealthy persons
quality of life, the lower will be his or her rating. If someone is expected to
live five years in a
healthy state, the grading will be 5; ten years of life estimated to be only 25
per cent healthy will rate
as 25 QALYs. The measure has proved controversial but nevertheless is an indicati
on of the likely
cost-effectiveness of a particular treatment, and can contribute to assessing wh
ether or not a proposed or
actual treatment or procedure is worthwhile both for patients and for the econom
y.
Q Fever A disease of worldwide distribution due to the organism Coxiella
burneti. It is characterised
by fever, severe headache and often PNEUMONIA. It was first described in 1937 am
ongst abattoir workers in
Brisbane. The disease was given the name Q fever, the Q (as in question mark) refe
rring to the unknown
cause of the disease when first described. The principal reservoir of human infe
ction in Britain is
probably cattle and sheep in which the infection is usually sub-clinical. The di
agnosis is confirmed by the
detection of serum antibodies to Coxiella burneti. The organism is sensitive to
tetracycline.
QRS Complex The section of an ELECTROCARDIOGRAM (ECG) that precedes the
S-T segment and registers
contraction of the VENTRICLE of the HEART.
Q-T Interval The interval in an ELECTROCARDIOGRAM (ECG) that registers t
he electrical activity
generated during ventricular contraction of the HEART.
Quack Colloquial description of an unqualified person claiming to be a m
edical doctor.
Quadrantanopia Inability to see in one quarter of the visual field.
Homonymous quadrantanopia is loss of vision in the same quarter of the f
ield in each EYE.
Quadriceps (More accurately quadriceps femoris) the large, four-headed m
uscle occupying the front and
sides of the thigh, which straightens the leg at the knee-joint and maintains th
e body in an upright
position. It comprises the rectus femoris, vastus lateralis, vastus intermedius
and vastus medialis.
Quadriplegia PARALYSIS
of the four limbs of the body.
Quadruplets See MULTIPLE BIRTHS.
Quintuplets
Quartan Fever Description of intermittent fever with paroxysms developin
g every fourth day. Usually
applied to MALARIA.
Quickening The first movements of a FETUS in the womb as experienced by
the mother, usually around the
16th week of pregnancy (see PREGNANCY AND LABOUR).
Quiescent The description applied to a disease in an individual which is
in an inactive phase and so
likely to be undiagnosed.
Quinghaosu A herbal drug used for two millennia in China to treat MALARI
A. Its action derives from
sesquiterpene lactone, a substance that cuts the number of blood-borne malarial
parasites.
Quinidine An alkaloid (see ALKALOIDS) obtained from cinchona bark and cl
osely related in chemical
composition and in action to QUININE. It is commonly used in the form of quinidi
ne sulphate to treat
cardiac irregularities such as supraventricular tachycardia and ventricular arrh
ythmias (see HEART,
DISEASES OF).
Quinine An alkaloid (see ALKALOIDS) obtained from the bark of various sp
ecies of cinchona trees. This
bark is mainly derived from Peru and neighbouring parts of South America and the
East Indies. Other
alkaloids and acid substances are also derived from cinchona bark, such as QUINI
DINE and cinchonine.
Quinine is generally used in the form of one of its salts, such as the sulphate
of quinine, or
dihydrochloride of quinine. All are sparingly soluble in water, much more so whe
n taken along with an acid.
Action Quinine is a powerful antiseptic (see
603
ANTISEPTICS).
Its best-known action is in checking the recurrence of attacks of MALARI
A, as it destroys malarial
parasites in the blood. In fevers it acts as an antipyretic (see ANTIPYRETICS).
Among its side-effects are
ringing in the ears, temporary impairment of vision, and sometimes disturbance o
f kidney function leading
to renal failure.
Uses The most important use of quinine is
ttacks of which it quickly cuts
short or prevents altogether. It has been largely
less toxic antimalarial
drugs; however, development of malarial parasites
evived the use of quinine.
For intravenous injection, when this is necessary
form of quinine, the
R Rabies
An acute and potentially fatal disease, caused by a rhabdovirus called L
yssavirus, which affects the
nervous system of animals, particularly carnivora, and may be communicated from
them to humans. Infection
from person to person is very rare, but those in attendance on a case should tak
e precautions to avoid
being bitten or allowing themselves to be contaminated by the patients saliva, as
this contains the
causative virus. The disease is ENDEMIC in dogs and wolves in some countries; an
EPIDEMIC may occasionally
occur. It also occurs in foxes, coyotes and skunks, as well as in vampire bats.
Thanks to QUARANTINE
measures, since 1897 rabies has been rare in Great Britain, which still retains
strict measures (the Rabies
Act) to prevent the entry of infected animals into the country, including a sixmonth quarantine period and
vaccination (see IMMUNISATION). This policy was relaxed somewhat in 2001 with th
e launch of the Pet Travel
Scheme; this allows cats and dogs to enter the UK from specified countries witho
ut the need for quarantine,
as long as stringent conditions as to microchipping and vaccinations are met. Fu
ll details can be obtained
from the Department for the Environment, Food and Rural Affairs (DEFRA) or from
a veterinary surgeon
engaged in operating the scheme. Six months has to elapse between vaccination ag
ainst rabies and a positive
blood test before the pet passport can be issued. Rabies is highly infectious from
the bite of an animal
already affected, but the chance of infection from different animals varies. Thu
s only about one person in
every four bitten by rabid dogs contracts rabies, whilst the bites of rabid wolv
es and cats almost
invariably produce the disease.
Symptoms In animals there are two types of the disease: mad rabies and d
umb rabies. In the former, the
dog (or other animal) runs about, snapping at objects and other animals, unable
to rest; in the latter,
which is also the final stage of the mad type, the limbs become paralysed and th
e dog crawls about or lies
still. In humans the incubation period is usually 68 weeks, but may be as short a
s ten days or as
long as two years. The disease begins with mental symptoms, the person b
ecoming irritable, restless and
depressed. Fever and DYSPHAGIA follow. The irritability passes into a form of MA
NIA and the victim has
great difficulty in swallowing either food or drink.
Treatment The best treatment is, of course, preventive. Local treatment
consists of immediate, thorough
and careful cleansing of the wound-surfaces and surrounding skin. This is follow
ed by a course of rabies
vaccine therapy. Only people bitten (or in certain circumstances, licked) by a r
abid animal or by one
thought to be infected with rabies need treatment; this is with rabies vaccine a
nd antiserum and one of the
IMMUNOGLOBULINS. A person previously vaccinated against rabies who is subsequent
Radionuclide
living tissue can cause biological damage which may affect existing tiss
ue or cause mutations in the
GENES of germ-cell nuclei (see GAMETE; CELLS). Non-ionising radiation agitates t
he constituent atoms of
nuclei but is insufficiently powerful to produce ions. Ionising radiation compri
ses X-RAYS, GAMMA RAYS and
particle radiation. X-rays are part of the continuous electromagnetic-wave spect
rum: this also includes
gamma rays, infra-red radiation, ultraviolet light and visible light. They have
a very short wavelength and
very high frequency, and their ability to penetrate matter depends upon the elec
trical energy generating
them. X-rays that are generated by 100,000 volts can pass through body tissue an
d are used to produce
images popularly known as X-rays. X-rays, generated at several million volts can
destroy tissue and are
used in RADIOTHERAPY for killing cancer cells. Gamma rays are similar to X-rays
but are produced by the
decay of radioactive materials. Particle radiation, which can be produced electr
ically or by radioactive
decay, comprises parts of atoms which have mass as well as (usually) an electric
al charge. Non-ionising
radiation includes ultraviolet light, radio waves, magnetic fields and ULTRASOUN
D. Magnetic fields are used
in magnetic resonance imaging (MRI) and ultrasound, which is inaudible high-freq
uency sound waves, and is
used for both diagnoses and treatment in medicine.
Radiation Sickness The term applied to the nausea, vomiting and loss of
appetite which may follow
exposure to RADIATION for example, at work or the use of RADIOTHERAPY in the tre
atment of cancer and
other diseases. People exposed to radiation at work should have that exposure ca
refully monitored so it
does not exceed safety limits. Doses of radiation given during radiotherapy trea
tment are carefully
measured: even so, patients may suffer side-effects. The phenothiazine group of
tranquillisers, such as
CHLORPROMAZINE, as well as the ANTIHISTAMINE DRUGS, are of value in the preventi
on and treatment of
radiation sickness.
605
Radioactive Isotopes See ISOTOPE.
Radioactivity Breakdown of the nuclei of some elements resulting in the
emission of energy in the form
of alpha, beta and gamma rays. Because of this particle emission, the elements d
ecay into other elements.
Radium and uranium are naturally occurring radioactive elements. RADIOTHERAPY tr
eatment utilises
artificially produced isotopes (alternative forms of an element) such as iodine131 and cobalt-60.
Radiographer An individual trained in the techniques of taking X-ray pic
tures (see X-RAYS) of areas of
the body is known as a diagnostic radiographer. One who is trained to treat pati
606 RadioOpaque
RadioOpaque Substances which absorb XRAYS, rather than transmitting th
em, appear white on Xray film
and are described as radioopaque. This is true of bones, teeth, certain types o
f gallstones, renal stones
and contrast media used to enhance the accuracy of radiographic imaging.
Radiotherapy
R
The treatment of disease (mainly CANCER) with penetrating RADIATION. For
many years RADIUM and XRAYS
were the only sources available, but developments in knowledge led to the use of
powerful Xrays, beta rays
or gamma rays, either produced by linear accelerator machines or given off by ra
dioactive isotopes (see
ISOTOPE). The latter is rarely used now. Beams of radiation may be directed at t
he tumour from a distance,
or radioactive material in the form of needles, wires or pellets may be implante
d in the body.
Sometimes germcell tumours (see SEMINOMA; TERATOMA) and lymphomas (see LYMPHOMA
) are particularly
sensitive to irradiation which therefore forms a major part of management, parti
cularly for localised
disease. Many head and neck tumours, gynaecological cancers, and localised prost
ate and bladder cancers are
curable with radiotherapy. Radiotherapy is also valuable in PALLIATIVE CARE, chi
efly the reduction of pain
from bone metastases (see METASTASIS). Sideeffects are potentially hazardous and
these have to be balanced
against the substantial potential benefits. Depending upon the type of therapy a
nd doses used, generalised
effects include lethargy and loss of appetite, while localised effects depending
on the area treated
include dry, itchy skin; oral infection (e.g. thrush see CANDIDA); bowel problem
s; and DYSURIA.
Radium The radiations of radium consist of: (1) alpha rays, which are po
sitively charged helium nuclei;
(2) beta rays negatively charged electrons; (3) gamma rays, similar to XRAYS bu
t of shorter wavelength.
These days the use of radium is largely restricted to the treatment of carcinoma
of the neck of the womb,
the tongue, and the lips. Neither Xrays nor radium supersede active surgical me
asures when these are
available for the complete removal of a tumour.
Radius The outer of the two bones in the forearm.
Rle See CREPITATIONS.
Raloxifene A drug used to prevent and treat postmenopausal osteoporosis
(see under BONE, DISORDERS OF).
Its action differs from hormonereplacement drugs in that it does not modify the
symptoms of the MENOPAUSE.
Randomised Controlled Trial A method of comparing the results between tw
o or more groups of patients
Read Codes
rather than simply an attempt to achieve sexual gratification. The major
ity of rapes are probably
unreported because of the victims shame, anxiety about publicity and fear that th
e rapist will take
reprisals. It is legally recognised that rape can happen within marriage. There
are moves to make court
proceedings less traumatic for victims, whose attackers are often known to them.
Anxiety, DEPRESSION and
POSTTRAUMATIC STRESS DISORDER (PTSD) are common after rape: many victims are no
w given help by rape crisis
counselling. A recent report suggests that in at least 50 per cent of reported r
apes, the attacker was
known to, or had been a friend of, the victim. The deliberate misuse of alcohol
or drugs to reduce a
potential victims resistance seems to be increasing (see DRUG ASSISTED RAPE; FLUN
ITRAZEPAM.)
607
confined to the occurrence of dead fingers the fingers (or the toes, ears,
or nose) becoming white,
numb, and waxylooking. This condition may last for some minutes, or may not pas
s off for several hours, or
even for a day or two.
Treatment People who are subject to these
A ridge or furrow between the halves of an organ.
attacks should be careful in winter to protect the feet and hands from c
old, and should always use warm
water when washing the hands. In addition, the whole body should be kept warm, a
s spasm of the arterioles
in the feet and hands may be induced by chilling of the body. Sufferers should n
ot smoke. VASODILATORS are
helpful, especially the calcium antagonists. In all patients who do not respond
to such medical treatment,
surgery should be considered in the form of sympathectomy: i.e. cutting of the s
ympathetic nerves to the
affected part. This results in dilatation of the arterioles and hence an improve
d blood supply. This
operation is more successful in the case of the feet than in the case of the han
ds.
Rarefaction
RCN
Diminution in the density of a BONE as a result of withdrawal of calcium
salts from it. (See BONE,
DISORDERS OF Osteoporosis.)
Stands for Royal College of Nursing.
Raphe
Rash See ERUPTION.
608 Receptor
security and confidentiality. The codes accommodate the different views
of specialists, but use simple
terms without any loss of the fine detail necessary in specialist terminology. T
he Read Codes are being
merged with the worlds other leading coding and classification system: the Colleg
e of American
Pathologists Systemised Nomenclature of Medicine (SNOMEDRT).
Receptor (1) Organs, which may consist of one cell or a small group of c
ells, that respond to different
forms of external or internal stimuli by conveying impulses down nerves to the C
ENTRAL NERVOUS SYSTEM,
alerting it to changes in the internal or external environment. (2) A small, dis
crete area on the cell
membrane or within the cell with which molecules or molecular complexes (e.g. ho
rmones, drugs, and other
chemical messengers) interact. When this interaction takes place it initiates a
change in the working of
the cell.
Recessive Tending to recede. In genetic terms, a recessive gene is one w
hose expression remains dormant
if paired with an unlike allele. The trait will only be manifest in an individua
l homozygous for the
recessive gene. (See GENES.)
Recombinant DNA DNA or deoxyribonucleic acid containing GENES from vario
us sources that have been
combined by GENETIC ENGINEERING.
Recombinant DNA Technology See GENETIC ENGINEERING.
Reconstructive (Plastic) Surgery R Reconstructive surgery on the skin an
d underlying tissues that have
been damaged or lost as a result of disease or injury. Congenital malformations
are also remedied using
reconstructive surgery. Surgeons graft healthy skin from another part of the bod
y to repair skin damaged or
destroyed by burns or injuries. New techniques are under development for growing
new skin in the laboratory
to be used in reconstructive surgery. Surgeons also repair damage using skin fla
ps prepared in another part
of the body for example, a skin flap from the arm may be used to repair a badly
injured nose or face.
Reconstructive surgery is also used to repair the consequences of an operation f
or cancer of, say, the neck
or the jaw. Plastic surgeons undertake cosmetic surgery to improve the appearanc
e of noses, breasts,
abdomens and faces.
Recovered Memory Syndrome See REPRESSED MEMORY THERAPY.
Recovery Position If an individual is unconscious whether as a result of
accident or illness or when
in the postoperative recovery unit but is breathing and has a pulse, he or she s
hould be placed in the
recovery position. The individual is turned on his or her side to allow the tong
ue to fall forwards and so
reduce the likelihood of pharyngeal obstruction (see PHARYNX). Fluid in the mout
h can also drain outwards
instead of into the TRACHEA and LUNGS. The person can lie on either side with up
per or lower leg flexed.
Sometimes the semiprone position is used; this gives better drainage from the m
outh and greater stability
during transport, but makes it more difficult to observe the face, colour or bre
athing. (See APPENDIX 1:
BASIC FIRST AID.)
Recrudescence The reappearance of a disease after a period without signs
or symptoms of its presence.
Rectum The last part of the large INTESTINE. It pursues a more or less s
traight course downwards
through the cavity of the pelvis, lying against the sacrum at the back of this c
avity. This section of the
intestine is about 23 cm (9 inches) long: its first part is freely movable and c
orresponds to the upper
three pieces of the sacrum; the second part corresponds to the lower two pieces
of the sacrum and the
coccyx; whilst the third part, known also as the anal canal, is about 25 mm (1 i
nch) long, runs downwards
and backwards, and is kept tightly closed by the internal and external SPHINCTER
muscles which surround it.
The opening to the exterior is known as the ANUS. The structure of the rectum is
similar to that of the
rest of the intestine.
Rectum, Diseases of The following are described under their separate dic
tionary entries: FAECES;
HAEMORRHOIDS; FISTULA; DIARRHOEA; CONSTIPATION.
Imperforate anus, or absence of the anus, may occur in newly born childr
en, and the condition is
relieved by operation.
due to
piles,
e anal
bathed
Reflux Fluid flowing in the opposite direction to normal (i.e. back flow
). Often refers to
regurgitation of stomach contents into the OESOPHAGUS (see also OESOPHAGUS, DISE
ASES OF), or of urine from
the URINARY BLADDER back into the ureters (see URETER).
Refraction The deviation of rays of light on passing from one transparen
t medium into another of
different density. The refractive surfaces of the EYE are the anterior surface o
f the cornea (which
accounts for approximately twothirds of the focusing or refractive power of the
eye), and the lens
(onethird of the focusing power of the
Registrar (1) Divided into specialist registrar and GP registrar, this i
s a training grade for NHS
doctors. After a period in this grade usually 36 years they may be appointed as G
P principals or gain
a certificate of specialist training and be able to apply for NHS consultant pos
ts (provided they have
passed the appropriate higher examinations). In 2004 there were almost 15,000 sp
ecialist registrars in the
UK and more than 1,800 GP registrars. Registrar numbers are also regulated by th
e government to achieve a
balance between the numbers in training and the likely number of vacancies for c
areergrade doctors or
dentists in the future. (2) A public official responsible for registering births
, deaths, and marriages.
Regulation of Health Professions Professional staff working in health ca
re are registered with and
regulated by several statutory bodies: doctors by the GENERAL MEDICAL COUNCIL (G
MC); dentists by the
GENERAL DENTAL COUNCIL; nurses and midwives by the Council for Nursing and Midwi
fery, formerly the UK
Central Council for Nursing, Midwifery and Health Visiting (see NURSING); PHARMA
CISTS by the Royal
Pharmaceutical Society; and the professions supplementary to medicine (chiropody
, dietetics, medical
laboratory sciences, occupational therapy, orthoptics, physiotherapy and radiogr
aphy) by the Council for
Professions Supplementary to Medicine. In 2002, the Council for the Regulation o
f Health Care Professions
was set up as a statutory body that will promote cooperation between and give ad
vice to existing
Relapsing Fever
regulatory bodies, provide a qualitycontrol mechanism, and play a part
in promoting the interests of
patients. The new Council is accountable to a Select Committee of Parliament and
is a nonministerial
government department similar in status to the FOOD STANDARDS AGENCY. It has the
right to scrutinise the
decisions of its constituent bodies and can apply for judicial review if it feel
s that a judgement by a
disciplinary committee has been too lenient.
Regurgitation Regurgitation is a term used in various connections in med
icine. For instance, in
diseases of the HEART it is used to indicate a condition in which, as the result
of valvular disease, the
blood does not entirely pass on from the atria of the heart to the ventricles, o
r from the ventricles into
the arteries. The defective valve is said to be incompetent, and a certain amoun
t of blood leaks past it,
or regurgitates back, into the cavity from which it has been driven. (See HEART,
DISEASES OF.) The term is
also applied to the return to the mouth of food already swallowed and present in
the gullet or stomach (see
also REFLUX).
Rehabilitation The restoration to health and working capacity of a perso
n incapacitated by disease
mental or physical or by injury. Treatment usually includes OCCUPATIONAL THERAPY
, PHYSIOTHERAPY and
PSYCHOTHERAPY depending upon the type of disease or injury. Rehabilitation is co
mmonly carried out at
special centres, either on a daily or a residential basis. This allows different
types of specialists to
cooperate in the patients rehabilitation. (See also DISABLED PERSONS.)
Reiters Syndrome A condition probably caused by an immunological response
to a virus (see IMMUNITY),
in which the patient has URETHRITIS, ARTHRITIS and conjunctivitis (see under EYE
, DISORDERS OF). The skin
may also be affected by horny areas which develop in it. The disorder was first
described by a German
physician, H. Reiter (18811969); it is more common in men than in women, and is t
he most common cause of
arthritis in young men. It usually develops in people who have a genetic predisp
osition for it: around 80
per cent of sufferers have the HLA B27 tissue type. Treatment is symptomatic wit
h ANALGESICS and
NONSTEROIDAL ANTIINFLAMMATORY DRUGS (NSAIDS). (See also REACTIVE ARTHRITIS.)
611
Rejection A term used in transplant medicine (see TRANSPLANTATION) to de
scribe the bodys immunological
response to foreign tissue (see Various drugs, such as IMMUNITY). CICLOSPORIN A,
can be used to dampen the
hosts response to a graft or organ transplant and reduce the risk of rejection.
Relapse The return of a disease that a patient has had and apparently re
covered from. It may also be a
has occurred in
(see ENTERIC FE
now known as th
is transmitted fr
Anyone seeking help can telephone or write for an appointment. No fees are charg
ed, but those receiving
help are encouraged to donate what they can.
Renal Tubule
Relaxation Therapy This is a treatment in which patients are helped to r
educe their levels of anxiety
by reducing their muscle tone. It can be used on its own or in conjunction with
a broader PSYCHOTHERAPY
regime. The technique guides people on how to cope with stressful situations and
deal with phobias see
PHOBIA.
See KIDNEYS.
Renin An
ENZYME produced by the kidney (see KIDNEYS) and released into the blood
in response to STRESS. Renin
reacts with a compound produced by the liver to produce ANGIOTENSIN.
This causes blood vessels to constrict and raises the blood pressure. If
too much renin is produced,
this results in renal HYPERTENSION.
Rennin A milkcoagulating ENZYME produced by the lining of the stomach.
Rennin converts milk protein
(caseinogen) into insoluble casein, thus ensuring that milk stays in the stomach
for some time, during
which it can be digested by various enzymes before passing into the small intest
ine.
Renography The radiological examination of the KIDNEYS using a gamma cam
era. This is a device that can
follow the course of an injected radioactive (see RADIOACTIVITY) compound which
is concentrated and
excreted by the kidneys. This 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
614 Resection
R
invention of nonexistent patient subjects; or sharing one electrocardio
gram or blood sample amongst
many subjects. Research fraud should be first suspected by a clinicaltrial moni
tor who recognises that
data are not genuine, or by a qualityassurance auditor who cannot reconcile dat
a in clinicaltrial report
forms with original patient records. Unfortunately, it often comes to light by c
hance. There may be
suspicious similarities between data ostensibly coming from more than one source
, or visits may have been
recorded when it was known that the clinic was shut. Statistical analysis of a l
ikely irregularity will
frequently confirm such suspicion. The motivation for fraud is usually greed, bu
t a desire to publish at
all costs, to be the original author of a medical breakthrough, to bolster appli
cations for research
grants, or to strengthen a bid for more departmental resources are other recogni
sed reasons for committing
fraud. In the USA, those proved to have committed fraud are debarred from receiv
ing federal funds for
research purposes or from undertaking governmentfunded therapeutic research. Th
e four Nordic countries
(Denmark, Finland, Norway and Sweden) have committees on research dishonesty tha
t investigate all cases of
suspected research misconduct. In the United Kingdom, an informal system operate
d by the pharmaceutical
industry, using the disciplinary mechanism of the General Medical Council (GMC),
has led to more than 16
doctors in the past ten years being disciplined for having committed research fr
aud. Editors of many of the
worlds leading medical journals have united to form the Committee on Publishing E
thics, which advises
doctors on proper practice and assists them in retracting or refusing to publish
articles found or known to
be false. (See ETHICS; ETHICS COMMITTEES.) Where an author does not offer a sati
sfactory explanation, the
matter is passed to his or her institution to investigate; where an editor or th
e committee is not
satisfied with the result they may pass the complaint to the appropriate regulat
ory body, such as the GMC
in Britain.
be used as an antihypertensive (see
HYPERTEN
SION) and a tranquillising agent.
Reserve Volume The additional amount of air that a person could breathe
in or out if he or she were not
using the full capacity of their LUNGS. (See also LUNG VOLUMES.)
Residual Volume The amount of air left in the LUNGS after an individual
has breathed out as much as
possible. It is a measure of lung function: for example, in a person with EMPHYS
EMA the residual volume is
Respiration
without the formation of PUS. Thus a pneumonic lung is said to resolve whe
n the material exuded into
it is absorbed into the blood and lymph, so that recovery takes place naturally;
an inflamed area is said
to resolve when the inflammation diminishes and no abscess forms; a glandular en
largement is said to
resolve when it decreases in size without suppuration. Resolution is also used t
o describe the extent to
which individual details for example, cell structures can be identified by the e
ye when using a light
microscope.
Resonance The lengthening and intensification of sound produced by strik
ing the body over an
aircontaining structure such as the lung. Decrease of resonance is called dullne
ss and increase of
resonance is called hyperresonance. The process of striking the chest or other
part of the body to
discover its degree of resonance is called PERCUSSION, and according to the note
obtained, an opinion can
be formed as to the state of consolidation of aircontaining organs, the presenc
e of abnormal cavities, and
the dimensions and relations of solid and aircontaining organs lying together. (
See also AUSCULTATION.)
Resorcinol A white, crystalline, antiseptic substance soluble in water,
alcohol and oils. It can be
used in combination with sulphur to treat ACNE.
Respiration The process in which air passes into and out of the lungs so
that the blood can absorb
oxygen and give off carbon dioxide and water. This occurs 18 times a minute in a
healthy adult at rest and
is called the respiratory rate. An individual breathes more than 25,000 times a
day and during this time
inhales around 16 kg of air.
Mechanism of respiration For the structure of the respiratory apparatus,
see AIR PASSAGES; CHEST;
LUNGS. The air passes rhythmically into and out of the air passages, and mixes w
ith the air already in the
lungs, these two movements being known as inspiration and expiration. INSPIRATIO
N is due to a muscular
effort which enlarges the chest, so that the lungs have to expand in order to fi
ll up the vacuum that would
otherwise be left, the air entering these organs by the air passages. The increa
se of the chest in size
from above downwards is mainly due to the diaphragm, the muscular fibres of
615
which contract and reduce its domed shape and cause it to descend, pushi
ng down the abdominal organs
beneath it. EXPIRATION is an elastic recoil, the diaphragm rising and the ribs s
inking into the position
that they naturally occupy, when muscular contraction is finished. Occasionally,
forced expiration may
occur, involving powerful muscles of the abdomen and thorax; this is typically s
Retrospectoscope 617
Retardation
Retinoids
Slowing down; developmental delay. Psychomotor retardation is a signific
ant slowing down of speech and
activity which eventually leads to a person being unable to cope with daily acti
vities or to maintain
personal hygiene. It is a symptom of severe DEPRESSION.
Any one of a collection of drugs that are derived from vitamin A (see AP
PENDIX 5: VITAMINS). They can
be taken orally or applied topically, and affect the skin by causing drying and
peeling, with a reduction
in the production of SEBUM. These properties are useful in the treatment of ACNE
and PSORIASIS.
Retching Retching is an ineffectual form of VOMITING.
Retention of Urine See URINE RETENTION.
Reticulocytes These are newly formed red blood corpuscles, in which a fi
ne network can be demonstrated
by special staining methods. Where a large number are present, one can infer tha
t the patient is recovering
from ANAEMIA for example, after a previous bleed (HAEMORRHAGE) or as a result of
treatment of iron
deficiency.
ReticuloEndothelial System
Retinol Retinol is the official chemical name of vitamin A. (See APPENDI
X 5: VITAMINS.)
Retinopathy See EYE, DISORDERS OF
Retina, disorders of.
Retractor An instrument for pulling apart the edges of an incision to al
low better surgical access to
the organs and tissues being operated on.
RetroA prefix signifying behind or turned backwards.
Retrobulbar Neuritis
This consists of highly specialised cells scattered throughout the body,
but found mainly in the
SPLEEN, BONE MARROW, LIVER, and LYMPH nodes or glands. Their main function is th
e ingestion of red blood
cells and the conversion of HAEMOGLOBIN to BILIRUBIN. They are also able to inge
st bacteria and foreign
colloidal particles.
Inflammation of the optic nerve behind (rather than within) the EYE. It
usually occurs in young adults
and presents with a rapid deterioration in vision over a few hours. Colour visio
n is also impaired. Usually
vision recovers over a few weeks, but colour vision may be permanently lost. It
can be associated with
certain viral illnesses and with MULTIPLE SCLEROSIS (MS). (See also EYE, DISORDE
RS OF.)
Retina
Retrograde
See EYE.
See EYE, DISORDERS OF.
Movement in a contrary or backward direction from normal (e.g. a retrogr
ade pyelogram introduces dye
into the pelvis of the kidney by passing it up the ureters).
Retinoblastoma
Retropharyngeal Abscess
Retina, Disorders of
A rare malignant growth of the retina (see EYE) which occurs in infants.
It can sometimes be discovered
at birth because shining a light in the babys pupil produces a white reflection r
ather than a red one.
Alternatively, the infant may present with a SQUINT or a mass in the abdomen. In
25 per cent of cases there
is a family history of the condition and abnormality of chromosome 13 is common
(see CHROMOSOMES). It is
treated by removing the eye or, if affecting both eyes, by laser PHOTOCOAGULATIO
N with or without
RADIOTHERAPY.
An ABSCESS occurring in the cellular tissue behind the throat (PHARYNX).
It is the result in general of
disease in the upper part of the SPINAL COLUMN.
Retrospective Study The opposite of a PROSPECTIVE STUDY, involving a his
torical review of the
characteristics of a collection of people to assess MORBIDITY, often by obtainin
g and analysing their
casenotes. The procedure is commonly used in studying the EPIDEMIOLOGY of diseas
e.
Retinoic Acid
Retrospectoscope
A synthetic vitamin A derivative. (See APPENDIX 5: VITAMINS.)
A mockhumorous term used by doctors to imply that one can always see th
ings more
R
618 Retroversion
clearly after the event than at the time. One danger of making a judgeme
nt on the competence of a
doctor treating a patient is that it is easier to know what was the right thing
to have done once you know
the end of the story.
Retroversion An abnormal position of the UTERUS, occurring in about 20 p
er cent of women, in which its
long axis is pivoted backwards in relation to the CERVIX UTERI and VAGINA instea
d of forwards.
Retrovirus A VIRUS containing ribonucleic acid (RNA) which is able to ch
ange its genetic material into
deoxyribonucleic acid (DNA) using an ENZYME called reverse transcriptase. This c
onversion enables the
retrovirus to become integrated into the host cells DNA. Retroviruses are believe
d to be involved in the
development of some cancers; they are also associated with disorders linked with
an impaired immune system
(see IMMUNITY). HIV is a retrovirus. Retroviruses are also used in the developme
nt of gene therapy (see
GENETIC ENGINEERING).
The cause is not known, but there is evidence that ASPIRIN may also play
a part in its causation.
Doctors recommend that children should be given PARACETAMOL in place of aspirin.
The initial feature is
severe, persistent vomiting and fever. This is followed by outbursts of wild beh
aviour, DELIRIUM and
CONVULSIONS terminating in COMA and death, often from liver failure. The MORTALI
TY rate is around 23 per
cent, and 50 per cent of the survivors may have persistent mental or neurologica
l disturbances. The younger
the patient, the higher the death rate and the more common the permanent residua
l effects. Since aspirin
has no longer been licensed for use in children and young people the incidence o
f the condition has fallen
dramatcally. Some cases, previously thought to be Reyes syndrome, have subsequent
ly turned out to have
been due to certain inherited metabolic diseases and to be unconnected with aspi
rin.
Rhabdoviruses A group of viruses which includes the virus.
Revalidation
Rhesus Factor
The periodic assessment of a doctors professional competence. Revalidatio
n began in the UK in 2004, to
ensure that those doctors on the Medical Register of the GENERAL MEDICAL COUNCIL
(GMC) as active
practitioners are capable of providing appropriate standards of medical care. Th
e process depends, amongst
other things, upon the doctor being able to demonstrate that he or she has maint
ained a continuing
programme of professional development: lifelong learning.
Rheumatoid Arthritis
red rash, looking like the outline of a map, characteristic of the condi
tion. Cardiac involvement
includes PERICARDITIS, ENDOCARDITIS, and MYOCARDITIS. The main longterm complic
ation is damage to the
mitral and aortic valves (see HEART). The chief neurological problem is chorea (
St Vituss dance) which may
develop after the acute symptoms have subsided.
Chronic rheumatic heart disease occurs subsequently in at least half of
those who have had rheumatic
fever with carditis. The heart valve usually involved is the mitral; less common
ly the aortic, tricuspid
and pulmonary. The lesions may take 1020 years to develop in developed countries
but sooner elsewhere. The
heart valves progressively fibrose and fibrosis may also develop in the myocardi
um and pericardium. The
outcome is either mitral stenosis or mitral regurgitation and the subsequent mal
function of this or other
heart valves affected is chronic failure in the functioning of the heart. (see H
EART, DISEASES OF).
Treatment
Eradication of streptococcal infection is essential. Other features are
treated symptomatically.
PARACETAMOL may be preferred to ASPIRIN as an antipyretic in young children. One
of the NONSTEROIDAL
ANTIINFLAMMATORY DRUGS (NSAIDS) may benefit the joint symptoms. CORTICOSTEROIDS
may be indicated for more
serious complications. Patients who have developed cardiacvalve abnormalities r
equire antibiotic
prophylaxis during dental treatment and other procedures where bacteria may ente
r the bloodstream.
Secondary cardiac problems may occur several decades later and require replaceme
nt of affected heart
valves.
Rheumatism An obsolete medical term which no longer has a defined meanin
g. It remains a lay term
covering any painful condition of the muscles and/or joints of the arms, legs or
spine.
Rheumatoid Arthritis A chronic inflammation of the synovial lining (see
SYNOVIAL MEMBRANE) of several
joints, tendon sheaths or bursae which is not due to SEPSIS or a reaction to URI
C ACID crystals. It is
distinguished from other patterns of inflammatory arthritis by the symmetrical i
nvolvement of a large
number of peripheral joints; by the common bloodfinding of rheumatoid factor an
tibody; by the presence of
bony erosions around joints; and, in a few, by the presence of
619
subcutaneous nodules with necrobiotic (decaying) centres.
Causes There is a major immunogenetic predisposition to rheumatoid arthr
itis in people carrying the
HLADR4 antigen (see HLA SYSTEM). Other minor immunogenetic factors have also be
en implicated. In addition,
there is a degree of familial clustering which suggests other unidentified genet
ic factors. Genetic factors
cannot alone explain aetiology, and environmental and chance factors must be imp
ortant, but these have yet
to be identified. Epidemiology Rheumatoid arthritis more commonly occurs in wome
n from the age of 30
onwards, the sex ratio being approximately 4:1. Typical rheumatoid arthritis may
occur in adolescence, but
in childhood chronic SYNOVITIS usually takes one of a number of different patter
ns, classified under
juvenile chronic arthritis.
Pathology The primary lesion is an inflammation of the synovial membrane
of joints. The synovial fluid
becomes diluted with inflammatory exudate: if this persists for months it leads
to progressive destruction
of articular CARTILAGE and BONE. Cartilage is replaced by inflammatory tissue kn
own as pannus; a similar
tissue invades bone to form erosions. Synovitis also affects tendon sheaths, and
may lead to adhesion
fibrosis or attrition and rupture of tendons. Subcutaneous and other bursae may
be involved. Necrobiotic
nodules also occur at sites outside synovium, including the subcutaneous tissues
, the lungs, the
pericardium and the pleura. Clinical features Rheumatoid arthritis varies from t
he very mild to the
severely disabling. Many mild cases probably go undiagnosed. At least 50 per cen
t of patients continue to
lead a reasonably normal life; around 25 per cent are significantly disabled in
terms of work and leisure
activities; and a minority become markedly disabled and are limited in their ind
ependence. There is often
an early acute phase, followed by substantial remission, but in other patients g
radual stepwise
deterioration may occur, with progressive involvement of an increasing number of
joints. The diagnosis of
rheumatoid arthritis is largely based on clinical symptoms and signs. Approximat
ely 70 per cent of patients
have rheumatoid factor ANTIBODIES in the SERUM but, because of the large number
of false positives and
false negatives, this test has very little value in clinical practice. It may be
a useful
R
620 Rheumatology
pointer to a worse prognosis in early cases if the level is high. XRAYS
may help in diagnosing early
cases and are particularly helpful when considering surgery or possible complica
tions such as pathological
fracture. Patients commonly develop ANAEMIA, which may be partly due to gastroin
testinal blood loss from
antiinflammatory drug treatment (see below).
Treatment
involves physical, pharmacological, and surgical measures, together with
psychological and social
support tailored to the individual patients needs. Regular activity should be mai
ntained. Resting of
certain joints such as the wrist with splints may be helpful at night or to assi
st prolonged manual
activities. Sound footwear is important. Early use of antirheumatic drugs reduce
s longterm disability.
Drug treatment includes simple ANALGESICS,
NONSTEROIDAL ANTIINFLAMMATORY DRUGS (NSAIDS), and slowacting drugs in
cluding GOLD SALTS (in the form
of SODIUM AUROTHIOMALATE), PENICILLAMINE, SULFASALAZINE, METHOTREXATE and AZATHI
OPRINE.
R
The nonsteroidal agents are largely effective in reducing pain and earl
ymorning stiffness, and have
no effect on the chronic inflammatory process. It is important, especially in th
e elderly, to explain to
patients the adverse effects of NSAIDs, the dosage of which can be cut by prescr
ibing paracetamol at the
same time. Combinations of antirheumatic drugs seem better than single agents.
The slowacting drugs take
approximately three months to act but have a more global effect on chronic infla
mmation, with a greater
reduction in swelling and an associated fall in erythrocyte sedimentation rate (
ESR) and rise in the level
of HAEMOGLOBIN. Local CORTICOSTEROIDS are useful, given into individual joints.
Systemic corticosteroids
carry serious problems if continued long term, but may be useful under special c
ircumstances. Much research
is currently going on into the use of tumour necrosis factor antagonists such as
INFLIXIMAB and etanercept,
but their precise role remains uncertain.
Rheumatology The medical speciality concerned with the study and managem
ent of diseases of the JOINTS
and CONNECTIVE TISSUE.
Rh Factor See BLOOD GROUPS.
Rhinitis Inflammation of the mucous membrane of the NOSE. (See also NOSE
, DISORDERS OF.)
Rhinophyma The condition characterised by swelling of the NOSE due to en
ormous enlargement of the
Rickets 621
are arguable in that circumstance: the babies are likely to recover with
out treatment. Ribavarin, along
with INTERFERON alpha2b, is given orally to treat patients with chronic HEPATIT
IS C infection. It is also
used to treat LASSA FEVER.
Riboflavin
while the 11th and 12th are free from any such connection and are theref
ore known as floating ribs.
Each rib has a head, by which it is joined to the upper part of the body of the
vertebra with which it
corresponds, as well as to the vertebra immediately above. The greater part of t
he bone is made up of the
shaft, which runs at first outwards and at the angle turns sharply forwards. On
the lower margin of the
shaft is a groove, which lodges the corresponding intercostal artery and nerve.
The British Pharmacopoeia name for what used to be known as vitamin B2.
The minimal daily requirement
for an adult is 153 mg, but is greater during pregnancy and lactation. Deficiency
in the diet is thought
to cause inflammation of the substance of the cornea (see EYE), sores on the lip
s, especially at the angles
of the mouth (CHEILOSIS), and DERMATITIS. (See APPENDIX 5: VITAMINS.)
Rice-Water
Ribonucleic Acid See RNA.
A disease of childhood characterised chiefly by a softened condition of
the bones (see BONE), and by
other evidence of poor nutrition.
Ribosome
Causes This disease is the result of deficiency
Granules either found free within the cell, or attached to a reticular n
etwork within the cells
endoplasm (the inner part of a cells cytoplasm see CELLS). Consisting of approxim
ately 65 per cent RNA
and 35 per cent PROTEIN, they are the sites where protein is made.
of vitamin D in the diet. Healthy bones cannot be built up without calci
um (or lime) salts, and the
body cannot use these salts in the absence of vitamin D. Want of sunlight and fr
esh air in the dwellings
where children are reared is also of importance. Once a common condition in indu
strial areas, it had almost
disappeared in Great Britain but has recurred in recent years, largely amongst c
hildren of Asian and
African origin. The periosteum the membrane enveloping the bones becomes inflame
d, and the bone formed
beneath it is defective in lime salts and very soft. Changes also occur at the g
rowing part of the bone,
the epiphyseal plate.
622 Rickettsia
sufficient supply of milk. Rickets is very rare in breast-fed children b
ut it is a wise precaution to
give breast-fed babies supplementary vitamin D. After the child is weaned, the p
rovision of suitable food
is vital, supplemented with some source of vitamin D. Regular exposure to sunlig
ht is desirable.
Controversy exists as to whether vitamin D should be added in the manufacture of
flour, particularly of
types used by the Asian community. Deficiency of vitamin D in adults results in
osteomalacia (see under
BONE, DISORDERS OF). (See also APPENDIX 5: VITAMINS.)
Rickettsia The general term given to a group of microorganisms which are
intermediate between BACTERIA
and viruses (see VIRUS). They are the causal agents of TYPHUS FEVER and a number
of typhus-like diseases,
such as ROCKY MOUNTAIN SPOTTED FEVER, Japanese River fever, and scrub typhus. Th
ese micro-organisms are
usually conveyed to man by lice, fleas, ticks, and mites.
Visceral rickettsia is a disease transmitted by mites from an infected h
ouse mouse, which occurs in the
USA, South Africa, Korea and the former Soviet Union. The causal organism is Ric
kettsia akari. The
incubation period is 714 days and the characteristic features are fever, headache
, and a non-irritating
rash on the face, trunk and extremities. The disease is non-fatal and responds r
apidly to TETRACYCLINES.
Rifampicin
R
An antibiotic derived from Streptomyces mediterranei, rifampicin is a ke
y component of the treatment of
TUBERCULOSIS. Like ISONIAZID, it should always be included unless there is a spe
cific contraindication. It
is also valuable in the treatment of BRUCELLOSIS, LEGIONNAIRES DISEASE, serious s
taphylococcal (see
STAPHYLOCOCCUS) infections and LEPROSY. It is also given to contacts of certain
forms of childhood
MENINGITIS.
Rifampicin is given by mouth; during the first two months it often cause
s transient disturbance of
LIVER function, with raised concentrations of serum transaminases, but usually t
reatment need not be
interrupted. In patients with pre-existing liver disease more severe toxicity ma
y occur, and liver function
should be carefully monitored both before starting and during rifampicin treatme
nt. It induces hepatic
enzymes which accelerate the metabolism of various drugs including ANTICOAGULANT
S, SULPHONYLUREAS,
PHENYTOIN SODIUM, CORand OESTROGENS. The TICOSTEROIDS
effectiveness of oral contraceptives is reduced and alternative family-p
lanning advice should be
offered. Rifampicin should be avoided during pregnancy and breast feeding, and e
Risk Register
infect skin, hair and nails. The important clinical patterns are:
Tinea capitis Usually seen in children in Britain and caused by microspo
rum species of human or animal
(frequently a kitten) origin. Typically, patches of ALOPECIA are seen with broke
n-off hair stumps which
fluoresce bright green under an ultraviolet (Woods) lamp. In Asia a chronic, scar
ring alopecia may be
caused by a specific trichophyton (favus).
Tinea corporis is usually due to trichophyton species and forms ringed (
hence ringworm) patches of
redness and scaling on the trunk or limbs.
Tinea pedis (athletes foot) is caused by epidermophyton or trichophyton s
pecies. Its minor form
manifests as itching, scaling or blistering in the lateral toe clefts. More seve
re forms can be extensive
on the sole. Trichophyton rubrum can cause a chronic, dry, scaling inflammation
of the foot, eventually
extending into the nails and on to the soles and top of the foot which may persi
st for years if untreated.
Tinea cruris typically causes a butterfly rash on the upper inner thighs in young
adult males. It is
usually caused by spread from the feet.
Tinea unguium (onychomycosis) Affecting the nails, especially of the toe
s, T. rubrum is the usual cause
and may persist for decades.
Tinea barbae This rash of the face and beard is rare. It may be very inf
lammatory and is usually
contracted from cattle by farm workers.
Treatment Tinea of the toe clefts and groin will usually respond to an a
ntifungal cream containing
terbinafine or an azole. Tinea capitis, barbae, extensive tinea corporis and all
nail infections require
oral treatment with terbinafine or itraconazole (a triazole antifungal agent tak
en orally and used for
candidiasis of the mouth, throat and vulgovaginal area as well as for ringworm)
which have largely
superseded the earlier treatment with the antiobiotic griseofulvin. (See FUNGAL
AND YEAST INFECTIONS.)
623
ing, it is placed beside the ear. Normal subjects can then hear the nois
e once more, but in people with
conductive DEAFNESS, air conduction does not persist after bone conduction has c
eased. It can help to
distinguish between nerve (sensorineural) and conduction deafness.
Ripple Beds A development of the conventional air-beds. Their essential
feature is a mattress which is
alternately pressurised by a compressor to create a gentle rippling effect along
the entire length of the
mattress. This provides a continuous massaging motion which stimulates the circu
Rocky Mountain Spotted Fever A fever of the typhus group (see TYPHUS FEV
ER). It received its name from
the fact that it was first reported in the Rocky Mountain States of the United S
tates; these are still the
most heavily infected areas, but the fever is now found in all parts of the US.
The causative organism is
Rickettsia rickettsi, which is transmitted to humans by tics.
Rodent Ulcer A chronic form of BASAL CELL CARCINOMA, the most common for
m of skin cancer.
Rohypnol See FLUNITRAZEPAM.
Rombergism A term applied to marked unsteadiness when a person stands wi
th the eyes shut. It is found
as a symptom in some nervous diseases, such as peripheral NEUROPATHY and tabes d
orsalis (neurosyphilis).
Root Filling Also called root-canal therapy, this is the treatment given
when the nerve of a tooth (see
TEETH) has been exposed while the tooth is being prepared for a filling, or if i
t has died or become
infected. The nerve debris is removed and, when the chamber is clear of infectio
n, an inert material is
inserted to seal off the root.
Rorschach Test A psychological test (see PSYCHOLOGY) for investigating p
ersonality and disorders of
personality. Also called the ink blot test, it is now rarely used. It was devised
by a Swiss
psychiatrist, Hermann Rorschach (18841922), who determined individuals reactions t
o a series of
symmetrical ink-blots, ten in number and standardised by him.
Rosacea Common chronic inflammation of the facial skin, this condition i
s seen in middle and late life.
Redness, obvious dilatation of venules and crops of ACNE-like papules and pustul
es affect mainly the
central forehead, cheeks, nose and chin. A keratoconjunctivitis (combined
Rubella
inflammation of the cornea and conjunctiva of the EYE) may be associated
. Subjects flush easily,
especially after alcohol or hot drinks. Eventually the affected areas may become
thickened and oedematous,
and in men, proliferation of fibrous and sebaceous tissue may lead to gross thic
kening and enlargement of
the nose (RHINOPHYMA).
625
Rouleaux The term applied to the heaps into which red blood corpuscles (
ERYTHROCYTES) collect as seen
under the microscope.
Roundworms See ASCARIASIS.
Rous Sarcoma Treatment Long-term, low-dose, oral tetracycline (see ANTIB
IOTICS; TETRACYCLINES) is the
treatment of choice. In mild cases, METRONIDAZOLE gel can be helpful. Potent top
ical CORTICOSTEROIDS are
contraindicated and make rosacea worse.
A malignant tumour of fowls which is caused by a virus. This tumour has
been the subject of much
experimental work on the nature of CANCER.
Royal College of Nursing (RCN) See APPENDIX 8: PROFESSIONAL ORGANISATION
S.
Roseola Infantum A transient EXANTHEM of toddlers. Mild malaise is follo
wed by a RUBELLA-like rash. It
is caused by herpes virus 6 (see HERPES VIRUSES).
Rotator Cuff A musculo-tendinous structure that helps to stabilise the s
houlder-joint. The cuff may be
damaged as a result of a fall; complete rupture requires surgical treatment and
intensive PHYSIOTHERAPY.
Rotaviruses A group of viruses (so-called because of their wheel-like st
ructure: rota is Latin for
wheel) which are a common cause of GASTROENTERITIS in infants (see also DIARRHOE
A). They cause from 25 to
80 per cent of childhood diarrhoea in different parts of the world, and in the U
nited Kingdom they are
responsible for 60 65 per cent of cases. They infect only the cells lining the sm
all intestine. In the UK,
death from rotavirus is rare.
Roughage Dietary fibre is that part of food which cannot be digested in
the gastrointestinal tract,
although it can be metabolised in the colon by the micro-organisms there. Rougha
ge falls into four groups:
cellulose, hemicelluloses, lignins and pectins, found in unrefined foods such as
wholemeal cereals and
flour, root vegetables, nuts and fruit. It has long been known to affect bowel f
unction, probably because
of its capacity to hold water in a gel-like form. It plays an important role in
the prevention of
626 Rupture
information on fetal abnormalities, see under PREGNANCY AND LABOUR). The
incidence of such defects is
not precisely known, but probably around 20 per cent of children whose mothers h
ave had German measles in
the first three months of the pregnancy are born with congenital defects. These
defects take a variety of
forms, but the most important ones are: low birth weight with retarded physical
development; malformations
of the HEART; cataract (see under EYE, DISORDERS OF); and DEAFNESS.
Treatment There is no specific treatment. Children who develop the disea
se should not return to school
until they have recovered, and in any case not before four days have passed from
the onset of the rash. In
view of the possible dangerous effect of the disease upon the fetus, particular
care should be taken to
isolate pregnant mothers from contact with infected subjects. As the risk is par
ticularly high during the
first 16 weeks of
R
pregnancy, any pregnant mother exposed to infection during this period s
hould be given an intramuscular
injection of GAMMA-GLOBULIN. A vaccine is available to protect an individual aga
inst rubella (see
IMMUNISATION). In the United Kingdom it is NHS policy for all children to have t
he combined measles, mumps
and rubella vaccine (see MMR VACCINE), subject to parental consent. All women of
childbearing age, who have
been shown by a simple laboratory test not to have had the disease, should be va
ccinated, provided that the
woman is not pregnant at the time and has not been exposed to the risk of pregna
ncy during the previous
eight weeks.
Rupture A popular name for HERNIA.
Ryles Tube See NASOGASTRIC TUBE.
S Sabin Vaccine
Introduced in 1962, the attenuated live oral vaccine (Sabin) against POL
IOMYELITIS replaced the
previous inactivated vaccine introduced in 1956 (see SALK VACCINE).
Saccharine A sweetening agent that is 400 times as sweet as cane sugar,
but with no energy content.
Apart from its rather bitter aftertaste, it has practically no effect on the tis
sues, and escapes from the
body unchanged. Destroyed by heat, saccharine is not used in cooking, but is an
important component of all
diabetic and low-calorie diets.
Saccharomyces Another name for YEAST.
Sacral Nerves The five pairs of spinal nerves that leave the SPINAL COLU
MN in the sacral area. They
carry motor and sensory fibres from the anal and genital regions and from both l
egs.
Sacral Vertebrae The five fused vertebrae that link the thoracic spine a
nd the coccyx and form the
sacrum (see SPINAL COLUMN).
Sacroileitis (See SACROILIAC JOINT.) Inflammation of one or both sacroil
iac joints, which lie between
the sacrum and the iliac bones. The condition may be the result of RHEUMATOID AR
THRITIS, ankylosing
spondylitis (see under SPINE AND SPINAL CORD, DISEASES AND INJURIES OF), REITERS
SYNDROME, or the
arthritis that occurs with PSORIASIS or infection. Sacroileitis causes pain in t
he lower back, buttocks,
thighs, and groin. Stiffness may occur with ankylosing spondylitis. NON-STEROIDA
L ANTI-INFLAMMATORY DRUGS
(NSAIDS) relieve the symptoms. If the cause is infection, antibiotics should be
used.
Sacroiliac Joint One of a pair of joints between each side of the SACRUM
and each ILIUM. Strong
ligaments between the ilium and the sacrum stabilise the joint, permitting littl
e movement. Childbirth or
strenuous sporting activities may strain the joint, causing pain in the lower pa
rt of the
back and buttocks. Such strains may take a long time to mend; PHYSIOTHER
APY is the treatment. The
joint(s) may become inflamed (see SACROILEITIS).
Sacrum The portion of the SPINAL COLUMN near its lower end. The sacrum c
onsists of five vertebrae fused
together to form a broad triangular bone which lies between the two haunch-bones
and forms the back wall of
the pelvis.
Sadism The term applied to a form of sexual perversion, in which satisfa
ction is derived from the
infliction of cruelty upon another person. The condition is commoner in men than
in women and is sometimes
linked with MASOCHISM (a wish to be hurt or abused).
Safe Period That period during the menstrual cycle (see MENSTRUATION) wh
en fertilisation of the OVUM is
unlikely to occur. OVULATION usually occurs about 15 days before the onset of th
e menstrual period. A woman
is commonly believed to be fertile for about 11 days in each menstrual cycle in
other words, on the day
of ovulation and for five days before and five days after this; this would be th
e eighth to the 18th day of
the usual 28-day menstrual cycle. Outside this fertile period is the SAFE PERIOD
: the first week and the
last ten days of the menstrual cycle. On the other hand, there is increasing evi
dence that the safest
period is the last few days before menstruation. In the case of irregular menstr
uation it is not possible
to calculate the safe period. In any event, the safety is not absolute. (See als
o CONTRACEPTION.)
Safety of Drugs The
COMMITTEE ON SAFETY OF MEDICINES (CSM) has the function of scrutinising
the efficacy, quality and
safety of new DRUGS before
clinical trials and before marketing, as well as the surveillance of eac
h drug after marketing so that
adverse reactions are monitored and documented, and warnings issued as required.
Early clinical trials of a
drug can only be carried out after a clinical-trial certificate has been issued
by the licensing authority.
The major defect in this system is the difficulty in obtaining reports of advers
e reactions. Evidence
suggests that at most, about 10 per cent of such reactions are reported. One met
hod of trying to obtain
this information is the yellow card system. It is so called because it is based on
the distribution of
yellow cards to all
628 Sagittal
doctors, pharmacists and dentists, on which they are asked to report any
adverse reaction happening to
someone taking a drug, whether or not they think it is the cause. Alternatively
the CSM has a Freephone
line and on-line computer facilities (ADROIT) for practitioners to use. Even tho
ugh the annual number of
adverse reactions reported in this way has risen from around 5,000 in 1975 to mo
re than 18,000, this is
probably fewer than the number actually occurring. Two further committees in thi
s safety screen are the
Joint Committee on Vaccination and Immunisation and the Adverse Reactions to Vac
cines and Immunological
Substances Committee.
Sagittal The term applied to a structure or section running from front t
o back in the body.
Salaam Attacks See INFANTILE SPASMS.
Salbutamol A short-acting selective beta2-adrenoceptor stimulant deliver
ed via a metered-dose aerosol
inhaler, a powder inhaler or through a nebuliser to control symptoms of ASTHMA.
If stimulant inhalation is
needed more than twice a day to control asthma attacks, prophylactic treatment s
hould be considered
including, in severe cases, oral CORTICOSTEROIDS. Salbutamol relaxes the muscles
which cause bronchial
spasms in the lungs the prime symptom of asthma. There are other similar prepara
tions such as
terbutaline.
Salicylic Acid S
A crystalline substance sparingly soluble in water that is used external
ly in ointments and pastes. It
has antifungal properties and helps to loosen and remove scales. In high concent
rations it is useful in
treatment of verrucae (WARTS) and corns (see CORNS AND BUNIONS).
Saline Normal saline is a solution containing 09 per cent of sodium chlor
ide (common salt). Saline is
used clinically to dilute drugs given by injection; it is also given as an intra
venous infusion to restore
blood volume if blood loss from accident or operation is not too serious, or to
tide a patient over until
PLASMA or blood for TRANSFUSION becomes available. Saline is also given orally t
o severely dehydrated
children or adults suffering from diarrhoea and, in particular, CHOLERA.
Saliva The fluid secreted by the SALIVARY GLANDS into the mouth. The ing
estion of food stimulates
saliva production. Saliva contains mucus and an ENZYME known as PTYALIN, which c
hanges starch into dextrose
and maltose (see DIGESTION); also many cells of different types. About 750 milli
litres are produced daily.
The principal function of saliva is to aid in the initial processes of digestion
, and it is essential for
the process of mastication (chewing), whereby food is reduced to an homogeneous
Saphenous
629
Cutaway diagram of left side of face showing position of salivary glands
in relation to tongue and
lower jaw.
Salpingitis Inflammation situated in the FALLOPIAN TUBES; these run from
the OVARIES to the UTERUS and
carry the ova or eggs. The disorder is commonly caused by infection spreading up
wards from the VAGINA,
cervix or uterus. It is one feature of PELVIC INFLAMMATORY DISEASE (PID). Salpin
gitis is potentially
serious and requires treatment with antibiotics and sometimes surgery to drain a
ny PUS or, in persistent
infections, to remove the Fallopian tubes.
SalpingoA prefix indicating a connection with either the FALLOPIAN TUBES
or the EUSTACHIAN TUBES.
Salpingography Radiography (see X-RAYS) of one or both FALafter radio-op
aque material has been injected
into them via the UTERUS.
LOPIAN TUBES
Salpingo-Ophorectomy Surgical removal of a Fallopian tube (see FALLOPIAN
TUBES) and its accompanying
ovary (see OVARIES).
Salt The substance produced by the replacement of the acidic hydrogen of
an acid by a metal or basic
radical. It is also a synonym for common salt or sodium chloride. Sodium chlorid
e is a vital constituent of
cells, and a proper balance between it and other salts in the cells and body tis
sues is important for their
viability.
Sandfly Fever This is a short, sharp fever occurring in many parts of th
e tropics and subtropics,
including most of the Mediterranean littoral. It is due to a virus, called phleb
ovirus, conveyed by the
bite
of a small hairy midge or sandfly (Phlebotomus papatasi). The incubation
period is 37 days.
Symptoms There are headache, feverishness, general sensations like those
of INFLUENZA, flushed face and
bloodshot eyes, but no signs of CATARRH. The fever passes off in three days, but
the patient may take some
time to convalesce.
Treatment As there is no specific remedy, is important. This consists of
the spraying of rooms with an
insecticide such as GAMMEXANE; the application of insect repellents such as dime
thyl phthalate to the
exposed parts of the body (e.g. ankles, wrists and face), particularly at sunset
; and the use of sandfly
nets at night. Once the infection is acquired, treatment consists of rest in bed
, light diet and aspirin
and codeine. PROPHYLAXIS
Sanguineous This term means containing blood.
Sanitary Protection Disposable sanitary towels or tampons (see TAMPON) u
sed to protect clothing from
bloodstains during MENSTRUATION. They are available in different absorbencies to
meet womens individual
needs.
Saphenous The name given to the two large superficial veins of the leg.
The small saphenous vein, which
runs up the outside and back of the leg, joins the deep veins at the bend of the
knee; the great saphenous
vein the longest vein in the body, which has a course from the inner ankle to th
e groin is especially
subject, with its branches, to become the site of VARICOSE VEINS.
S
630 Saprophyte
Saprophyte An organism which lives usually upon decaying and dead matter
and produces its
decomposition.
SarcoA prefix signifying flesh or fleshy.
Sarcoidosis An uncommon chronic inflammatory disease of unknown origin w
hich can affect many organs,
particularly the SKIN, eyes (see EYE) and LUNGS. Commonly, it presents as ERYTHE
MA nodosum in association
with lymph-gland enlargement within the chest. In the eyes it causes UVEITIS. BI
OPSY of affected tissue
allows diagnosis, which is confirmed by a KVEIM TEST. Often sarcoidosis is selflimiting, but in severe
cases oral CORTICOSTEROIDS may be needed.
Sarcoma See CANCER.
Sarcoptes Mites which infest humans and animals. Sarcoptes scabei homini
s causes human SCABIES. Other
species infest dogs (sarcoptic mange), cats and birds.
SARS
S
In 2003, an outbreak occurred of a previously unrecognised illness terme
d SARS, or severe acute
respiratory syndrome. It was caused by infection with a newly identified coronav
irus, SARS-COV. Infection
produced an illness with PNEUMONIA as a prominent feature, but some patients dev
eloped other events such as
loss of appetite, diarrhoea and bleeding from the stomach. Many of those who dev
eloped the disease were
health-care workers and the contagion rate was vey high. Exceptional isolation p
rocedures became necessary
as the EPIDEMIC threatened to spread worldwide from its origin in Hong Kong. For
example, patients were
concentrated in individual hospitals which were turned into isolation units with
a no visiting policy.
Staff and other patients exposed to those with the disease were quarantined (see
QUARANTINE) in the special
units. All non-urgent hospital inpatient care was cancelled, and potential conta
cts were closely screened.
Travel restrictions were put in place. These measures, coordinated by the World
Health Organisation,
brought the epidemic under control.
Scab The crust which forms on superficial injured
areas. It is composed of FIBRIN, which is exuded from the raw surface, t
ogether with blood corpuscles
and epithelial cells entangled in its meshes. Healing takes place naturally unde
r this protection, and the
scab dries up and falls off when healing is complete. Scabs appearing on the fac
e without any previous
abrasion are usually caused by an infection (see IMPETIGO).
632 Schistomicide
rash usually appears within 24 hours of the onset of fever and lasts abo
ut a week.
Complications The most common and serious of these is glomerulonephritis
(see under KIDNEYS, DISEASES
OF), which may arise during any period in the course of the fever, but particula
rly when DESQUAMATION
occurs. Occasionally the patient develops chronic glomerulonephritis. Another co
mplication is infection of
the middle ear (otitis media see under EAR, DISEASES OF). Other disorders affect
ing the heart and lungs
occasionally arise in connection with scarlet fever, the chief of these being EN
DOCARDITIS, which may lay
the foundation of valvular disease of the heart later in life. ARTHRITIS may pro
duce swelling and pain in
the smaller rather than in the larger joints; this complication usually occurs i
n the second week of
illness. Scarlet fever, which is now a mild disease in most patients, should be
treated with PENICILLIN.
Schistomicide A drug used to treat SCHISTOSOMIASIS. Praziquantel is the drug of
choice, with a combination
of effectiveness, broad-activity spectrum and few side-effects.
Schistosomiasis
S
Also known as BILHARZIASIS. This infection results from one of the human
Schistosoma species. It is
common in Africa, South America, the Far East, Middle East, and, to a limited ex
tent, the Caribbean. The
life-cycle is dependent on fresh-water snails which act as the intermediate host
for the fluke; the
cercarial stage of the fluke enters via intact human skin and matures in the por
tal circulation.
Clinically, swimmers itch may occur at the site of cercarial skin penetration. Acut
e schistosomiasis
(Katayama fever) can result in fever, an urticarial rash (see URTICARIA), and en
largement of LIVER and
SPLEEN. The adult male is about 12 mm and the female 24 mm in length. S. haemato
bium causes CYSTITIS and
haematuria passage of blood in the urine; bladder cancer and ureteric obstructio
n, giving rise to
hydronephrosis and kidney failure, are longterm sequelae in a severe case. S. ma
nsoni can cause colonic
symptoms and in a severe case, POLYPOSIS of the COLON; diarrhoea, which may be b
loody, can be a presenting
feature. In a heavy infection, eggs surrounded by granulomas are deposited in th
e liver, giving rise to
extensive damage (pipe-stem fibrosis) associated with PORTAL HYPERTENSION, oesop
hageal varices, etc.
However, unlike in CIRRHOSIS, hepatocellular function is preserved until late in the disease. S. japonicum (
which is confined to the Far
East, especially Indonesia) behaves similarly to S. mansoni infection; liver inv
olvement is often more
severe. Diagnosis can be made by microscopic examination of URINE or FAECES. The
Sciatica 633
sufferers have a one in ten chance of developing the disorder; a twin ha
s a 50 per cent chance if the
other twin has schizophrenia. Some BRAIN disorders such as temporal lobe EPILEPS
Y, tumours and ENCEPHALITIS
seem to be linked with schizophrenia. Certain drugs for example, AMPHETAMINES ca
n precipitate
schizophrenia and DOPAMINE-blocking drugs often relieve schizophrenic symptoms.
Stress may worsen
schizophrenia and recreational drugs may trigger an attack.
Symptoms These usually develop gradually until the individuals behaviour
becomes so distrubing or
debilitating that work, relationships and basic activities such as eating and sl
eeping are interrupted. The
patient may have disturbed perception with auditory HALLUCINATIONS, illogical th
ought-processes and
DELUSIONS; low-key emotions (flat affect); a sense of being invaded or controlled
by outside forces; a
lack of INSIGHT and inability to acknowledge reality; lethargy and/or agitation;
a disrespect for personal
appearance and hygiene; and a tendency to act strangely. Violence is rare althou
gh some sufferers commit
violent acts which they believe their inner voices have commanded. Relatives and f
riends may try to cope
with the affected person at home, but as severe episodes may last several months
and require regular
administration of powerful drugs patients are not always good at taking their me
dication hospital
admission may be necessary.
Treatment So far there is no cure for schizophrenia. Since the 1950s, ho
wever, a group of drugs called
antipsychotics also described as NEUROLEPTICS or major tranquillisers have relie
ved florid symptoms
such as thought disorder, hallucinations and delusions as well as preventing rel
apses, thus allowing many
people to leave psychiatric hospitals and live more independently outside. Only
some of these drugs have a
tranquillising effect, but their sedative properties can calm patients with an a
cute attack. CHLORPROMAZINE
is one such drug and is commonly used when treatment starts or to deal with an e
mergency. Halperidol,
trifluoperazine and pimozide are other drugs in the group; these have less sedat
ive effects so are useful
in treating those whose prominent symptoms are apathy and lethargy. The antipsyc
hotics mode of action is
by blocking the activity of DOPAMINE, the chemical messenger in the brain that i
s faulty in schizophrenia.
The drugs quicken the onset and prolong the remission of the disorder, and it is
very important that patients take them indefinitely. This is easier to e
nsure when a patient is in
hospital or in a stable domestic environment. CLOZAPINE a newer, atypical antips
ychotic drug is used
for treating schizophrenic patients unresponsive to, or intolerant of, conventio
nal antipsychotics. It may
cause AGRANULOCYTOSIS and use is confined to patients registered with the Cloraz
il (the drugs registered
634 Scirrhus
is due to a PROLAPSED INTERVERTEBRAL DISC in the lower part of the SPINA
L CORD. What probably happens
is that degenerative changes take place in the annulus fibrosus (see SPINAL COLU
MN) as a result of some
special strain caused, for example, by heavy lifting or spontaneously. The cushi
oning disc between the
two neighbouring vertebral bodies slips through the rent in the annulus fibrosus
, and presses on the
neighbouring roots, thus causing the pain. The precise distribution of the pain
will thus depend on which
of the nerve roots are affected. As a rule, the pain is felt in the buttock, the
back of the thigh and the
outside and front of the leg, sometimes extending on to the top of the foot, the
back of the thigh and the
calf, and then along the outer border of the foot towards the little toe. Rare c
auses include a tumour in
the spine or spinal column, tuberculosis of the spine, ankylosing spondylitis (s
ee SPINE AND SPINAL CORD,
DISEASES AND INJURIES OF) or a tumour in one of the organs in the pelvis such as
the UTERUS.
Treatment consists essentially of rest in bed in the early stages until
the acute phase is over.
ANALGESICS, such as aspirin and codeine, are given to relieve the pain. Expert o
pinion varies as to the
desirability of wearing a PLASTER OF PARIS jacket or a specially made corset; al
so, as to the desirability
of manipulation of the spine and operation. Surgeons are selective about which p
atients might benefit from
a LAMINECTOMY (removal of the protruding disc). Scirrhus A hard form of cancer c
ontaining fibrous tissue.
Sclera See EYE.
S Scleritis See under EYE, DISORDERS OF.
Scleroderma A rare autoimmune disease. Scleroderma circumscriptum (morph
oea) affects the skin, usually
of the trunk, producing indurated plaques which resolve over many years. The mor
e serious systemic form of
scleroderma usually begins with RAYNAUDS DISEASE, eventually producing a deformin
g hardening and clawing
of the hands. Later the face and sometimes the internal organs, particularly the
gastrointestinal tract and
kidneys, may be affected.
Sclerosis This term means literally hardening, and is
applied to conditions in which portions of organs harden and lose their
function as the result of an
excessive production of CONNECTIVE TISSUE. The term is especially applied to a c
hange of this type taking
place in the nervous system. (See MULTIPLE SCLEROSIS (MS)).
Sclerotherapy A treatment that involves injecting varicose veins (see VE
INS, DISEASES OF) with a
sclerosing fluid. This causes fibrosis of the lining of the vein and its eventua
l obliteration.
Sclerotherapy is also used to treat varicose veins in the legs, anus (HAEMORRHOI
DS) and at the junction of
the OESOPHAGUS with the stomach.
Scoliosis The name applied to curvature of the spine. (See SPINE AND SPI
NAL CORD, DISEASES AND INJURIES
OF.)
Scorbutic This is an adjective characterising SCURVY; typically swollen,
spongy gums that bleed easily,
and spontaneous haemorrhages and bruising anywhere in the body.
Scotoma An area of blindness in the field of vision.
Screening Test The screening of apparently healthy people to identify th
ose who may have treatable
diseases. Cervical smears are done when screening women to detect if they have c
ancer or precancer of the
neck of the womb (cervix). Newborn babies are screened for hip dislocation. Scre
ening tests are not
designed to diagnose individual persons, but rather to divide a population into
a large number at low risk
and a small number at high risk of a condition. This allows clinicians to concen
trate on a sub-section of
the population. All screening tests produce false negative and false positive re
sults, a problem often
misunderstood by those at the receiving end. Factors to be assessed when plannin
g screening procedures
include the severity, frequency and distribution of the disease, and the availab
ility and effectiveness of
treatment. Convenience, safety, sensitivity and cost should also be assessed. In
the United Kingdom the
government has supported the extension of screening procedures for breast cancer
, cervical cancer,
hypertension and diabetes. (See PREVENTIVE MEDICINE.)
Scriveners Palsy Another name for writers cramp (see MUSCLES, DISORDERS OF
).
Sebum
Scrofula This is a traditional term for TUBERCULOSIS of the lymph glands
in the neck. It was formerly
known in England as kings evil, from the belief that the touch of the sovereign cou
ld effect a cure.
This superstition can be traced back to the time of Edward the Confessor in Engl
and, and to a much earlier
period in France. The disease, which is treated with antituberculous drugs, is n
ow rare in developed
societies and usually affects young children.
Scrombotoxin Poisoning This occurs from eating poorly preserved scromboi
d fish such as tuna, mackerel
and other members of the mackerel family. In such fish, a toxic histamine-like s
ubstance is produced by the
action of bacteria or histidine, a normal component of fish flesh. This toxin pr
oduces nausea, vomiting,
headache, upper abdominal pain, difficulty in swallowing, thirst, itching and so
metimes URTICARIA. The
condition settles as a rule in 12 hours. ANTIHISTAMINE DRUGS sometimes ameliorat
e the condition.
Scrotum The pouch of skin and fibrous tissue, positioned outside the abd
omen behind the root of the
PENIS, within which the testicles (see TESTICLE) are suspended. It consists of a
purse-like fold of skin,
within which each testicle has a separate investment of muscle fibres, several l
ayers of fibrous tissue,
and a serous membrane known as the tunica vaginalis. The extraabdominal site mea
ns that the production and
storage of sperm (see SPERMATOZOON) in the testicles is at a lower temperature t
han internal body heat.
Temperature control is facilitated by contraction and relaxation of the scrotal
muscles.
Scrum-Pox A popular name for a contagious condition of the face affectin
g rugby football players. It is
most likely to occur in forwards as a result of face-to-face contact with indivi
duals with the infection in
the opposing side of the scrum. Other possible sources of infection are changing
rooms and communal baths.
The condition may take the form of IMPETIGO or HERPES SIMPLEX.
Scurf See DANDRUFF.
Scurvy Scurvy, or scorbitus, is caused by deficiency of
635
vitamin C (ascorbic acid see APPENDIX 5: VITand is now rarely seen in de
veloped countries except in
people on poor diets, such as homeless down-and-outs. Ascorbic acid is a water-s
oluble vitamin derived from
citrus fruits, potatoes and green vegetables. Nowadays woody haemorrhagic OEDEMA
of the legs is the usual
way in which the disease presents. The former classic disease of sailors living
on salt beef and biscuits
was characterised by bleeding of the gums, loss of teeth, haemorrhage into joint
s, ANAEMIA, lethargy and
DEPRESSION. The introduction of fresh lime juice into the seamans diet in 1795 el
iminated scurvy in the
Royal Navy. Vitamin C is curative. AMINS)
Sea-Sickness See MOTION (TRAVEL) SICKNESS.
Seasonal Affective Disorder Syndrome Known colloquially as SADS, this is
a disorder in which an
affected individuals mood changes with the seasons. He or she is commonly depress
ed in winter, picking up
again in the spring. The diagnosis is controversial and its prevalence is not kn
own. The moodchange is
probably related to light, with MELATONIN playing a key role. (See also MENTAL I
LLNESS.)
Sebaceous Cyst A misnomer applied to epidermoid cysts of the skin whose
contents are kerateous not
sebaceous. The common wen of the scalp arises from follicular epithelium and is si
milar.
Sebaceous Glands The minute glands situated alongside hairs and opening
into the follicles of the
latter a short distance below the point at which the hairs emerge on the surface
. These glands secrete an
oily material, and are especially large upon the nose, where their openings form
pits that are easily
visible. In the mouth the glands open directly on the mucosal surface. (See also
SKIN.)
Seborrhoea Excessive production of ACNE vulgaris.
SEBUM;
it occurs in
Sebum The secretion of the SEBACEOUS GLANDS. It acts as a natural lubric
ant of the hair and skin and
protects the skin from the effects of moisture or excessive dryness. It may also
have antibacterial action.
S
Sensation
Selenium Sulphide This is used as a shampoo in the treatment of dandruff
and seborrhoeic DERMATITIS of
the scalp. In view of its potential toxicity it should only be used under medica
l supervision. It must
never be applied to inflamed areas of the scalp, and it must not be allowed to g
et into the eyes as it may
cause conjunctivitis or keratitis. It is also used in the treatment of tinea ver
sicolor (see RINGWORM).
Self-Poisoning See POISONS.
Sella Turcica The deep hollow on the upper surface of the sphenoid bone
in which the PITUITARY GLAND is
enclosed.
Semen Fluid produced by the male on ejaculation from the penis at sexual
orgasm. Each ejaculate
contains up to 500 million spermatozoa (male germ cells) suspended in a fluid th
at is secreted by the
PROSTATE GLAND, seminal vesicles (see TESTICLE), and Cowpers glands a pair of sma
ll glands (also called
the bulbo-urethral glands) that open into the URETHRA at the base of the penis.
Semen, or seminal fluid,
contains a form of sugar (fructose) essential for the motility of sperm. The hor
mone TESTOSTERONE is a key
element in the production of sperm and of seminal fluid.
Semilunar Cartilages Two crescentic layers of fibro-cartilage on the out
er and inner edges of the
knee-joint, which form hollows on the upper surface of the tibia in which the co
ndyles at the lower end of
the femur rest. The inner cartilage is especially liable to be displaced by a su
dden and violent movement
at the KNEE.
Seminal Vesicle One of the small paired sacs lying on either side of the
male URETHRA, which collect
and store spermatozoa. (See TESTICLE.)
Seminiferous Tubules The long tortuous tubules that form much of the tes
tis (see TESTICLE) and carry
the SEMEN to the URETHRA.
Seminoma A malignant tumour of the testis (see TESTICLE) that appears as
an often painless swelling.
This tumour usually occurs in an older age-group of
637
men than does TERATOMA. The treatment is surgical removal. (See also TES
TICLE, DISEASES OF.)
Senile Dementia DEMENTIA was traditionally divided into presenile and se
nile types; this is
increasingly recognised as an arbitrary division of a condition in which there i
s a general and often slow
decline in mental capabilities. Around 10 per cent of people over 65 years of ag
e and 20 per cent over 75
are affected by dementing illness, but people under 65 may also be affected. Tre
atable causes such as brain
tumour, head injury, ENCEPHALITIS and alcoholism are commoner in younger people.
Other causes such as
cerebrovascular disease which is a major factor, especially among older people o
r ALZHEIMERS DISEASE
are not readily treatable, although ANTIHYPERTENSIVE DRUGS for the former disord
er may help, and
symptomatic treatment for both is possible. Individuals with dementia suffer a g
radual deterioration of
memory and of the ability to grasp what is happening around them. They often cov
er up their early failings
and the condition may first become apparent as a result of emotional outbursts o
r uncharacteristic
behaviour in public. Eventually personal habits and speech deteriorate and they
become thoroughly confused
and difficult to look after. Treatment is primarily a matter of ameliorating the
symptoms, coupled with a
sympathetic handling of the sufferer and the relatives. Admission to hospital or
nursing home may be
necessary if relatives are unable to look after the patient at home. (See also M
EDICINE OF THE AGEING.)
Senility See AGEING.
Senna The leaves of various species of Cassia senna. It is one of the mo
st active of the simple
laxative drugs (see LAXATIVES). Senna is excreted in the urine, giving it a dark
red or yellow colour. In
the case of nursing mothers, some of the drug is excreted in the milk and may af
fect the infant. A
standardised preparation of senna, Senokot , is widely used for the management of
constipation in children
and old people. A side-effect of senna is HYPOKALAEMIA; like other laxatives, it
should not be used too
often.
Sensation See PAIN; TOUCH.
S
638 Sensitisation
Sensitisation See ALLERGY; ANAPHYLAXIS.
Sensitivity The extent to which a SCREENING TEST detects the proportion
of true cases of the disease
being screened.
Sensory Description applied to the part of the nervous system dedicated
to bringing information on
sensations affecting the body to the brain. The opposite of sensory nerves is mo
tor nerves; these carry
instructions for action to the voluntary muscles in the body.
Sensory Cortex See BRAIN.
Sensory Deprivation A substantial reduction in the volume of SENSinforma
tion impinging on the body
for instance, sitting in a dark, silent room. Prolonged deprivation is potential
ly harmful as the body
needs constant stimulation in order to function normally. The main input organs
are the eyes, ears, skin
and nose. The absence of sensations disorients a person and results in neurologi
cal dysfunction. Some
interrogation techniques involve sensory deprivation to soften up the individual b
eing questioned. ORY
Sepsis Poisoning by the products of the growth of micro-organisms in the
body, the general symptoms
which accompany it are those of INFLAMMATION. Sepsis is prevented by the various
procedures mentioned under
ASEPSIS, and is treated locally with ANTISEPTICS and systemically with ANTIBIOTI
CS.
S Septal Defect A congenital abnormality of the HEART affecting about 26
0 babies in every 100,000, in
which there is a hole in the septum the dividing wall between the left and right
sides of the heart.
The effects of the defect depend upon its size and position. A defect in the wal
l between the atria (upper
chambers of the heart) is called an atrial septal defect, and that between the v
entricles, a ventricular
septal defect the most common form (25 per cent of all defects). Both defects al
low blood to circulate
from the left side of the heart, where pressures are highest, to the right. This
abnormal flow of blood is
described as a shunt and the result is that too much blood flows into the lungs. P
ULMONARY HYPERTENSION
occurs and, if the shunt is large,
heart failure may develop. A small septal defect may not need treatment
but a large one will need to be
repaired surgically.
Septicaemia A serious condition caused by the presence of micro-organism
s in the bloodstream. A very
high temperature may be the only sign, but there is often associated shivering (
rigor), profuse sweating
and pains in the joints and muscles. If the condition is not brought to a halt b
y the early use of
Serum Sickness
639
Sequelae
Serous Membranes
The term applied to symptoms or effects which are liable to follow certa
in diseases. For example,
BRONCHITIS and other chest complaints may be sequelae of MEASLES; heart disease
is often a sequelae of
RHEUMATIC FEVER; PARALYSIS may follow DIPHTHERIA.
These are smooth, transparent membranes that line certain large cavities
of the body. The chief serous
membranes are the PERITONEUM, lining the cavity of the abdomen; the pleurae (see
PLEURA), one of which
lines each side of the chest, surrounding the corresponding lung; the PERICARDIU
M, in which the heart lies;
and the tunica vaginalis on each side, enclosing a testicle. The name of these m
embranes is derived from
the fact that the surface is moistened by thin fluid derived from the serum of b
lood or LYMPH. Every serous
membrane consists of a visceral portion, which closely envelops the organs conce
rned, and a parietal
portion, which adheres to the wall of the cavity. These two portions are continu
ous with one another so as
to form a closed sac, and the opposing surfaces are close together, separated on
ly by a little fluid. This
arrangement enables the organs in question to move freely within the cavities co
ntaining them. For further
details, see
Sequestrum A fragment of dead bone cast off from the living bone in the
process of NECROSIS. (See also
BONE, DISORDERS OF.) A sequestrum often remains in contact with, and partly enve
loped by, newly formed
bone, so that a SINUS is produced; a constant discharge goes on until the dead b
one is removed.
Seroconversion The production of specific ANTIBODIES to antigens (see AN
TIGEN) present in the body.
This may happen as a result of infection by a virus, or IMMUNISATION with a VACC
INE. Thus, if blood has
been tested before the event there may be little or no evidence of antibody to t
he condition in question;
but when a sample is taken 12 weeks later there may be a high level of antibody c
onfirming that recent
infection has taken place. Sometimes this is the only way to prove that a partic
ular infection has occurred
or that a vaccination has taken.
Serotonin Also known as 5-hydroxytryptamine, this is a substance widely
distributed in the body tissue,
but especially in the PLATELETS in the blood, the lining of the gastrointestinal
tract, and the BRAIN.
Serotonin is believed to have a similar function to that of HISTAMINE in INFLAMM
ATION. In the gut it
inhibits gastric secretion and stimulates smooth (involuntary) muscle in the wal
ls of the INTESTINE.
Serotonin participates in the transmission of nerve impulses and may have a func
tion in controlling mood
and states of consciousness. (See also SELECTIVE SEROTONIN-REUPTAKE INHIBITORS (
SSRIS).)
Serotype A classification of a substance according to its serological ac
tivity. This is done in the
context of the antigens (see ANTIGEN) that it contains, or the ANTIBODIES it may
provoke. Microorganisms of
the same species may be classified according to the different antigens that they
produce.
Serous Relating to, containing or resembling SERUM.
under PERITONEUM.
Serpiginous A term describing a creeping or extending skin lesion such a
s an ULCER.
Serum The fluid which separates from blood, LYMPH, and other body fluids
when clotting occurs (see
COAGULATION; HAEMORRHAGE). PLASMA is the fluid of the blood, including FIBRIN, w
hich carries the
circulating blood cells and PLATELETS.
Serum is a clear, yellowish fluid containing around 7 per cent proteins
and globulins, small quantities
of salts, fat, sugar, urea, and uric acid, and even smaller quantities of immuno
globulins, essential in the
prevention of disease (see IMMUNITY; IMMUNOLOGY). The serum given in the commonl
y used vaccines is
generally derived from horses blood, after they have been subjected to a long cou
rse of treatment.
Serum Sickness A hypersensitivity reaction due to circulating antigen-an
tibody complexes (see ANTIGEN;
ANTIBODIES), so-called because it was a not uncommon reaction to the administrat
ion of foreign SERUM which
used to be given as a form of passive IMMUNITY before the days of antibiotics. B
y definition, it is a
manifestation of sensitivity to serum but the same clinical and pathological pic
ture can occur 13 weeks
after the administration of drugs such as PENICILLIN and STREPTOMYCIN. It is cha
racterised by fever,
ARTHRALGIA and LYMPHADENOPATHY and is
S
an X chromosome fertilises
an ovum (which, as stated, must have an X chromosome) the offspring will be fema
le; if a sperm with a Y
chromosome fertilises the ovum
ferent pairs exchange segments.
usually self-limiting as it resolves when the supply of antigen is used
up.
Serum Therapy See IMMUNOLOGY.
Sesamoid Bones Rounded nodules of bone usually embedded in tendon. They
are usually a few millimetres
in diameter, but some are larger, such as the PATELLA, or knee-cap.
Sessile A growth or tumour that has no stalk.
Severe Acute Respiratory Syndrome (SARS) See SARS.
Sevoflurane
S
Inversion Where a segment of a chromosome becomes detached and re-attach
ed the other way around. GENES
will then appear in the wrong order and thus will not correspond with their oppo
site numbers on homologous
chromosomes.
Duplication Where a segment of a chromosome is included twice over. One
chromosome will have too little
nuclear material and one too much. The individual inheriting too little may be n
on-viable and the one with
too much may be abnormal.
Errors in division of centromere Sometimes the centromere divides transv
ersely instead of
longitudinally. If the centromere is not central, one of the daughter chromosome
s will arise from the two
short arms of the parent chromosome and the other from the two long arms. These
abnormal daughter
chromosomes are called isochromosomes. These changes have important bearings on
heredity, as the effect of
a gene depends not only upon its nature but also upon its position on the chromo
some with reference to
other genes. Genes do not act in isolation but against
Sex Education
the background of other genes. Each gene normally has its own position o
n the chromosome, and this
corresponds precisely with the positon of its allele on the homologous chromosom
e of the pair. Each member
of a pair of chromosomes will normally carry precisely the same number of genes
in exactly the same order.
Characteristic clinical syndromes, due to abnormalities of chromosome structure,
are less constant than
those due to loss or gain of a complete chromosome. This is because the degree o
f deletion, inversion and
duplication is inconstant. However, translocation between chromosomes 15 and 21
of the parent is associated
with a familial form of mongolism (see DOWNS (DOWN) SYNDROME) in the offspring, a
nd deletion of part of an
X chromosome may result in TURNERS SYNDROME.
Non-disjunction Whilst alterations in the structure of chromosomes arise
as a result of deletion or
translocation, alterations in the number of chromosomes usually arise as a resul
t of non-disjunction
occurring during maturation of the parental gametes (germ cells). The two chromo
somes of each pair
(homologous chromosomes) may fail to come together at the beginning of meiosis a
nd continue to lie free. If
one chromosome then passes to each pole of the spindle, normal gametes may resul
t; but if both chromosomes
pass to one pole and neither to the other, two kinds of abnormal gametes will be
produced. One kind of
gamete will contain both chromosomes of the pair, and the other gamete will cont
ain neither. Whilst this
results in serious disease when the autosomes are involved, the loss or gain of
sex chromosomes seems to be
well tolerated. The loss of an autosome is incompatible with life and the malfor
mation produced by a gain
of an autosome is proportional to the size of the extra chromosome carried. Only
a few instances of a gain
of an autosome are known. An additional chromosome 21 (one of the smallest autos
omes) results in mongolism,
and trisomy of chromosome 13 and 18 is associated with severe mental, skeletal a
nd congenital cardiac
defects. Diseases resulting from a gain of a sex chromosome are not as severe. A
normal ovum contains 22
autosomes and an X sex chromosome. A normal sperm contains 22 autosomes and eith
er an X or a Y sex
chromosome. Thus, as a result of nondisjunction of the X chromosome at the first
meiotic division during
the formation of female gametes, the ovum may contain two X chromosomes or none
at all, whilst in the male
the sperm may contain both X and Y chromosomes
(XY) or none at all. (See
641
also CHROMOSOMES;
GENES.)
Sex Education Information given to children and young adults about sexua
l relationships. Evidence
suggests that young people want more information about the emotional aspects of
sexual relationships, and
about homosexuality and AIDS/HIV. There is growing concern about sexual risktaki
ng behaviour among
adolescents, many of whom feel that sex education was provided too late for them
. Although most parents or
guardians provide some guidance by the age of 16, friends, magazines, television
and films are a more
significant source of information. Schools have been targeted as a place to addr
ess and possibly limit
risky behaviour because they are geared towards increasing knowledge and improvi
ng skills, and have a
captive audience of young adults. There are concerns that the conditions in scho
ols may not be ideal: class
time is limited; teachers are often not trained in handling sensitive subjects;
and considerable
controversy surrounds teaching about subjects such as homosexuality. Sex educati
on in schools is regarded
as an effective way of reducing teenaged pregnancy, especially when linked with
contraceptive services.
Several studies have shown that it does not cause an increase in sexual activity
and may even delay the
onset of sexual relationships and lessen the number of partners. Programmes taug
ht by youth agencies may be
even more effective than those taught in the classroom possibly because teaching
takes place in small
groups of volunteer participants, and the programmes are tailored to their targe
t populations. Despite
improvements in sex education, the United Kingdom has the highest incidence of t
eenaged pregnancies in the
European Community. Sex education, including information about AIDS/HIV and othe
r sexually transmitted
infections (STIs), is compulsory in all statemaintained secondary schools in Eng
land and Wales. The
National Curriculum includes only biological aspects of AIDS/HIV, STIs and human
sexual behaviour. All
maintained schools must have a written statement of their policy, which is avail
able to parents. The local
education authority, governing body and headteacher should ensure that sex educa
tion encourages pupils to
have due regard to moral considerations and the value of family life. Sex-educat
ion policies and practices
are monitored by the Office for Standards in Education (OFSTED) and the Office o
f HM
S
Shellfish Poisoning
sexual dysfunction include stress, depression and guilt.
Sexually Transmitted Diseases (STDs) Sexually transmitted diseases tradi
tionally called venereal
diseases are infections transmitted by sexual intercourse (heterosexual and homo
sexual). In the United
Kingdom they are treated in genito-urinary medicine (GUM) clinics. The incidence
s of these diseases are
more common among people who have several sexual partners, as STDs are very infe
ctious; some of the major
STDs, particularly AIDS/HIV, are also transmitted by blood and so can result fro
m needle-sharing by drug
addicts, or by TRANSFUSION. The traditional STDs SYPHILIS, GONORRHOEA and CHANCROI
D now comprise only
10 per cent of all such diseases treated in STD clinics: these clinics also trea
t patients with CHLAMYDIA,
TRICHOMONIASIS, HERPES GENITALIS, MOLLUSCUM CONTAGIOSUM and genital WARTS. SCABI
ES and pubic lice (see
PEDICULOSIS Pediculus pubis) can also be transmitted by sexual intercourse, and
HEPATITIS B is also
recognised as an STD. The incidence of STDs rose sharply during World War II but
the advent of PENICILLIN
and subsequent antibiotics meant that syphilis and gonorrhoea could be treated e
ffectively. The arrival of
oral contraception and more tolerant public attitudes to sexual activities resul
ted in an increase in the
incidence of sexually transmitted infections. The diagnosis of NONSPECIFIC URETH
RITIS (NSU), once given to
many patients whose symptoms were not due to the traditional recognised infectio
ns, was in the 1970s
realised to be wrong, as the condition was proved to be the result of infection
by chlamydia. Most STDs are
treatable, but herpes is an infection that could become chronic, while hepatitis
B and, of course, AIDS/HIV
are potentially fatal although treatment of HIV is now proving more effective. A
s well as the treatment
and subsequent monitoring of patients with STDs, one of the important functions
of clinics has been the
tracing, treatment and follow-up of sexual contacts of infected individuals, a p
rocedure that is conducted
confidentially. Apart from AIDS/HIV, the incidence of STDs fell during the 1980s
; however in some countries
the agents causing syphilis and gonorrhoea began to develop resistance to antibi
otics, which showed the
continued importance of practising safe sex in particular by restricting the num
ber of sexual partners
and ensuring the
643
regular use of condoms. In the United Kingdom the rates per million of
he male population infected by
syphilis rose from 8.8 in 1991 to 9.7 in 1999; in females the figures were 4.0
o 4.5, respectively. For
gonorrhoea, the figures for men were 399.4 in 1991 and 385 in 1999, with women
lso showing a reduction,
from 216.5 to 171.3. In 1991, 552.6 per million of men had chlamydia, a figure
hich rose to 829.5 in 1999;
t
t
a
w
for women in the same period the incidence also rose, from 622.5 to 1,077.1 per
million. For genital herpes
simplex virus, the infection rate for men fell from 236.6 per million to 227.7,
whereas the figures for
women showed a rise, 258.5 to 357. The incidence of AIDS/HIV is given under the
relevant entry. (These
figures are based on information in United Kingdom Health Statistics, 2001 editi
on, UKHSI, published by the
Office of National Statistics.)
Shaken Impact Syndrome A type of non-accidental head-injury to infants.
A study published in 2000
(Lancet, 4 November) suggests that almost 25 out of 100,000 children under a yea
r old sustain brain damage
from shaken impact syndrome, even if they do not strike any hard surface. So, of
around 685,000 babies in
this agegroup in Britain, as many as 170 a year may suffer injury from violent s
haking. The median age for
admission to hospital for the condition in Scotland was 2.2 months in the 18 mon
ths from July 1998. A
Swedish report has concluded that children at risk from CHILD ABUSE can be ident
ified and the incidence
reduced by legislation banning corporal punishment. (See also NON-ACCIDENTAL INJ
URY (NAI).)
Shellfish Poisoning In the United Kingdom this occurs in two main forms.
Shellfish may be the cause of
typhoid fever (see ENTERIC FEVER) as a result of their contamination by sewage c
ontaining the causative
organism. They may also be responsible for what is known as paralytic shellfish
poisoning. This is caused
by a toxin, or poison, known as saxotoxin, which is present in certain planktons
which, under unusual
conditions, multiply rapidly, giving rise to what are known as red tides. In these
circumstances the
toxin accumulates in mussels, cockles and scallops which feed by filtering plank
ton. The manifestations of
such poisoning are loss of feeling in the hands, tingling of the tongue, weaknes
s of the arms and legs, and
difficulty in breathing. There is also growing evidence that some shellfish pois
oning
S
pulse). These signs may be associated with clinical evidence of poor tissue perf
usion, for example to the
brain and kidneys, leading to mental apathy, confusion or restlessness and
S
OLIGURIA.
Shock may result from loss of blood or plasma volume. This may occur as
a result of haemorrhage or
severe diarrhoea and vomiting. It may also result from peripheral pooling of blo
od due to such causes as
TOXAEMIA or ANAPHYLAXIS. The toxaemia is commonly the result of a SEPTICAEMIA in
which leakage through
capillaries reduces circulating blood volume. Another form is called cardogenic
shock, and is due to
failure of the heart as a pump. It is most commonly seen as a result of myocardi
al infarction (see under
HEART, DISEASES OF). If failure of adequate blood flow to vital organs is prolon
ged, the effects can be
disastrous. The ischaemic intestine permits the transfer of toxic bacterial prod
ucts and proteins across
its wall into the blood; renal ISCHAEMIA
Shock Therapy Short-Sight A condition in which objects near at hand are
seen clearly, while objects at
a distance are blurred. The condition is technically known as myopia. (See EYE,
DISORDERS OF Errors of
refraction; VISION.)
Short Stature See DWARFISM.
Shoulder The joint formed by the upper end of the HUMERUS and the should
er-blade or SCAPULA. The
acromion process of the scapula and the outer end of the collar-bone (see CLAVIC
LE) form a protective bony
arch above the joint, and from this arch the wide and thick deltoid muscle passe
s downwards, protecting the
outer surface of the joint and giving to the shoulder its rounded character. The
joint itself is of the
ball-and-socket variety, the rounded head of the humerus being received into the
hollow glenoid cavity of
the scapula, which is further deepened by a rim of cartilage. One tendon of the
biceps muscle passes
through the joint, grooving the humerus deeply, and being attached to the upper
edge of the glenoid cavity.
The joint is surrounded by a loose fibrous capsule, strengthened at certain plac
es by ligamentous bands.
The main strength of the joint comes from the powerful muscles that unite the up
per arm with the scapula,
clavicle and ribs.
Shoulder-blade or scapula. A flat bone, about as large as the flat hand
and fingers, 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 the arm are attached to it.
It is not in contact with the
ribs, and its only attachment to the trunk of the body is through a joint betwee
n its acromion process and
the clavicle on the tip of the shoulder and by the powerful muscles which suspen
d it from the backbone and
ribs. With the arm hanging by the side, the scapula extends from the second to t
he seventh rib, but, as the
arm is raised and lowered, it slides freely over the back of the chest. On the r
ear surface of the bone is
a strong process, the spine of the scapula. This arches upwards and forwards int
o the acromion process. The
latter forms the bony prominence on the top of the shoulder, where it unites in
a joint with the outer end
of the clavicle.
applied to the intense competition that sometimes occurs between brother
s and/or sisters. The birth of
a new baby in the family may prompt jealousy and rivalry that can persist throug
hout life.
Sickle-Cell Anaemia See under ANAEMIA.
Sickness See VOMITING; MOTION (TRAVEL) SICKNESS.
Side-Effects
Passage of blood through a channel that is not its normal one. This may
occur as a result of a
congenital deformity (see SEPTAL DEFECT) or of surgery for example, a porto-cava
l shunt in which the main
portal vein is joined up to the inferior vena cava.
This refers to an effect of a drug which is not that which doctor and pa
tient require. Some
side-effects are almost inevitable: for example, drowsiness with older ANTIHISTA
MINE DRUGS; others are very
rare, such as REYES SYNDROME with ASPIRIN. Some can be predicted to occur if the
dose is raised, while
others may occur at the lowest of doses due to the individual patients susceptibi
lity. In deciding whether
to prescribe or take a drug, a balance must always be struck between its benefit
s and risks. (See also
MEDICINES Safe use of medicines.)
Sialagogues
Siderosis
Substances which produce a copious flow of
Chronic FIBROSIS of the LUNGS occurring in iron-workers and due to the i
nhalation of fine iron
particles. The term is also applied to the condition in which there is an excess
following leakages, so that its use in breast surgery in particular has now been
restricted. RECONSTRUCTIVE
(PLASTIC) SURGERY.
Silicosis The most important industrial hazard in those industries in wh
ich SILICA is encountered: in
other words, the pottery industry, the sandstone industry, sandblasting, metal-g
rinding, the tin-mining
industry, and anthracite coal-mines. It is a specific form of PNEUMOCONIOSIS cau
sed by the inhalation of
free silica. Among pottery workers the condition has for long been known as pott
ers asthma, whilst in the
cutlery industry it was known as grinders rot. For the production of silicosis, t
he particles of silica
must measure 055 micrometres in diameter, and they must be inhaled into the alveol
i (air sacs) of the
lungs, where they produce FIBROSIS. This diminishes the efficiency of the lungs,
resulting in slowly
progressive shortness of breath. The main danger of silicosis, however, is that
it is liable to be
complicated by TUBERCULOSIS. The incidence of silicosis is steadily being reduce
d by various measures which
diminish the risk of inhaling silica dust. These include adequate ventilation to
draw off the dust; the
suppression of dust by the use of water; the wearing of respirators where the ri
sk is particularly great
and it is not possible to reduce the amount of dust for example, in sand-blastin
g; and periodic medical
examination of workpeople exposed to risk. Fewer than 100 new cases a year are d
iagnosed now in the United
Kingdom. (See also OCCUPATIONAL HEALTH, MEDICINE AND DISEASES.)
Simmonds Disease A rare condition in which wasting of the skin and the bo
nes, IMPOTENCE, and loss of
hair (ALOPECIA) occur as a result of destruction of the PITUITARY GLAND.
Simvastatin One of the STATINS a group of LIPID-lowering drugs which are
effective in combination
with a low CHOLESTEROL diet in reducing the incidence of heart attacks (see HEAR
T, DISEASES OF Coronary
thrombosis).
Skeleton
647
Singers Nodule
Sinusoid
A small excrescence on the vocal cords (see LARYNX) which causes hoarsen
ess. This tends to develop in
people who abuse their voices for example, singers, or people who shout excessiv
ely.
A small blood vessel like an enlarged capillary (see CAPILLARIES) occurr
ing, for example, in the LIVER,
which contains a large number of them. The sinusoids in the liver are drained by
the hepatic veins.
Sinoatrial Node
Sinus Tachycardia
This is the natural pacemaker of the HEART, and comprises a collection o
f specialised muscle cells in
the wall of the upper chamber (atrium) of the heart. The cells initiate electric
al impulses at a rate of up
to 100 a minute. These impulses stimulate the muscles of the heart to contract.
The rate is altered by the
effects of certain hormones and various impulses from the nervous system. Damage
or disease of the node
affects the regular beating of the heart. (See also CARDIAC PACEMAKER.)
A regular heart rate of 100 or more beats a minute, caused by increased
electrical activity in the
SINOATRIAL NODE (see also HEART). This level of tachycardia is normal during and
just after exercise, and
may also be caused by stress or anxiety. If tachycardia persists when the person
is resting, it may be due
to underlying disease such as thyrotoxicosis (see under THYROID GLAND, DISEASES
OF) and investigation is
advisable.
Sinus A term applied to narrow cavities of various kinds, occurring natu
rally in the body, or resulting
from disease. Thus it is applied to the air-containing cavities which are found
in the frontal, ethmoidal,
sphenoidal and maxillary bones of the SKULL, and which communicate with the NOSE
. The function of these
paranasal sinuses, as they are known, is doubtful, but they do lighten the skull
and add resonance to the
voice. They enlarge considerably around puberty and in this way are a factor in
the alteration of the size
and shape of the face. The term is also used in connection with the wide spaces
through which the blood
circulates in the membranes (MENINGES) of the BRAIN. Cavities which are produced
when an ABSCESS has burst,
but remain unhealed, are also known as sinuses (see also FISTULA).
Sinusitis Sinusitis is inflammation of the mucosal lining of a SINUS. Th
e term is usually applied to
inflammation of the sinuses in the face. Most cases occur as a result of infecti
on spreading to the sinuses
from the NOSE along the passages that drain mucus secreted by the linings of the
sinuses to the nose. The
bacterial infection usually follows a viral infection of the upper respiratory t
ract. Treatment with
ANTIBIOTICS is usually effective but the condition tends to recur. If the episod
es are severe, they can be
disabling, with bad headaches. Surgery is sometimes necessary to drain the sinus
es. Rarely, sinusitis may
lead to cerebral abscess or venous sinus thrombosis.
SI Units The international system of measurement-units used throughout t
he sciences. SI units, which
derive from metres, kilograms, and seconds, comprise seven basic units and two s
upplementary ones. Among
the other base units are ampere (electric current) and mole (amount of a substan
ce at molecular level).
Derived SI units include joule (energy), pascal (pressure), becquerel (activity)
, and newton (force). (See
APPENDIX 6: MEASUREMENTS IN MEDICINE.)
Sjogrens Syndrome A disorder of CONNECTIVE TISSUE, with dryness of the mo
uth (xerostomia) and dryness
of the eye (kerato conjunctivitis sicca) occurring in association with RHEUMATOI
D ARTHRITIS. It occurs in
approximately 10 per cent of patients with the latter condition, but it can occu
r and frequently does so
independently of rheumatoid disease. The lack of tears gives rise to symptoms of
dryness and grittiness
of the eyes; the dry mouth can occasionally be so severe as to cause a DYSPHAGIA
. The disease is due to the
autoimmune destruction of the SALIVARY GLANDS and the lacrimal glands (see EYE L
acrimal apparatus). The
disorder is usually associated with specific HLA antigen (see HLA SYSTEM). Treat
ment is unsatisfactory and
is limited to oral and ocular hygiene as well as the provision of artificial tea
rs in the form of cellulose
eye drops.
Skeletal Muscle Muscle under a persons voluntary control (see MUSCLE; VOL
UNTARY MUSCLE).
Skeleton The comprehensive term applied to the hard structures that supp
ort or protect the softer
S
648 Skin
tissues of the body. Many animals are possessed of an exoskeleton, consi
sting of superficial plates of
bone, horn, or the like; but in humans the skeleton is entirely an endoskeleton,
covered everywhere by soft
parts and consisting mainly of bones, but in places also of cartilage. The chief
positions in which
cartilage is found in place of bone are the larynx and the front of the chest. (
For details of the
skeleton, see BONE.)
Skin The membrane which envelops the outer surface of the body, meeting
at the bodys various orifices,
with the mucous membrane lining the internal cavities.
Structure
S
CORIUM The foundation layer. It overlies the subcutaneous fat and varies
in thickness from 053.0 mm.
Many nerves run through the corium: these have key roles in the sensations of to
uch, pain and temperature
(see NEURON(E)). Blood vessels nourish the skin and are primarily responsible fo
r regulating the body
temperature. Hairs are bedded in the corium, piercing the epidermis (see below)
to cover the skin in
varying amounts in different parts of the body. The sweat glands are also in the
corium and their ducts
lead to the surface. The fibrous tissue of the corium comprises interlocking whi
te fibrous elastic bundles.
The corium contains many folds, especially over joints and on the palms of hands
and soles of feet with the
epidermis following the contours. These are permanent throughout life and provid
e unique fingerprinting
identification. HAIR Each one has a root and shaft, and its varying tone origina
tes from pigment scattered
throughout it. Bundles of smooth muscle (arrectores pilorum) are attached to the
root and on contraction
cause the hair to stand vertical. GLANDS These occur in great numbers in the ski
n. SEBACEOUS GLANDS secrete
a fatty substance and sweat glands a clear watery fluid (see PERSPIRATION). The
former are made up of a
bunch of small sacs producing fatty material that reaches the surface via the ha
ir follicle. Around three
million sweat or sudoriparous glands occur all over the body surface; sited belo
w the sebaceous glands they
are unconnected to the hairs. EPIDERMIS This forms the outer layer of skin and i
s the cellular layer
covering the body surface: it has no blood vessels and its thickness varies from
1 mm on the palms and
soles to 01 mm on the face. Its outer, impervious, horny layer comprises several
thicknesses of flat cells
(pierced only by hairs and sweat-gland openings) that are constantly rub
bed off as small white scales;
they are replaced by growing cells from below. The next, clear layer forms a typ
e of membrane below which
the granular stratum cells are changing from their origins as keratinocytes in t
Skin, Diseases of 649 LARVA MIGRANS; LICHEN; LUPUS; MADURA FOOT; MELANOMA; MILIA
RIA; MOLLUSCUM
650 Skin-Grafting
Cancer may arise from the population of melanocytes of the skin (see MEL
ANOCYTE; MELANOMA). Apart from
these three most frequent forms of skin cancer, various forms of cancer can aris
e from cells of the dermis,
of which LYMPHOMA is the most important (see also MYCOSIS FUNGOIDES). Lastly, se
condary deposits from
internal cancer, particularly from the breast, may metastasise to the skin.
Dermatitis
S
and eczema These are broadly synonymous, and the terms are frequently in
terchangeable. Eczema is a
pattern of inflammation with many potential causes. Dermatitis is commonly used
to suggest an eczema caused
by external factors; it is a common pattern of inflammation of the skin characte
rised by redness and
swelling, vesiculation (see VESICLE), and scaling with intense itching and often
exudation (weeping).
Fissuring, thickening (lichenification see LICHEN) and secondary bacterial infec
tion may follow.
Dermatitis can affect any part of the body. It may be genetically detemined or d
ue to other internal
factors, such as venous HYPERTENSION in a leg, or stress. Often it is external in
origin due to strong
irritants or chemical allergens. (See also ALLERGY; ALLERGEN.) ATOPIC DERMATITIS
is genetic in origin and
usually begins in infancy. It may persist for years, and ASTHMA, allergic RHINIT
IS and conjunctivitis (see
under EYE, DISORDERS OF) hay fever may be associated. Atopic children tend to have
multiple
allergies, especially to inhaled allergens such as house-dust mite, cat and dog
dander and pollens. Allergy
to foods is less common but potentially more dangerous, especially if to nuts, w
hen it can cause acute
URTICARIA or even ANAPHYLAXIS. Atopic subjects are particularly prone to persist
ent and multiple verrucae
(see WARTS) and mollusca (see MOLLUSCUM CONTAGIOSUM) and to severe HERPES SIMPLE
X infections. (See also
ATOPY.) EXFOLIATE DERMATITIS (PITYRIASIS RUBRA)
Generalised exfoliation and scaling of the skin, commonly with ERYTHEMA.
Drugs may cause it, or the
disorder may be linked with other skin diseases such as benign dermatoses and lu
pus erythematosus (see
under LUPUS). SUMMER POMPHOLYX is an acute vesicular eczema of the palms and sol
es recurring every summer.
Inhaled allergens are a frequent cause. VENOUS (STASIS) DERMATITIS begins on a l
ower calf, often in
association with PURPURA, swelling and sometimes ulceration. Chronic venous
hypertension in the leg, consequent on valvular incompetence in the deep
leg veins owing to previous
deep vein thrombosis (see VEINS, DISEASES OF), is the usual cause. NEURODERMATIT
IS A pattern of
well-defined plaques of lichenified eczema particularly seen on the neck, ulnar
forearms or sides of the
calves in subjects under emotional stress. IRRITANT CONTACT DERMATITIS Most ofte
n seen in an industrial
setting (occupational dermatitis), it is due to damage by strong chemicals such
as cutting oils, cement,
detergents and solvents. In almost all cases the hands are most severely affecte
d. ALLERGIC CONTACT
DERMATITIS, in contrast, can affect any part of the body depending on the cause
for example, the face
(cosmetics), hands (plants, occupational allergens) or soles (rubber boots). Par
ticularly common allergens
include metals (nickel and chromate), rubber addititives, and adhesives (epoxy r
esins).
Treatment Avoidance of irritants and contact allergens, liberal use of E
MOLLIENTS, and topical
application of corticosteroid creams and ointments (see CORTICOSTEROIDS) are cen
tral.
Skin-Grafting An operation in which large breaches of SKIN surface due t
o wounding, burns or ulceration
are closed by TRANSPLANTATION of skin from other parts. There are three methods
by which this is done. Most
frequently the epidermis only is transplanted, using a method introduced by Reve
rdin and by Thiersch, and
known by their names. For this purpose, a broad strip of epidermis is shaved off
the thigh or upper arm,
after the part has been carefully sterilised, and is transferred bodily to the r
aw or ulcerated surface, or
is cut into smaller strips and laid upon it. A second method is for small pieces
of the skin in its whole
thickness to be removed from the arm and thigh, or even from other people, and t
hen implanted and bound
upon the raw surface. (This method has the disadvantage that the true skin must
contract at the spot from
which the graft is taken, leaving an unsightly scar.) When very large areas requ
ire to be covered, a third
method is commonly used. A large flap of skin, amply sufficient to cover the gap
, is raised from a
neighbouring or distant part of the body, in such a way that it remains attached
along one margin, so that
blood vessels can still enter and nourish it. It is then turned so as to cover t
he gap; or, if it be
situated on a distant part, the two parts are brought together and fixed in this
position until the flap
grows firmly to its new bed. The old connection of the
Sleep
flap is then severed, leaving it growing in its new place. Researchers a
re having success in growing
human skin in the laboratory for grafting on to people who have been badly burne
d and have insufficient
intact skin surface to provide an autologous graft (one provided by the recipien
t of the graft). Other
techniques being researched are the use of specially treated shark skin and the
production of artificial
skin.
Sleep Sleep is a state which alternates with wakefulness, and in which a
wareness and responsiveness to
the environment are reduced. It is not, however, uniform and can be divided into
two main states
differentiated according to electrical recordings of brain activity (EEG), of th
e muscles (EMG), and of the
eye movements (EOG).
Non-rapid-eye-movement (NREM) sleep This is subdivided into four stages,
of
Skull This is the collection of 22 flat and irregularly shaped bones whi
ch protect the brain and form
the face (see BONE).
Arrangement of the bones In childhood, the bones are independent, gradua
lly fusing together by sutures,
and in old age fusing completely so that the cranium forms a solid bony case. At
the time of birth the
growth of several bones of the infants head has not been quite completed, so that
six soft spots, or
fontanellas, present; here the brain is covered only by skin and membranes, and
the pulsations of its blood
vessels may be seen. One of these spots, the anterior fontanelle, does not close
completely until the child
is 18 months to 2 years old.
Parts of the skull The cranium, enclosing the brain, consists of eight b
ones, while the face, which
forms a bony framework for the eyes, nose and mouth, consists of 14 bones. These
two parts can be detached.
Shape of the skull The development of large central hemispheres of the b
rain in humans has influenced
the skull shape. Unlike in other mammals, the cranium extends above as well as b
ehind the face which
therefore looks forwards. The skulls proportions change with age: the cranium in
children is larger in
comparison with the face oneeighth of the whole head than is the case in adults,
where sizes are about
the same. Old age reduces the size of the face because of the loss of teeth and
absorption of their bony
sockets. Womens skulls tend to be lighter and smoother with less obvious protuber
ances than those in men.
Slapped Cheek Syndrome See ERYTHEMA
651
Erythema infectiosum.
SLE See SYSTEMIC LUPUS ERYTHEMATOSUS (SLE).
which stage 1 is the lightest and stage 4 the deepest. The activity of t
he cerebral cortex (see BRAIN)
is diminished and the bodys functions are mainly regulated by brain-stem activity
. The metabolic rate is
reduced; in keeping with this the temperature falls, respiration is reduced, car
diac output, heart rate,
and blood pressure fall, and activity of the sympathetic nervous system is reduc
ed. NREM sleep normally
occurs at the onset of sleep except in neonates. During adult life, the duration
particularly of stages 3
and 4 of NREM sleep becomes less, and very little of this deep sleep occurs afte
r the age of 60 years.
NREM sleep has been thought to have several functions, such as energy conservati
on and growth. Growth
hormone is produced in bursts during stages 3 and 4, and more cell division occu
rs during this type of
sleep than during wakefulness. A controversial proposal has been that processing
of information acquired
during wakefulness occurs during NREM sleep.
Rapid-eye-movement (REM) sleep This is characterised by the presence of
rapid eye movements and a
reduction in muscle tone. Cerebral cortical activity is prominent and its blood
flow increased. This
activity is, however, different from wakefulness and may cause irregular movemen
ts of the body as well as
of the eyes. Most dreams occur in REM sleep: these may represent a process of re
organising mental
associations after the period of wakefulness. The analysis of the content of dre
ams has been subject to a
variety of interpretations, but no consensus view has evolved. Physiological cha
nges, such as a fall in
temperature and blood pressure, take place just before sleep and continue during
the early stages of NREM
sleep. There is an intrinsic rhythm of sleep which in most subjects has a period
icity of around 25 hours.
This can be modified by external factors to bring it into line with the 24-hour
day. Two peaks of a
tendency to sleep have been identified, and these usually occur between around 1
4.0018.00 hours, and
S
Smell
neck (Winterbottoms sign) may be striking. Onset of disease is accompanie
d by fever, progressive
ANAEMIA, and enlarged glands; these signs and symptoms are followed by increasin
g lethargy, slowing of
mentality, and physical weakness, and give way to headache and an increasing ten
dency to sleep. These
symptoms are caused by proliferation of parasites in the patients cerebral blood
vessels; this is
accompanied by inflammatory changes and disorganisation of nervous tissue. Patie
nts become emaciated and
develop bed sores. Death finally takes place either as a result of gross emaciat
ion or of an intercurrent
infection. Diagnosis is by detection of trypanosomes in a blood specimen or, alt
ernatively, a sample of
cerebrospinal fluid. Serological tests are of great value in diagnosis. Treatmen
t is with suramine or
pentamidine; when cerebral involvement has ensued, melarsoprol which penetrates
the blood-brain barrier
is of value. In T.b. gambiense infection, eflornithine has recently given encour
aging results; however,
this form of CHEMOTHERAPY is not effective in a T.b. rhodesiense infection. From
the point of view of
prevention, control of the tsetse-fly population is crucial; even so, only a ver
y small percentage of these
vectors is infected with Trypanosoma spp.
Sling A hanging bandage for the support of injured or diseased parts. Sl
ings are generally applied for
support of the upper limb, in which case the limb is suspended from the neck. Th
e lower limb may also be
supported in a sling from an iron cage placed upon the bed on which the patient
lies, the object usually
being to aid the circulation, and so quicken the healing of ulcers on the leg.
Slipped Disc The popular name for a PROLAPSED INTERVERTEBRAL DISC. (See
also SPINAL COLUMN; SCIATICA.)
Slough Slough (pronounced sluff) is dead tissue separated by natural proce
sses from the living body.
The term is applied to hard external parts which the lower animals cast off natu
rally in the course of
growth, like the skin of snakes or the shell of crabs. In humans, however, the p
rocess is generally
associated with disease, and is then known as GANGRENE. Sloughs may be of very s
mall size, as in the case
of the core of a boil, or they may include a whole limb; but in general a slough
involves a limited area of
skin or of the
653
underlying tissues. The process of separation of a slough is described u
nder gangrene.
Small-Bowel Transplantantion Before the advent of small-bowel transplant
s, long-term intravenous
feeding (total parenteral nutrition or TPN) was the last option for patients wit
h chronic intestinal
Sodium Valproate
condition is painful but resolves if the eyes are covered with pads for
a day or two. Prolonged
exposure may seriously damage the cornea and impair vision.
Snuffles The traditional name applied to noisy breathing in children due
to the constant presence of
nasal discharge. (For treatment, see under NOSE, DISORDERS OF.)
Social Classes As factors such as the cause of death and the incidence o
f diseases vary in different
social strata, the Registrar-General evolved the following social classification
, which has now been in
official use for many years:
Class I Professional occupations, such as lawyers, clergymen, and commis
sioned officers in the Armed
Forces.
Class II Intermediate occupations, such as teachers, managers and nurses
.
Class III N: non-manual for example, clerical workers.
Class III M: skilled manual occupations such as miners and bricklayers.
Class IV Partly skilled occupations, such as agricultural workers.
Class V Unskilled occupations, such as building and dock labourers.
Social Medicine See PUBLIC HEALTH.
Sodium A metal, the salts of which are white, crystalline, and very solu
ble. The fluids of the body
contain naturally a considerable quantity of sodium chloride.
Sodium carbonate, commonly known as soda or washing soda, has a powerful
softening action upon the
tissues.
Sodium bicarbonate, or baking soda, is used as an antacid (see ANTACIDS)
in relieving indigestion
associated with increased acidity of the gastric secretion. The citrate and the
acetate of sodium are used
as DIURETICS.
655
Sodium Aurothiomalate A gold compound given by deep intramuscular inject
ion in the treatment of
RHEUMATOID ARTHRITIS in children and adults. Known as a second-line or disease-m
odifying antirheumatoid
drug, its therapeutic effect may take up to six months to achieve a full respons
e. If this fails to happen,
the drug should be stopped. If the patient responds, treatment may be continued
at increasingly long
intervals (up to four weeks) for as long as five years. Gold treatment is partic
ularly useful for
palindromic arthritis in which the disease comes and goes.
Sodium Chloride The chemical name for common salt (see SODIUM).
Sodium Cromoglycate Used in the prophylaxis of ASTHMA, it is administere
d by inhalation and can reduce
the incidence of asthmatic attacks but is of no value in the treatment of an acu
te attack. It acts by
preventing the release of pharmacological mediators of BRONCHOSPASM, particularl
y HISTAMINE, by stabilising
mast-cell membranes. It is of particular use in patients whose asthma has an all
ergic basis; children over
four may respond better than adults. It is less potent than inhaled steroids. Th
e dose frequency is
adjusted to the patients response but is usually administered by inhalation four
times daily. Sodium
cromoglycate is also used in the prophylaxis of allergic RHINITIS and to treat a
llergic conjunctivitis (see
under EYE, DISORDERS OF).
Sodium Diatrizoate An organic iodine salt that is radio-opaque and there
fore used as a contrast medium
to outline various organs in the body in X-ray films (see XRAYS). It is given in
travenously. Its main use
is in PYELOGRAPHY that is, in rendering the kidneys radio-opaque but it is also
used to outline the
blood vessels (ANGIOGRAPHY) and the gall-bladder and bile ducts (CHOLANGIOGRAPHY
).
Sodium Hypochlorite A disinfectant by virtue of the fact that it gives o
ff chlorine. For domestic use
as, for example, for sterilising baby feeding bottles it is available in a varie
ty of proprietary
preparations.
Sodium Valproate A drug of first choice for the treatment of several for
ms of EPILEPSY, including
primary generalised epilepsy, generalised absences and myoclonic seizures; it ma
y also be tried in
S
656 Sodomy
atypical absence, atonic and tonic seizures. Usually taken orally, the d
rug has shown promising initial
results from controlled trials in partial epilepsy. It probably has similar effi
cacy to CARBAMAZEPINE and
PHENYTOIN SODIUM. Sodium valproate has widespread metabolic effects and may have
dose-related side-effects.
There has been concern over severe hepatic or pancreatic toxicity, but such adve
rse effects are rare. Other
adverse effects include digestive upsets, drowsiness, muscle incoordination and
skin rashes. Rare reports
have been given of behavioural disturbances, with occasional aggression. Initiat
ion and withdrawal of
treatment should always be slow. Patients should reduce their alcohol intake; an
y other drugs they are
taking that are metabolised by the liver should be carefully monitored.
ERANCE to the volatile substances may develop over months, but acute int
oxication may lead to
aggressive and impulsive behaviour. Treatment of addiction is difficult and requ
ires professional
counselling. Victims with acute symptoms require urgent medical attention. In Br
itain, most solvent
misusers are males under 20 years of age. Around 150 deaths occur every year. (S
ee also DEPENDENCE.)
Sodomy
A group of disorders in which the affected individuals suffer from repea
ted physical symptoms for which
no physical cause can be discovered. Somatisation is the process by which a pers
ons psychological needs
are expressed in the form of physical symptoms. (See also PSYCHOSOMATIC DISEASES
.)
Sexual intercourse in which the penis penetrates the anus and the rectum
. Sodomy may occur between men,
between a man and a woman, or between a man and an animal (bestiality).
Solar Plexus A large network of sympathetic nerves and ganglia situated
in the abdomen behind the
stomach, where it surrounds the coeliac artery. Branches of the VAGUS nerve the
most important part of
the PARASYMPATHETIC NERVOUS SYSTEM lead into the solar plexus, which in turn dis
tributes branches to the
stomach, intestines and several other abdominal organs. A severe blow in the sol
ar plexus may cause
temporary unconsciousness.
Solution A liquid preparation containing one or more soluble drugs, usua
lly dissolved in water.
S Solvent Abuse (Misuse) Also known as volatile-substance abuse, this is
the deliberate inhalation of
intoxicating fumes given off by some volatile liquids. Glue-sniffing was the mos
t common type of solvent
abuse, but inhalation of fuel gases such as butane, especially in the form of li
ghter refills, is now a
greater problem and has become common among children particularly teenagers. Sol
vents or volatile
substances are applied to a piece of cloth or put into a plastic bag and inhaled
, sometimes until the
person loses consciousness. He or she may become acutely intoxicated; chronic ab
users may suffer from
ulcers and rashes over the face as well as damage to peripheral nerves. Death ca
n occur, probably as a
result of an abnormal rhythm of the heart. TOLSomatic (1) A term describing tissues of the body that do not form any p
art of the reproductive
process. A somatic MUTATION cannot be passed on to the next generation. (2) It i
s also used to refer to the
body rather than the mind (see PSYCHOSOMATIC DISEASES).
Somatoform Diseases
Somatostatin Also known as the growth-hormone-releaseinhibiting factor,
this is a hormone secreted by
the HYPOTHALAMUS and some non-nervous tissues (including the gastrointestinal tr
act and pancreas). It stops
the pituitary-releasing somatotrophin GROWTH HORMONE. Somatostatin and growth-ho
rmone-releasing hormone
are controlled by complicated neural mechanisms linked to exercise, sleep patter
ns, stress,
NEUROTRANSMITTERS and blood GLUCOSE.
Somatotype The physical build of a person. Attempts have been made to li
nk body build with personality
type, but with no great success. One approach is to classify people as endomorph
s (heavy physique and
sociable personality); mesomorphs (strong, muscular build with well-developed bo
nes linked with a
physically adventurous temperament); and ectomorphs (thin and lightly built with
an introspective nature).
Somnambulism Sleep-walking. (See SLEEP.)
Soporifics Soporifics are measures which induce (See also HYPNOTICS.)
Sore Sore is a popular term for ULCER.
SLEEP.
Specialist
Sore Throat A raw sensation at the back of the throat. A common symptom,
the cause is usually
PHARYNGITIS, sometimes TONSILLITIS. It is often the presenting symptom of colds,
INFLUENZA, LARYNGITIS and
infectious MONONUCLEOSIS. Sore throats caused by streptococcal infection (see ST
REPTOCOCCUS) should be
treated with antibiotics, as should other bacteria-initiated sore throats; other
wise, symptomatic treatment
with analgesics and antiseptic gargles is sufficient for this usually self-limit
ing condition.
Sotalol See BETA-ADRENOCEPTOR-BLOCKING DRUGS.
Sound A rod with a curve at one end used to explore body cavities such a
s the bladder, or to dilate
strictures in the urethra or other channels in the body. (See URINARY BLADDER, D
ISEASES OF.)
Soya Bean The bean of Glycine soja, a leguminous plant related to peas a
nd beans. It has a high protein
and fat content. Starch is almost completely absent and there is much mineral ma
tter, for example a
variable but large amount of iron: 67 to 30 mg per 100 grams of soya flour compar
ed with 1 mg in white
flour and 3 mg in 100 grams of wholemeal flour. It is a good source of thiamine
and riboflavine, and of
vitamin A in the form of carotene. It is used in infant formulas, especially for
those babies thought to
have cows milk protein intolerance.
Space Medicine A medical specialty dealing with the physiological, PSYCH
OLOGICAL and pathological
consequences of space flight in which the body has to cope with unusual variatio
ns in gravitational forces,
including weightlessness, a constricted environment, prolonged close contact wit
h work colleagues in very
demanding technical circumstances, and sustained periods of emotional pressure i
ncluding fear. Enormous
progress has been made in providing astronauts with as normal an environment as
possible, and they have to
undergo prolonged physical and mental training before embarking on space travel.
Spanish Fly A popular term for cantharides, which is used as a blisterin
g agent.
Spasm An involuntary, and, in severe cases, painful
657
contraction of a muscle or of a
may be due to affections in
the muscle where the spasm takes place,
of that part of the nervous
system which controls the spasmodically
re are usually spoken of as
CONVULSIONS; spasms of a painful nature
ISORDERS OF) when they
affect the muscles of the limbs, and as
658 Specificity
up-to-date. For doctors, the GENERAL MEDICAL which is responsible for ov
erseeing the training and
registration of all medical doctors in the UK, also notes in its annual Medical
Register those doctors who
have completed appropriate specialist training. Doctors who have qualified and t
rained overseas have to
pass appropriate GMC tests before they can practise in the UK. COUNCIL (GMC),
Specificity An epidemiological term (see EPIDEMIOLOGY) describing the ex
tent to which a SCREENING TEST
for the presence of the precursors of disease for example, pre-malignant cells i
n the cervix throws up
false positives. A specific test has few false positives.
Speculum An instrument designed to aid the examination of the various op
enings on the surface of the
body. Many specula are provided with small electric lamps so placed as to light
up the cavity of the mouth,
ear, nose, rectum or vagina.
Speech Disorders
S
These may be of physical or psychological origin or a combination of bot
h. Difficulties may arise at
various stages of development: due to problems during pregnancy; at birth; cause
d by childhood illnesses;
or as a result of delayed development. Congenital defects such as CLEFT PALATE o
r lip may make speech
unintelligible until major surgery is performed, thus discouraging talking and d
elaying development.
Recurrent ear infections may make hearing difficult; the childs experience of spe
ech is thus limited, with
similar results. Childhood DYSPHASIA occurs if the language-development area of
the BRAIN develops
abnormally; specialist education and SPEECH THERAPY may then be required. Dumbne
ss is the inability to
pronounce the sounds that make up words. DEAFNESS is the most important cause, b
eing due to a congenital
brain defect, or acquired brain disease, such as tertiary SYPHILIS. When hearing
is normal or only mildly
impaired, dumbness may be due to a structural defect such as tongue-tie or enlar
ged tonsils and adenoids,
or to inefficient voice control, resulting in lisping or lalling. Increased tens
ion is a common cause of
STAMMERING; speech disorders may occasionally be of psychological origin. Normal
speech may be lost in
adulthood as a result of a STROKE or head injury. Excessive use of the voice may
be an occupational hazard;
and throat cancer may require a LARYNGECTOMY,
with subsequent help in communication. Severe psychiatric disturbance ma
y be accompanied by impaired
social and communication skills. (See also VOICE AND SPEECH.)
Treatment The underlying cause of the problem should be diagnosed as ear
ly as possible; psychological
and other specialist investigations should be carried out as required, and any p
hysical defect should be
repaired. People who are deaf and unable to speak should start training in lip-r
eading as soon as possible,
and special educational methods aimed at acquiring a modulated voice should simi
larly be started in early
childhood provided by the local authority, and continued as required. Various ty
pes of speech therapy or
PSYCHOTHERAPY may be appropriate, alone or in conjunction with other treatments,
and often the final result
may be highly satisfying, with a good command of language and speech being obtai
ned. Help and advice may be
obtained from AFASIC (Unlocking Speech and Language).
Speech Therapy Professionally trained speech therapists assist, diagnose
and treat the whole spectrum
of acquired or developmental communication disorders. They work in medical and e
ducation establishments,
often in an advisory or consultative capacity. The medical conditions in which s
peech therapy is employed
include: dysgraphia, DYSLEXIA, DYSARTHRIA, DYSPHASIA, DYSPHONIA, DYSPRAXIA, AUTI
SM, BELLS PALSY, CEREBRAL
PALSY, DEAFNESS, disordered language, delayed speech, disordered speech, DOWNS (D
OWN) SYNDROME,
LARYNGECTOMY, LEARNING DISABILITY, MACROGLOSSIA, MOTOR NEURONE DISEASE (MND), ma
lformations of the PALATE,
PARKINSONISM, STAMMERING, STROKE and disorders of voice production. Speech thera
pists form a small
independent profession, most of whom work for the National Health Service in com
munity clinics, general
practices and hospitals. They may also work in schools or in units for the handi
capped, paediatric
assessment centres, language units attached to primary schools, adult training c
entres and day centres for
the elderly. A speech therapist undergoes a four-year degree course which covers
the study of disorders of
communication in children and adults, phonetics and linguistics, anatomy and phy
siology, psychology and
many other related subjects. Further information on training can be obtained fro
m the College of Speech
Therapists. If the parents of a child are concerned about
Sphygmomanometer
their childs speech, they may approach a speech therapist for assessment
and guidance. Their general
practitioner will be able to give them local addresses or they should contact th
e district speech
therapist. Adults are usually referred by hospital consultants. The College of S
peech Therapists keeps a
register of all those who have passed a recognised degree or equivalent qualific
ation in speech therapy. It
will be able to direct you to your nearest NHS or private speech therapist.
659
spermatozoon travels at a rate of 153 millimetres a minute and remains mob
ile for several days after
insemination, but quickly loses its potency for fertilisation. As it takes only
about 70 minutes to reach
the ovarian end of the uterine tube, it is assumed that there must be factors ot
her than its own mobility,
such as contraction of the muscle of the womb and uterine tube, that speed it on
its way.
Spermicide
Spermatic
Contraceptive preparations that kill sperm. They may be in the form of g
els, pessaries, cream or foam
and should be used with a barrier contraceptive such as a diaphragm or a condom.
(See CONTRACEPTION.)
The name applied to the blood vessels and other structures associated wi
th the TESTICLE.
Sphenoid
Spermatic Cord
A bone lying in the centre of the base of the SKULL, and supporting the
others like a wedge or
keystone.
Sperm See SPERMATOZOON.
This comprises the VAS DEFERENS, nerves and blood vessels, and it runs f
rom the cavity of the ABDOMEN
to the TESTICLE in the SCROTUM.
Spermatogenesis The production of mature sperm (see SPERMATOZOON) in the
testis (see TESTICLE). The
sperm cells originate from the outermost layer of the seminiferous tubules in th
e testis: these multiply
throughout reproductive life and are transformed into mature spermatozoa, a proc
ess that takes up to 80
days.
Spermatorrhoea
Sphincter A circular muscle which surrounds the opening from an organ, a
per cent of all cases. Usually affecting the lumbo-sacral region, the range of s
everity may vary
considerably and, while early surgery with careful attention in a minor case may
achieve good mobility,
normal bladder function and intellect, a more extensive protrusion may cause com
plete ANAESTHESIA of the
skin, with increased risk of trauma; extensive paralysis of the trunk and limbs,
with severe deformities;
and paralysis and insensitivity of the bladder and bowel. Involuntary movements
may be present, and
hydrocephalus occurs in 80 per cent of cases. The decision to operate can only b
e made after a full
examination of the infant to determine the extent of the defect and any co-exist
ent congenital
abnormalities. The childs potential can then be estimated, and appropriate treatm
ent discussed with the
parents. Carefully selected patients should receive long-term treatment in a spe
cial centre, where full
attention can be paid to all their various problems. There is growing evidence o
f the value of vitamin
supplements before and during pregnancy in reducing the incidence of spina bifid
a. Parents of affected
infants may obtain help, advice, and encouragement from the Association for Spin
a Bifida and Hydrocephalus
which has branches throughout the country, or the Scottish Spina Bifida Associat
ion.
Spinal Anaesthesia See under ANAESTHESIA.
Spinal Column Also known as the spine, this forms an important part of t
he skeleton, acting both as the
rigid pillar which supports the upper parts of the body and as a protection to t
he SPINAL CORD and nerves
arising from it. The spinal column is built up of a number of bones placed one u
pon another, which, in
consequence of having a slight degree of turning-movement, are known as the vert
ebrae. The possession of a
spinal cord supported by a vertebral column distinguishes the higher animals fro
m the lower types, and is
why they are called vertebrates. Of the vertebrates, humans alone stand absolute
ly erect, and this erect
carriage of the body gives to the skull and vertebral column certain distinctive
characters. 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 from above. (Top) the spinal column.
inches) in length, and varies little in full-grown people; differences i
n height depend mainly upon the
length of the lower limbs. The number of vertebrae is 33 in children, although i
n adult life five of these
fuse together to form the sacrum, and the lowest four unite in the coccyx, so th
at the number of separate
bones is reduced to 26. Of these there are seven in the neck, known as cervical
vertebrae; 12 with ribs
attached, in the region of the thorax known as thoracic or dorsal vertebrae; fiv
e in the loins, called
lumbar vertebrae; five fused to form the sacrum; and four joined in the coccyx.
These
numbers are expressed in a formula thus: C7, D12, L5, S5, Coc4=33. Altho
ugh the vertebrae in each of
these regions have distinguishing features, all the vertebrae are constructed on
the same general plan.
Each has a thick, rounded, bony part in front, known as the body, and these bodi
es form the main thickness
of the column. Behind the body of each is a ring of bone, the neural ring, these
rings placed one above
another forming the bony canal which lodges the spinal cord. From each side of t
he ring a short process of
bone known as the transverse process stands out, and
S
which arises by an anterior and a posterior root that join before the nerve emer
ges from the spinal canal.
The openings for the nerves formed by notches on the ring of each vertebra have
been mentioned under the
entry for spinal column. To reach these openings, the upper nerves pass almost d
irectly outwards, whilst
lower down their obliquity increases, until below the point where the cord ends
there is a sheaf of nerves,
known as the cauda equina, running downwards to leave the spinal canal at their
appropriate openings. The
cord is a cylinder, about the thickness of the little finger. It has two slightl
y enlarged portions, one in
the lower part of the neck, the other at the last dorsal vertebra; and from thes
e thickenings arise the
nerves that pass to the upper and lower limbs. The upper four cervical nerves un
ite to produce the cervical
plexus. From this the muscles and skin of the neck are mainly supplied, and the
phrenic nerve, which runs
down through the lower part of the neck and the chest to innervate the diaphragm
, is given off. The
brachial plexus is formed by the union of the lower four cervical and first dors
al nerves. In addition to
nerves to some of the muscles in the shoulder region, and others to the skin abo
ut the shoulder and inner
side of the arm, the plexus gives off large nerves that proceed down the arm. Th
e thoracic or dorsal
nerves, with the exception of the first, do not form a plexus, but each runs aro
und the chest along the
lower margin of the rib to which it corresponds, whilst the lower six extend on
to the abdomen. The lumbar
plexus is formed by the upper four lumbar nerves, and its branches are distribut
ed to the lower part of the
abdomen, and front and inner side of the thigh. The sacral plexus is formed by p
arts of the fourth and
fifth lumbar nerves, and the upper three and part of the fourth sacral nerves. M
uch of the plexus is
collected into the sciatic nerves, the largest in the body, which go to the legs
. The sympathetic system is
joined by a pair of small branches given off from each spinal nerve, close to th
e spine. This system
consists of two parts, first, a pair of cords running down on the side and front
of the spine, and
containing on each side three ganglia in the neck, and beneath this a ganglion o
pposite each vertebra. From
the cord consists of the fasciculus gracilis and the fasciculus cuneatus, both c
onveying sensory
impressions upwards. The lateral column contains the ventral and the dorsal spin
o-cerebellar tracts passing
to the cerebellum, the crossed pyramidal tract of motor fibres carrying outgoing
impulses downwards
together with the rubro-spinal, the spino-thalamic, the spino-tectal, and the po
stero-lateral tracts. And,
finally, the anterior column contains the direct pyramidal tract of motor fibres
and an anterior mixed
zone. The pyramidal tracts have the best-known course. Starting from cells near
the central sulcus on the
brain, the motor nerve-fibres run down through the internal capsule, pons, and m
edulla, in the lower part
of which many of those coming from the right side of the brain cross to the left
side of the spinal cord,
and vice versa. Thence the fibres run down in the crossed pyramidal tract to end
beside nerve-cells in the
anterior horn of the cord. From these nerve-cells other fibres pass outwards to
form the nerves that go
direct to the muscles. Thus the motor nerve path from brain to muscle is divided
into two sections of
neurons, of which the upper exerts a controlling influence upon the lower, while
the lower is concerned in
maintaining the muscle in a state of health and good nutrition, and in directly
calling it into action.
(See also NERVE; NERVOUS SYSTEM.)
Spine and Spinal Cord, Diseases and Injuries of Scoliosis A condition wh
ere the spine is curved to one
side (the spine is normally straight when seen from behind). The deformity may b
e mobile and reversible, or
fixed; if fixed it is accompanied by vertebral rotation and does not disappear w
ith changes in posture.
Fixed scoliosis is idiopathic (of unknown cause) in 6580 per cent of cases. There
are three main types:
the infantile type occurs in boys under three and in 90 per cent of cases resolv
es spontaneously; the
juvenile type affects 49 year olds and tends to be progressive. The most common t
ype is adolescent
idiopathic scoliosis; girls are affected in 90 per cent of cases and the inciden
ce is 4 per cent. Treatment
may be conservative with a fixed brace, or surgical fusion may be needed if the
curve is greater than 45
degrees. Scoliosis can occur as a congenital condition and in neuromuscular dise
ases where there is
S
664 Spiramycin
muscle imbalance, such as in
FRIEDREICHS
ATAXIA.
Kyphosis is a backward curvature of the spine causing a hump back. It ma
y be postural and reversible in
obese people and tall adolescent girls who stoop, but it may also be fixed. Sche
uermanns disease is the
term applied to adolescent kyphosis. It is more common in girls. Senile kyphosis
occurs in elderly people
who probably have osteoporosis (bone weakening) and vertebral collapse. Disc deg
eneration is a normal
consequence of AGEING. The disc loses its resiliance and becomes unable to withs
tand pressure. Rupture
(prolapse) of the disc may occur with physical stress. The disc between the four
th and fifth lumbar
vertebrae is most commonly involved. The jelly-like central nucleus pulposus is
usually pushed out
backwards, forcing the annulus fibrosus to put pressure on the nerves as they le
ave the spinal canal. (See
PROLAPSED INTERVERTEBRAL DISC.)
Ankylosing spondylitis is an arthritic disorder of the spine in young ad
ults, mostly men. It is a
familial condition which starts with lumbar pain and stiffness which progresses
to involve the whole spine.
The discs and ligaments are replaced by fibrous tissue, making the spine rigid.
Treatment is physiotherapy
and anti-inflammatory drugs to try to keep the spine supple for as long as possi
ble. A National Association
for Ankylosing Spondylitis has been formed which is open to those with the disea
se, their families, friends
and doctors.
S
plaint is of pain after exercise. Treatment is bed rest in a bad attack
with surgery indicated only if
there are worrying signs of cord compression.
Spinal stenosis is due to a narrowing of the spinal canal which means th
at the nerves become squashed
together. This causes numbness with pins and needles (paraesthia) in the legs. C
OMPUTED TOMOGRAPHY and
nuclear magnetic resonance imaging scans can show the amount of cord compression
. If improving posture does
not help, surgical decompression may be needed.
Whiplash injuries occur to the neck, usually as the result of a car acci
dent when the head and neck are
thrown backwards and then forwards rapidly. This causes pain and stiffness in th
e neck; the arm and
shoulder may feel numb. Often a support collar relieves the pain but recovery co
mmonly takes between 18
months to three years.
Spleen
Spiritual Pain Spiritual pain is what may be felt when one of a persons f
our key spiritual
relationships (with other people, with oneself, with the world around, or with Li
fe itself ) is
traumatised or broken. A bad trauma in one of the first three relationships can
lead to damage to the last
of them that of the relationship with Life itself. For example, a wife deserted
by her husband for
another woman may not only feel devastated by the loss of her partner around the
place, but may also feel a
pain caused by the shattering of her beliefs about life (about faithfulness, hop
e, love, security, etc.).
It is as if there is a picture at the centre of each person of what life should
be about whether or not
held in a frame by a belief in God; this picture can be smashed by a particular
trauma, so that nothing
makes sense any more. The individual cannot get things together; everything lose
s its meaning. This
shattering of someones picture of life is the source of the deepest pain in any s
piritual trauma. The
connection is often made between spiritual pain and meaninglessness. If the shat
tering of the picture, on
the other hand, is done by the individual for instance, by breaking his or her o
wn moral or religious
code the pain may take the form of guilt and associated feelings. Hence, the the
rapist will be intent
upon helping a client to recognise and come to terms with this pain beneath the p
ain.
665
output of aldosterone in oedematous conditions (see OEDEMA) such as cong
estive heart failure, which
accentuates the oedema spironolactone is used, along with other DIURETICS.
Splanchnic Anything belonging to the internal organs of the body, as dis
tinguished from its framework.
Spleen An organ deeply placed in the abdomen and a major constituent of
the RETICULOENDOTHELIAL SYSTEM.
Position and size The spleen lies behind the stomach, high up on the lef
t side of the abdomen, and
corresponds to the position of the ninth, tenth and 11th ribs, from which it is
separated by the diaphragm.
It is a soft, highly vascular, plum-coloured organ, and has a smooth surface. It
is usually about 12515
cm (56 inches) in length, and weighs about 170 grams or more. In diseased conditi
ons the organ may reach a
weight of 89 kg.
Structure The spleen is enveloped by peritoneal membrane beneath which i
s a strong elastic tunic,
composed partly of fibrous tissue
Spirochaete An order of bacteria which has a spiral form. (See MICROBIOL
OGY.)
Spirometer A device to test how the lung is working (see also to assess
the effects of lung disease or
the progress of treatment a procedure called spirometry. The spirometer records
the total volume of air
breathed out the forced vital capacity. The machine also records the volume of a
ir breathed out in one
second the forced expiratory volume. In diseases such as ASTHMA, in which the ai
rways are obstructed, the
ratio of the forced expiratory volume to the forced vital capacity is reduced. (
See RESPIRATION.) PULMONARY
FUNCTION TESTS)
S
Spironolactone One of the group of substances known as spirolactones. Th
ese are steroids similar to
ALDOSTERONE in structure which competitively act as inhibitors of it; they can t
hus antagonise the action
of aldosterone in the renal tubules. As there is evidence that there is an incre
ased
Cross-section of cone of tissue from spleen.
Sports Medicine
Splenomegaly Enlargement of the size.
SPLEEN
667
Sporadic beyond its normal
Splinter Haemorrhages Linear bleeding under the fingernails. Although th
ey may result from injury, they
are a useful physical sign of infective ENDOCARDITIS.
Splints Supports for an injured or wounded part. They are most commonly
employed in cases in which a
bone is fractured, and consist then of some rigid substance designed to take the
place of the broken bone
in maintaining the shape of the limb, as well as to keep the broken ends at rest
and in contact and so
ensure their union. Splints are most commonly made of wood, either shaped to the
limb or consisting merely
of strips of wood about the width of the injured limb, and carefully padded with
wool or similar soft
material. Splints are also made of metal, poroplastic felt, leather, and cotton
stiffened with plaster of
Paris, as well as other materials. Splints may be improvised for first-aid out o
f walking-sticks, rifles,
broom-handles, branches, folded-up newspapers, and in fact anything of suitable
length and rigidity. (See
also BONE, DISORDERS OF Bone fractures.)
Spondylitis Another name for
ARTHRITIS of the spine (see SPINE AND SPINAL CORD, DISEASES AND INJURIES
OF).
Spondylolisthesis See SPINE AND SPINAL CORD, DISEASES AND INJURIES OF.
Spondylosis See SPINE AND SPINAL CORD, DISEASES AND INJURIES OF.
Spongiform Encephalopathy A disease of the neurological system caused by
a PRION. Spongy degeneration
of the BRAIN occurs with progressive DEMENTIA. Known examples of the disorder in
humans are
CREUTZFELDT-JAKOB DISEASE (CJD) and KURU. Among animals, scrapie in sheep and BO
VINE SPONGIFORM
ENCEPHALOPATHY (BSE) are caused by slow viruses. The latter has occurred as an o
utbreak in cattle over the
past decade or so, probably as a result of cattle being fed processed offal from
infected animals. Some
people have developed a form of CJD from eating infected beef.
The term applied to cases of disease occurring here and there, as oppose
d to EPIDEMIC outbreaks.
Spore Part of the lifecycle of certain BACTERIA when the vegetative cell
is encapsulated and metabolism
falls to a low level. The spore is resistant to changes in the environment and,
when these are
unfavourable, the spore remains dormant; when they improve, it starts to grow. C
ertain dangerous bacteria,
such as CLOSTRIDIUM, produce resistant ubiquitous spores, so sterilisation proce
dures need to be very
effective.
Sporozoa The name of a group of parasitic PROTOZOA which includes the pa
rasitic Plasmodium that causes
MALARIA. The life-cycles of sporozoa are complex, often with sexual and asexual
stages.
Sporozoites Sporozoites is one cell type of the many that are formed dur
ing the life-cycle of SPOROZOA.
In the case of MALARIA, sporozoites pass into the salivary glands of the mosquit
o and and are the infecting
agent of the human host when the insect next feeds on human blood.
Sports Medicine The field of medicine concerned with physical fitness an
d the diagnosis and treatment
of both acute and chronic sports injuries sustained during training and competit
ion. Acute injuries are
extremely common in contact sports, and their initial treatment is similar to th
at of those sustained in
other ways, such as falls and road traffic incidents. Tears of the muscles (see
MUSCLES, DISORDERS OF),
CONNECTIVE TISSUE and LIGAMENTS which are partial (sprains) are initially treate
d with rest, ice,
compression, and elevation (RICE) of the affected part. Complete tears (rupture)
of ligaments (see
diagrams) or muscles, or fractures (see BONE, DISORDERS OF Bone fractures) requi
re more prolonged
immobilisation, often in plaster, or surgical intervention may be considered. Th
e rehabilitation of injured
athletes requires special expertise an early graded return to activity gives the
best long-term results,
but doing too much too soon runs the risk of exacerbating the original injury. C
hronic (overuse) injuries
affecting the bones (see BONE), tendons (see TENDON) or BURSAE of the JOINTS are
common in many sports.
Examples include chronic INFLAMMATION of the common extensor tendon where it
S
Sputum 669
Anterior view of right knee-joint.
players returning to their activity before they are properly fit sometim
es by using physical or
pharmaceutical aids. This practice can adversely affect their long-term physical
capabilities and perhaps
their general health.
ference with the absorption of carbohydrates, vitamins, and minerals, le
ading to anaemia and
HYPOCALCAEMIA.
Symptoms Of gradual or rapid onset, there is
Also called FLOATERS, these can arise from a variety of causes including
inflammation and bleeding in
the eye, or preceding a retina detachment. They may also occur for a variety of
totally harmless reasons.
(See EYE, DISORDERS OF.)
initial weakness, soreness of the tongue, difficulty swallowing, indiges
tion, diarrhoea and poor
appetite. Anaemia is typically macrocytic, and mild HYPOGLYCAEMIA may occur. Unt
reated, the patient
steadily loses weight and, unless appropriate treatment is started early, death
may be expected because of
exhaustion and some intercurrent infection.
Spotted Fever
Treatment This consists of bed rest, a highSee MENINGITIS; EPIDEMIC; TYPHUS FEVER.
protein diet (initially skimmed milk), and treatment of the anaemia and
any other deficiencies present.
Minimum fat should be given to sufferers, who should also take folic acid and cy
anocobalamin for the
anaemia; large vitamin-B-complex supplements (such as Marmite ) are helpful. Vitam
ins A and D, together
with calcium supplements, help to raise the concentration of calcium in the bloo
d. A long convalescence is
often required, which may lead to marked depression, and patients should be sent
home to a temperate
climate. Non-tropical sprue is the result of GLUTEN hypersensitivty and is treat
ed with a gluten-free diet.
Spots Before the Eyes
Sprains Injuries in the neighbourhood of joints, consisting usually in t
earing of a ligament with
effusion of blood. (See JOINTS, DISEASES OF.)
Sprue A disease occurring most commonly in patients in or from the tropi
cs, and characterised by
diarrhoea with large, fatty stools; ANAEMIA; sore tongue; and weight loss. Its m
anifestations resemble
those of non-tropical sprue, or gluten enteropathy, and COELIAC DISEASE.
670 Squill
allergy (ASTHMA) or by breathing-in irritants such as tobacco smoke, smo
ke from a fire, or fumes from
chemical materials. Sputum is normally white, but infection will turn it to yell
ow or green, and blood from
the lungs may produce pink frothy sputum. Treatment is to deal with the underlyi
ng disorder. Production of
large quantities of sputum for instance, in BRONCHIECTASIS may require physiothe
rapy also and postural
drainage. (See EXPECTORATION.)
Squill A herbal extract (from a type of lily) that is included in some o
ver-the-counter cough remedies
because of its believed expectorant properties (see EXPECTORATION).
Squint Squint, or strabismus, is a condition in which the visual axes of
each EYE are not directed
simultaneously at the same fixation point (i.e. each eye is not pointing at the
same object at the same
time). Squints may be: (a) Paralytic, where one or more of the muscles, or their
nerve supply, is damaged;
this type usually results in double vision. (b) Non-paralytic, where the muscles
and nerves are normal. It
is usually found in children. This type of squint can either result in poor visi
on, or occasionally may
result from poor vision. Squints may be convergent (where one eye turns in) or div
ergent (one eye turns
out). Vertical squints can also occur but are less common. All squints should be
seen by an eye specialist
as soon as possible. Some squints can be corrected by exercises or spectacles; o
thers require surgery.
SSRIs S
See SELECTIVE SEROTONIN-REUPTAKE INHIBITORS (SSRIS).
Stabs See WOUNDS.
Staghorn Calculus A branched renal stone formed in the image of the coll
ecting system of the kidney
(see KIDNEYS). It fills the calyces and pelvis and is commonly associated with a
n infection of the urine,
particularly Proteus vulgaris. The calculus may lead to pyonephrosis and an ABSC
ESS of the kidney.
Stammering A disruption of the forward flow of speech. The individual kn
ows what he or she wants to
say,
but temporarily loses the ability to execute linguistically formulated s
peech. Stammering is
characterised by a silent or audible involuntary repetition/prolongation of an u
tterance, be it a sound,
syllable or word. Sometimes it is accompanied by accessory behaviours, or speech
related struggle. Usually
there are indications or the report of an accompanying emotional state, involvin
g excitement, tension, fear
or embarrassment. Idiopathic stammering begins at some time between the onset of
speech and puberty, mostly
between 25 years of age. Acquired stammering at a later age due to brain damage i
s rare. The prevalence of
stammering (the percentage of the population actually stammering at any point in
time) is approximately 09
per cent. Three times as many boys as girls stammer. About 70 per cent of stamme
ring children recover with
little or no therapy. Stammerers have not been shown to demonstrate differences
in personality from
non-stammerers; there are, however, indications that at least some stammerers sh
ow minimal differences from
fluent speakers in cerebral processing of verbal material. There is a genetic pr
edisposition towards
stammering. The risk of stammering among first-degree relatives of stammerers is
more than three times the
population risk. In 77 per cent of identical twins, either both stammer or both
are fluent. Only 33 per
cent of non-identical twins agree in this way. As there are identical twins who
differ for stammering,
environmental factors must be important for some stammerers. There are relativel
y large numbers of
stammerers in highly competitive societies, where status and prestige are import
ant and high standards of
speech competence are valued. Different treatments have been demonstrated to pro
duce considerable benefit,
their basic outline being similar. A long period of time is spent in training st
ammerers to speak in a
different way (fluency-shaping techniques). This may include slowing down the ra
te of speech, gentle onset
of utterance, continuous flow with correct juncturing, etc. When the targets hav
e been achieved within the
clinic, a series of planned speech assignments outside the clinic is undertaken.
In these assignments, and
initially in everyday situations, the fluency-enchancing techniques have to be u
sed conscientiously.
Gradually speech is shaped towards normality requiring less and less effort. The
rapy may also include some
work on attitude change (i.e. helping the client to see him or herself as a flue
nt speaker)
Statins
and possibly general communicative skills training. For information abou
t organisations concerned with
stammering, see Appendix 2.
671
A statistical measure of the spread of observations about their arithmet
ic mean. It is a measure
regularly used in working out the results of trials about clinical treatment.
ous enzymes (see ENZYME) such as the PTYALIN of the SALIVA. Starch forms
a chief constituent of the
carbohydrate foods (see DIET); and in the process of digestion, the above-mentio
ned change takes place to
prepare it for absorption. It is also slowly broken down in the process of cooki
ng. Starch is used as a
constituent of dusting powders for application to chafed or irritable areas of t
he skin.
Stannosis
Starvation
The form of PNEUMOCONIOSIS caused by the inhalation of stannous (tin) ox
ide, which occurs in tin-ore
mining.
A condition that results from a lack of food for a long time. The person
suffers weight loss and
changes in the bodys METABOLISM, with production of potentially harmful chemicals
called ketones (see
KETONE) and ACETONE. Sometimes starvation may occur as a result of an eating dis
order (see EATING DISORDERS
Anorexia nervosa). In cases of slow starvation, the vitality of the tissues is r
educed and they become
more liable to tuberculosis and other diseases. (See also FASTING.)
Standard Deviation
Stanozolol See ANABOLIC STEROIDS.
Stapedectomy An operation on the middle EAR to remove the STAPES and rep
lace it with an artificial
alternative. The procedure is aimed at treating DEAFNESS caused by otosclerosis
in which the stapes becomes
fixed by an overgrowth of bone, preventing it from transmitting sound. Stapedect
omy improves hearing in
around 90 per cent of those people who have the operation. (See EAR, DISEASES OF
.)
Stapes The innermost of the small trio of bones in the middle EAR. It is
stirrup-shaped, articulates
with the incus, and is linked to the oval window of the inner ear.
Staphylococcus Staphylococcus is a genus of gram-positive bacterium (see
GRAMS STAIN; BACTERIA) which
under the microscope appears in small masses like bunches of grapes. It is one o
f the most common
infectious micro-organisms and is found, for example, in the PUS discharged from
BOILS (FURUNCULOSIS). (See
also MICROBIOLOGY.)
Starch A substance belonging to that group of carbohydrate known as the
amyloses. It is the form in
which utilisable CARBOHYDRATE is stored in granules within the seeds and roots o
f many plants. Starch is
converted into sugar when treated with heat in presence of a dilute acid. It is
changed largely into
dextrin when exposed to a considerable degree of dry heat, as in toasting bread;
and a similar change into
dextrin and malt-sugar takes place under the action of variStasis A term applied to stoppage of the flow of blood in the vessels or
of the food materials down the
intestinal canal.
STAT An abbreviation (for statim) meaning straightaway usually applying
to a request by a doctor for
a drug to be given without delay.
Statins A group of LIPID-lowering drugs used to treat primary hyperchole
sterolaemia a condition in
which the concentrations of LIPOPROTEINS in the blood plasma are raised, increas
ing the likelihood of
affected individuals developing coronary heart disease. Statins act by competiti
vely inhibiting an ENZYME
called 3-hydroxy-3methylglutaryl coenzyme A (HMG CoA) reductase. This enzyme pla
ys a part in the synthesis
of CHOLESTEROL, particularly in the LIVER. Statins are more effective than other
classes of drugs in
lowering body concentrations of LDL-cholesterol but less effective than fibrates
in reducing triglyceride
concentration. Their use results in significant reductions in heart attacks (myo
cardial infarctions) and
other adverse cardiovascular events, such as STROKE. Recent research shows that
drugs which reduce lipid
concentrations may prevent as many as one-third of myocardial infarctions and de
aths from coronary disease.
Statins are valuable in preventing coronary events in patients at increased risk
of those conditions. They
should
S
Status Epilepticus
Steatoma A fatty, cystic tumour.
Steatorrhoea Any condition characterised by the passing of stools (FAECE
S) containing an excess of FAT.
(See MALABSORPTION SYNDROME.)
Stem Cell Stem
CELLS
develop a few days after an egg
S (ovum) is fertilised by a spermatozoon and starts developing to form a
n EMBRYO. These master cells
are crucial to the development of a normal embryo. They contain a specialised EN
ZYME that gives them the
facility to divide indefinitely, developing into the many different specialised
cells that comprise the
various tissues in the body for example, skin, blood, muscle, glands or nerves.
In a highly significant
advance in research, a scientific team in the United States obtained stem cells
from newly formed human
embryos donated by women who had become pregnant after successful in vitro ferti
lisation and
successfully cultivated these cells in the laboratory. This achievement opened t
he way to replicating in
the laboratory, the various specialised
Stent A surgical device used to assist the healing of an operative anast
amosis a joining-up of two
structures. A splint is left inside the lumen of a duct and this drains the cont
ents.
Stereognosis The faculty of recognising the solidity of objects, and thu
s their nature, by handling
them.
Stereotaxis The procedure using computer-controlled Xray images whereby
precise localisation in space
is achieved. It is applied to that branch of surgery known as stereotactic neuro
surgery, in which the
surgeon is able to localise precisely those areas of the brain on which he or sh
e wishes to operate.
Sterilisation Sterilisation means either (1) the process of rendering va
rious objects such as those
which
Stigma
come in contact with wounds, and various foods free from microbes, or (2
) the process of rendering a
person incapable of producing children. The manner of sterilising bedding, furni
ture, and the like, after
contact with a case of infectious disease, is given under DISINFECTION; whilst t
he sterilisation of
instruments, dressings, and skin surfaces, necessary before surgical procedures,
is mentioned in the same
article and also under ANTISEPTICS, ASEPSIS, and WOUNDS. For general purposes, o
ne of the cheapest and most
effective agents is boiling water or steam.
Bacteriological
sterilisation may be effected in many ways, and different methods are us
ed in different cases.
Reproductive sterilisation In women, this is performed by ligating (cutting) and
then tying the FALLOPIAN
TUBES the tubes that carry the OVUM from the ovary (see OVARIES) to the UTERUS.
Alternatively, the tubes
may be sealed-off by means of plastic and silicone clips or rings. The technique
is usually performed (by
LAPAROSCOPY) through a small incision, or cut, in the lower abdominal wall. It h
as no effect on sexual or
menstrual function, and, unlike the comparable operation in men, it is immediate
ly effective. The
sterilisation is usually permanent (around 005 pregnancies occur for every 100 wo
men years of use), but
occasionally the two cut ends of the Fallopian tubes reunite, and pregnancy is t
hen again possible. Removal
of the uterus and/or the ovaries also sterilises a woman but such procedures are
only used when there is
some special reason, such as the presence of a tumour. The operation for sterili
sing men is known as
VASECTOMY.
Sterility The state of (1) being free of infectious agents or (2) perman
ent INFERTILITY.
Sternum The scientific name for the breastbone. This is a long, flat, bo
ny plate that comprises the
central part of the chest. Made up of three parts: an upper triangular piece (ma
nubrium); a middle part
(the body); and at the bottom end the small, flexible xiphoid process. The two c
lavicles articulate to the
manubrium. Seven pairs of costal cartilages link the sternum to the ribs. The st
ernum is very strong and a
powerful blow is needed to fracture it: such an injury may damage the underlying
heart and lungs.
673
Steroid The group name for compounds that resemble CHOLESTEROL chemicall
y. The group includes the sex
hormones, the hormones of the adrenal cortex, and bile acids. They have a powerf
ul influence on the normal
functioning of the body, and natural and synthetic steroids are used in the trea
tment of many disorders.
674 Stilboestrol
physical defects that are found in people with learning disabilities (se
e LEARNING DISABILITY).
Stilboestrol A synthetic oestrogen (see OESTROGENS). Its physiological a
ctions are closely similar to
those of the natural ovarian hormone, and it has the great merit of being active
when taken by mouth. The
drug may help patients suffering from cancer of the PROSTATE GLAND, inducing in
some cases regression of
the primary tumour and of secondary deposits in bone.
Stilboestrol Diphosphate See OESTROGENS.
Stilet A stilet, or stilette, is the delicate probe or the wire used to
clear a catheter (see
CATHETERS) or hollow needle.
Stillbirth A stillborn child is any child which has issued forth from its
mother after the 24th week
of pregnancy and which did not at any time after being completely expelled from
its mother, breathe or show
any other sign of life. In the United Kingdom in 2002 the number of stillbirths a
nd deaths at under one
week of age (PERINATAL MORTALITY) was 5.6 per 1,000 live births.
Stills Disease Or juvenile rheumatoid arthritis see JUVENILE IDIOPATHIC A
RTHRITIS (JIA).
Stimulant
S
A drug or other agent that prompts the activity of a body system or func
tion. For example, the sight
and smell of food stimulates salivation, and the rods and cones in the retina of
the eye are stimulated by
light. Another example is the use of amphetamines and caffeine to stimulate the
central nervous system and
make an individual more alert and active or, if taken in excess, hyperactive. In
treatment procedures,
electrical stimulation may be used to bring muscles into action. Aromatics, spic
es and bitters are
traditional stimulants of digestive processes.
Stings See BITES AND STINGS.
Stitch A popular name for a sharp pain in the side. It is generally due
to cramp (see MUSCLES, DISfollowing unusually hard exertion, but care must be taken that this triv
ial condition is not taken for
PLEURISY or for a fractured rib. The word is also used to mean the repair of ski
n following surgery or any
other trauma. ORDERS OF)
St Johns Wort A herbal remedy which has achieved popularity as a treatmen
t for mild depression. It
may, however, induce the production of enzymes (see ENZYME) that metabolise drug
much greater than for patients with duodenal ulcer who have not had surg
ery.
Stress
gastritis Acute stress gastritis develops, sometimes within hours, in in
dividuals who have undergone
severe physical trauma, BURNS (Curling ulcers), severe SEPSIS or major diseases
such as heart attacks,
strokes, intracranial trauma or operations (Cushings ulcers). The disorder presen
ts with multiple
superficial erosions or ulcers of the gastric mucosa, with HAEMATEMESIS and MELA
ENA and sometimes with
perforation when the acute ulcers erode through the stomach wall. Treatment invo
lves inhibition of gastric
secretion with intravenous infusion of an H2-receptorantagonist drug such as RAN
ITIDINE or FAMOTIDINE, so
that the gastric contents remain at a near neutral pH. Despite treatment, a few
patients continue to bleed
and may then require radical gastric surgery. Gastric ulcer Gastric ulcers were
common in young women
during the 19th century, markedly fell in frequency in many western countries du
ring the first half of the
20th century, but remained common in coastal northern Norway, Japan, in young Au
stralian women, and in some
Andean populations. During the latter half of this century, gastric ulcers have
again become more frequent
in the West, with a peak incidence between 55 and 65 years. The cause is not kno
wn. The two factors most
strongly associated with the development of duodenal ulcers gastric-acid product
ion and gastric infection
with H. pylori bacteria are not nearly as strongly associated with gastric ulcer
s. The latter occur with
increased frequency in individuals who take aspirin or NSAIDs. In healthy indivi
duals who take NSAIDs, as
many as 6 per cent develop a gastric ulcer during the first week of treatment, w
hile in patients with
rheumatoid arthritis who are being treated long term with drugs, gastric ulcers
occur in 2040 per cent.
The cause is inhibition of the enzyme cyclo-oxygenase, which in turn inhibits th
e production of
repairpromoting PROSTAGLANDINS. Gastric ulcers occur especially on the lesser cu
rve of the stomach. The
ulcers may erode through the whole thickness of the gastric wall, perforating in
to the peritoneal cavity or
penetrating into liver, pancreas or colon. Gastric ulcers usually present with a
history of epigastric pain
of less than one year. The pain tends to be associated with anorexia and may be
aggravated by food,
although patients with prepyloric ulcers may obtain relief from eating
Strabismus
or taking antacid preparations. Patients with gastric ulcers also compla
in of nausea and vomiting, and
lose weight. The principal complications of gastric ulcer are haemorrhage from a
rterial erosion, or
perforation into the peritoneal cavity resulting in PERITONITIS, abscess or fist
ula. Aproximately one in
two gastric ulcers heal spontaneously in 23 months; however, up to 80 per cent of t
he patients relapse
within 12 months. Repeated recurrence and rehealing results in scar tissue aroun
d the ulcer; this may cause
a circumferential narrowing a condition called hour-glass stomach. The diagnosis o
f gastric ulcer is
confirmed by ENDOSCOPY. All patients with gastric ulcers should have multiple bi
opsies (see BIOPSY) to
exclude the presence of malignant cells. Even after healing, gastric ulcers shou
ld be endoscopically
monitored for a year. Treatment of gastric ulcers is relatively simple: a course
of one of the H2 RECEPTOR
ANTAGONISTS heals gastric ulcers in 3 months. In patients who relapse, long-term
indefinite treatment with
an H2 receptor antagonist such as ranitidine may be necessary since the ulcers t
end to recur. Recently it
has been claimed that gastric ulcers can be healed with a combination of a bismu
th salt or a gastric
secretory inhibitor for example, one of the PROTON PUMP INHIBITORS such as omepr
azole or lansoprazole
together with two antibiotics such as AMOXYCILLIN and METRONIDAZOLE. The long-te
rm outcome of such
treatment is not known. Partial gastrectomy, which used to be a regular treatmen
t for gastric ulcers, is
now much more rarely done unless the ulcer(s) contain precancerous cells.
677
pernicious anaemia, postgastrectomy mucosa, and atrophic gastritis (see
above). Around 90 per cent of
gastric cancers have the microscopic appearance of abnormal mucosal cells (and a
re called
adenocarcinomas). Most of the remainder look like endocrine cells of lymphoid tiss
ue, although tumours
with mixed microscopic appearance are common. Early gastric cancer may be sympto
mless and, in countries
like Japan with a high frequency of the disease, is often diagnosed during routi
ne screening of the
population. In more advanced cancers, upper abdominal pain, loss of appetite and
loss of weight occur. Many
present with obstructive symptoms, such as vomiting (when the pylorus is obstruc
ted) or difficulty with
swallowing. METASTASIS is obvious in up to two-thirds of patients and its presen
ce contraindicates surgical
cure. The diagnosis is made by endoscopic examination of the stomach and biopsy
of abnormal-looking areas
of mucosa. Treatment is surgical, often with additional chemotherapy and radioth
erapy.
Stomach Tube A soft rubber or plastic tube with rounded end, and usually
about 75 cm (30 inches) in
length, which is used for washing out the stomach when it contains some poisonou
678 Strain
Strain Stretching or tearing of muscle fibres caused by subjecting them
to sudden pulling. Bleeding
into the muscle causes pain and swelling and sometimes muscle spasm. Application
of ice packs and
strapping, coupled with a day or twos rest and analgesics, are usually sufficient
to remedy most strains.
Sometimes antiinflammatory drugs or physiotherapy may be required.
Strangulation The constriction of a passage or tube in the body that blo
cks the blood flow and disturbs
the working of the affected organ. It is usually caused by compression or twisti
ng. Strangulation
customarily occurs when part of the INTESTINE herniates either inside the abdome
n or outside as in an
inguinal HERNIA. If a section of the intestine twists, this may strangulate and
is known as a VOLVULUS.
Strangulation of a persons neck, either with a ligature or with the hands, obstru
cts the jugular veins in
the neck, preventing the normal outflow of blood from the brain and head. The TR
ACHEA is also compressed,
cutting off the supply of air to the lungs. The combination of these effects lea
ds to HYPOXIA and damage to
the brain. If not quickly relieved, unconsciousness and death follow. Strangulat
ion may be deliberate or
accidental the latter being a particular hazard for children, for example, when
playing with a rope.
Removal of the constriction, artificial respiration, and medical attention are u
rgently necessary.
Strangury
S
A condition in which there is constant desire to pass water, accompanied
by a straining sensation,
though only a few drops can be voided. It is a symptom of inflammation in the ur
inary tract.
and symptoms range from minor discomfort to sore throat, fever, general
malaise and enlarged LYMPH
nodes in the neck. If symptoms are severe the infection may lead to SCARLET FEVE
R. PENICILLIN is the
treatment of choice.
Streptococcus Streptococcus is a variety of gram-positive bacterium (see
GRAMS STAIN; BACTERIA) which
under the microscope has much the appearance of a string of beads. Most species
are saprophytic (see
SAPROPHYTE); a few are PATHOGENIC and these include haemolytic types which can d
estroy red blood cells in a
culture of blood agar. This offers a method of classifying the varying streptoco
ccal strains.
Alphahaeomolytic streptococci are usually associated with bacterial ENDOCARDITIS
. SCARLET FEVER is caused
by a -haeomolytic streptococcus called S. pyogenes. S. pneumoniae, also called PN
EUMOCOCCUS, causes
respiratory-tract infections, including PNEUMONIA. S. pyogenes may on its own, o
r with other acteria,
Stroke 679
griseus, first isolated in 1944 and the first antiiotic to e effective
against the tuercle acillus.
It was once routinely used to treat TUBERCULOSIS; ecause of side-effects and th
e development of other
drugs, it is now rarely used except for in cases of resistant tuerculosis. One
of the AMINOGLYCOSIDES,
streptomycin has two disadvantages. The most important of these is the tendency
of organisms to ecome
resistant to it. This means that the administration of this antiiotic must e c
arefully supervised to
ensure that correct dosage is eing used. The other disadvantage is that strepto
mycin produces toxic
effects, especially disturance of the vestiular and hearing apparatus. This ma
y result in DEAFNESS,
VERTIGO, and TINNITUS. Whilst in many cases these toxic manifestations disappear
when the antiiotic is
withdrawn, they may e permanent. For this reason therefore streptomycin must al
ways e used with special
care.
Stress Any factor or event that threatens a persons health or adversely a
ffects his or her normal
functioning. Injury, disease or worry are common examples; others include intern
al conflicts, emotive life
events such as the death of a close relative or friend, the irth of a ay, sep
aration or divorce
pressures at work or a hostile environment such as war or famine. Some individua
ls seem to e more prone
than others to develop medical prolems related to stress. Stress prompts the o
dy to raise its output of
HORMONES such as ADRENALINE and CORTISOL, causing changes in lood pressure, hea
rt rate and metaolism.
These are physiological responses intended to improve a persons physical and ment
al performance the
fight or flight reaction to fear. Stress may, however, disrupt the aility to cope
. Constant or recurrent
exposure to stress may produce symptoms such as anxiety, depression, headaches,
indigestion, diarrhoea,
palpitations and general malaise (see POST-TRAUMATIC STRESS DISORDER (PTSD)). Tr
eatment can e difficult
and prolonged; counselling can help as can ANXIOLYTICS or ANTIDEPRESSANT DRUGS
ut a change in jo or
lifestyle may e necessary in some circumstances.
training. The main initial feature is pain over the affected one that h
as een sujected to anormal
physical stress. This is usually insidious in onset, and worse at night and duri
ng and after exercise. It
is accompanied y tenderness, and a lump may e felt over the affected site. Xra
y evidence only appears
after several weeks. Treatment consists of rest, some form of external support,
and in the initial stage
ANALGESICS to deaden or kill the pain. (See also BONE, DISORDERS OF Bone fractur
es.)
Striae Stretch-marks seen in the skin, common in adolescent oys and gir
ls owing to stretching of the
skin y rapid growth (striae distensae). In oys, striae occur around the should
680 Stroma
which are associated with a higher incidence of strokes) or eing occlud
ed y lood clots arising from
distant organs such as infected heart valves or larger clots in the heart (see B
LOOD CLOT; THROMBOSIS).
Hearts with an irregular rhythm are especially prone to develop clots. Patients
with thick or viscous
lood, clotting disorders or those with inflamed arteries for example, in SYSTEM
IC LUPUS ERYTHEMATOSUS
(SLE) are particularly in danger of having strokes. Bleeding into the rain aris
es from areas of weakened
lood vessels, many of which may e congenital.
Symptoms Minor episodes due to temporary lack of lood supply and oxygen
(called TRANSIENT ISCHAEMIC
ATTACKS OR EPISODES (TIA, TIE)) are manifested y short-lived weakness or
numness in an arm or leg and may precede a major stroke. Strokes cause
sudden weakness or complete
paralysis of the muscles controlled y the part of the rain affected, as well a
s sensory changes (e.g.
numness or tingling). In the worst cases these symptoms and signs may e accomp
anied y loss of
consciousness. If the stroke affects the area of the rain controlling the laryn
x and throat, the patient
may suffer slurring or loss of speech with difficulty in initiating swallowing.
When the face is involved,
the mouth may droop and the patient drile. Strokes caused y haemorrhage may
e preceded y headaches.
Rarely, CVAs are complicated y epileptic fits (see EPILEPSY). If, on the other
hand, numerous small clots
develop in the rain rather than one major event, this may manifest itself as a
gradual deterioration in
the patients mental function, leading to DEMENTIA.
Investigations Tests on the heart or S
COMPUTED TOMOGRAPHY or ultrasonic ULTRASOUND) on arteries in the neck
scans (see may indicate the original sites of distantly arising clots. B
lood tests may show increased
thickness or tendency to clotting, and the diagnosis of general medical conditio
ns can explain the presence
of inflamed arteries which are prone to lock. Special rain X-rays show the pos
ition and size of the
damaged rain tissue and can usually distinguish etween a clot or infarct and a
rupture of and haemorrhage
from a lood vessel in the rain.
Management It is etter to prevent a stroke than try to cure it. The con
trol of a persons diaetes or
high lood pressure will reduce the risk of a stroke. Treatment with ANTICOAGULA
NTS prevents the formation
of clots; regular
small doses of aspirin stop platelets clumping together to form plugs in
lood vessels. Both treatments
Suarachnoid Haemorrhage
defect, with weight loss. During the migratory phase an itchy linear ras
h (larva currens) may e
present on the lower adomen, uttocks, and groins; this gives rise to recurrent
transient itching. In an
immunosuppressed individual, the hyperinfection syndrome may ensue; migratory larv
ae invade all organs
and tissues, including the lungs and rain. Associated with this widespread infe
ction, the patient may
develop an Enteroacteriacae spp. SEPTICAEMIA; this, together with S. stercorali
s larvae, produces a
MENINGOENCEPHALITIS. There is no evidence that this syndrome is more common in p
atients with HIV infection.
Diagnosis consists of visualisation of S. stercoralis (larvae or adults) in a je
junal iopsysection or
aspirate. Larvae may also e demonstrale in a faecal sample, especially followi
ng culture. Eosinophilia
may e present in peripheral lood, during the invasive stage of infection. Chem
otherapy consists of
alendazole. The formerly used enzimidazole compound, thiaendazole, is now rar
ely prescried in an
uncomplicated infection due to unpleasant side-effects; even so, in the hyperinfe
ction syndrome it
proaly remains the more effective of the two compounds.
Strychnine An alkaloid (see ALKALOIDS) derived from Strychnos nux-vomica
, the seeds of an East Indian
tree, as well as from the seeds of several other closely allied trees and shrus
. It is a white crystalline
ody possessed of an intensely itter taste, more itter perhaps than that of an
y other sustance, and it
is not very solule in water. It stimulates all parts of the nervous system, and
was at one time widely
used for this purpose. Strychnine poisoning is fortunately rare. It shows itself
in CONVULSIONS, which come
on very speedily after the person has taken the poison. The mental faculties rem
ain unaffected, and the
symptoms end in death or recovery within a few hours.
Treatment The patient should e kept quiet. Artificial respiration may
e necessary and intravenous
BENZODIAZEPINES to prevent convulsions may also e needed. (See POISONS; also AP
PENDIX 2: ADDRESSES:
SOURCES OF INFORMATION, ADVICE, SUPPORT AND SELFHELP.)
Stupor See UNCONSCIOUSNESS.
Stuttering See STAMMERING.
681
St Vituss Dance An osolete name for CHOREA.
Stye See under EYE, DISORDERS OF.
Styptics Applications which check leeding, either y making the lood v
essels contract more firmly or
y causing rapid clotting in the lood (see COAGULATION). Some possess oth mode
s of action.
Sudural Relating to the space etween the strong outer layer of the MEN
INGES, the memranes which
cover the BRAIN, and the arachnoid, which is the middle layer of the meninges. A
sudural haemorrhage
occurs when leeding takes place
A term used to indicate that the wom (see UTERUS) has failed to undergo
the usual involution, or
decrease in size, which naturally takes place within one month after a child is
orn.
Sujective A term applied to symptoms, and sensations, perceived only y
the affected individual. For
example, numness is a purely sujective sensation, whilst the jerk given y the
leg on tapping the tendon
of the knee is an ojective sign.
Sulimation The conversion of a solid sustance into a vapour and its re
condensation. The term is also
used in a mental sense for the process of converting instinctive sexual desires
to new aims and ojects
devoid of sexual significance.
Suluxation A partial dislocation of a joint; the term is sometimes appl
ied to a sprain.
Sumucosa The layer of CONNECTIVE TISSUE that occurs under a MUCOUS MEMB
RANE for example, in the
intestinal wall.
Suphrenic Ascess An
ABSCESS that develops PHRAGM, usually on the right
under the DIAside of the adomen etween the liver and the diaphragm. Th
e cause may e an organ that
has perforated for instance, a peptic ulcer in the stomach or intestine. An asc
ess may also occur after
an adominal operation, usually when the owel or stomach has een operated on.
Antiiotics and sometimes
surgery are the method of treatment.
Sustrate A compound on which an ENZYME acts: for instance, rionucleic
acid (RNA) is the sustrate for
rionuclease (an enzyme that catalyses the reakdown of rionucleic acid, a cell
ular compound involved in
the synthesis of PROTEIN).
Suicide
683
Succussion
Sudeks Atrophy
See THRILL.
Osteoporosis (see under BONE, DISORDERS OF) in the hand or foot which de
velops quickly as a result of
injury, infection or malignant growth.
A clinical technique in which a patient suspected of having excessive fl
uid in a ody cavity usually
the stomach or pleural cavity is gently shaken in order to elicit splashing soun
ds.
Suckling See INFANT FEEDING.
Sucrose Cane sugar.
Suction The use of a reduction in pressure to clear away fluids or other
material through a tue.
Suction is used to remove lood from the site of a surgical operation; it is com
monly necessary to remove
secretions from the airways of newly orn aies to help them reathe.
Sudden Infant Death Syndrome (SIDS) Sudden infant death syndrome, or cot
death, refers to the
unexpected death usually during sleep of an apparently healthy ay. Well over 1
,500 such cases are
thought to have occurred in the United Kingdom each year until 1992, when govern
ment advice was issued
aout laying aies on their acks. The figure was 192 in 2002 and continues to
fall. Boys are affected
more than girls, and over half of these deaths occur at the age of 26 months. Mor
e common in lower social
classes, the incidence is highest in the winter; most of the infants have een
ottle-fed (see also INFANT
FEEDING).
Causes These are unknown, with possile multiple aetiology. Prematurity
and low irthweight may play a
role. The sleeping position of a ay and an over-warm environment may e major
factors, since deaths have
fallen sharply since mothers were officially advised to place aies on their a
cks and not to overheat
them. Some deaths are proaly the result of respiratory infections, usually vir
al, which may stop
reathing in at-risk infants, while others may result from the infant ecoming s
mothered in a soft pillow.
Faults in the ays central reathing control system (central APNOEA) may e a fa
ctor. Other possile
factors include poor socioeconomic environment; vitamin E deficiency; or smoking
, drug addiction or anaemia
in the mother. Help and advice may e otained from the Foundation for the Study
of Infant Deaths and the
Cot Death Society.
684 Sulcus
cent will succeed in killing themselves over the following few years. In
young people, factors linked
to suicide and attempted suicide include alcohol or drug ause, unemployment, ph
ysical or sexual ause, and
the fact of eing in custody. (In the mid-1990s, 20 per cent of all prison suici
des were y people under
21.) Apart from the young, those at highest risk of dying y suicide include hea
lth professionals,
pharmacists, vets and farmers. Self-poisoning (see POISONS) is the common method
used y health
professionals for whom high stress levels, together with relatively easy access
to means, are important
factors. The World Health Organisation has outlined six asic steps for the prev
ention of suicide, focusing
particularly on reducing the availaility of common methods. Although suicide is
not a criminal offence in
the UK, assisting suicide is a crime carrying a potential sentence of 14 years im
prisonment. There are
several dilemmas faced y health professionals if they elieve that a patient is
considering suicide: one
is that the provision of information to the patient may make them an accessory (
see elow). A dilemma after
suicide is the common demand from insurers for medical information, although, et
hically, the duty of
confidentiality extends eyond the patients death (see ETHICS). (Legally, some di
sclosure is permitted to
those with a claim arising from the patients death.) Life-insurance contracts gen
erally render invalid any
claim y the heirs on the policy of an individual who commits suicide, so that d
isclosure y a doctor often
creates tensions with the relatives. Non-disclosure of relevant medical informat
ion, however, may result in
a fraudulent insurance claim eing made.
Physician-assisted suicide
S
Although controversial, a special legal exemption applies to doctors in
a few countries who assist
terminally ill patients to kill themselves. Oregon in the United States legalise
d physician-assisted
suicide in 1997, where it still occurs; assisted suicide was riefly legal in th
e Australian Northern
Territory in 1996 ut the legislation was repealed. (It is also practised, ut n
ot legally authorised, in
the Netherlands and Switzerland.) In the UK there have een unsuccessful parliam
entary attempts to legalise
assisted suicide, such as the 1997 Doctor Assisted Dying Bill. In law, a distinc
tion is made etween
killing people with their consent (classified as murder) and assisting them to c
ommit suicide (a statutory
offence under the Suicide Act 1961). The distinction is etween acting as a perp
etrator and as an
accessory. Doctors may e judged to
have aided and aetted a suicide if they knowingly provide the means or
even if they simply provide
advice aout the toxicity of medication and tell patients the lethal dosage. Som
e argue that the
distinction etween EUTHANASIA and physician-assisted suicide has no moral or pr
actical relevance,
particularly if patients are too disaled to act themselves. In theory, patients
retain ultimate control in
cases of assisted suicide, whereas control rests with the doctor in euthanasia.
Surveys of health
professionals appear to indicate a feeling y some that less responsiility or c
ulpaility attaches to
assisting suicide than to euthanasia. In a recent UK court case (2002), a judge
declared that a mentally
alert woman on a permanent life-support regime in hospital had a right to ask fo
r the support system to e
switched off. (See also MENTAL ILLNESS.)
Sulcus The term applied to any groove or furrow, ut especially to a fis
sure of the BRAIN.
Sulfadiazine A highly active drug which in moderate dosage produces a hi
gh and persistent lood
concentration. It is relatively non-toxic and is sometimes used to prevent the r
ecurrence of RHEUMATIC
FEVER.
Sulfamethoxazole has een used in comination with TRIMETHOPRIM (as co-t
rimoxazole) to treat infections
of the URINARY TRACT. Increasing acterial resistance to sulphonamides and the i
ncidence of side-effects
means that caution is needed in prescriing co-trimoxazole.
Sulfasalazine A chemical comination of sulphapyridine and 5-aminosalyci
lic acid. It is used to treat
ULCERATIVE COLITIS (valuale as oral therapy for mild symptomatic disease; also
availale as suppositories
for rectal disease) and RHEUMATOID ARTHRITIS. The salicylate part is now availa
le alone in drugs such as
mesalazine and olsalazine. Several reports of lood dyscrasias from patients tak
ing these drugs have
prompted the COMMITTEE ON SAFETY OF MEDICINES (CSM) to recommend that patients w
ith unexplained lood
disorders should stop treatment and e given an immediate lood count.
Sulfinpyrazone A derivative of phenylutazone which is of value in the p
rophylaxis and treatment of
GOUT.
Suppuration
Sulphonylureas Sulphonylureas are sulphonamide derivatives which lower t
he lood sugar when they are
given y mouth y enhancing the production of INSULIN. They are effective in tre
ating DIABETES MELLITUS
only when some residual pancreatic eta-cell function is present. All may lead t
o HYPOGLYCAEMIA if given in
overdose and this is particularly common when longacting sulphonylureas are give
n to elderly patients.
There is no evidence for any difference in the effectiveness of the various sulp
honylureas. TOLBUTAMIDE was
the first of the sulphonlyurea drugs; it has a short duration of action and is u
sually given twice daily.
CHLORPROPAMIDE has a more prolonged action and only needs to e given once daily
, ut its prolonged action
causes more side-effects including sensitivity reactions. Other oral hypoglycaem
ic agents of this family
include glienclamide, which has a duration of action intermediate etween tolu
tamide and chlorpropamide
and also produces side-effects (in aout 30 per cent of outpatients, according t
o a recent study). Other
sulphonlyureas include acetohexamide, gliornuride, gliclazide, glipizide, gliqu
idone and tolazamide.
Glymidine is a related compound with a similar action to the sulphonylureas. It
is particularly useful in
patients who are hypersensitive to sulphonylureas. Sulphonylureas are est avoid
ed in patients who are
overweight, as they tend to stimulate the appetite and aggravate oesity. They s
hould e used with caution
in patients with hepatic or renal disease. Side-effects are infrequent and usual
ly not severe, the most
common eing epigastric discomfort with occasional nausea, vomiting and anorexia
. In aout 10 per cent of
patients, chlorpropamide and tolutamide may cause facial flushing after drinkin
g alcohol. Some patients
are hypersensitive to oral hypoglycaemic agents and develop rashes which may pro
gress to ERYTHEMA
multiforme and exfoliative DERMATITIS. These reactions usually appear in the fir
st 68 weeks of treatment.
Sulphur Chemical cominations of this sustance were once applied topica
lly ecause of their
antimicroial activity; they are no longer used.
Sumatriptan A drug used in the treatment of MIGRAINE attacks. Given y s
ucutaneous injection, it
provides quick relief of pain, acting on the same receptors as 5-hydroxytryptami
ne a neuro685
transmitter and vasoconstrictor agent. It may also e taken orally, ut
sumatriptan should not e used
within 24 hours of treatment with ERGOTAMINE, the standard antimigraine treatmen
t.
Summer Diarrhoea See DIARRHOEA; INFANT FEEDING.
Sunurn See PHOTODERMATOSES.
rgery, RECONSTRUCTIVE
(PLASTIC) SURGERY, and UROLOGY. Remotely controlled surgery using televisual and
rootic techniques is also
eing developed. It takes up to 15 years to train a surgeon from the time at whi
ch he or she enters medical
school; after graduating as a doctor a surgeon has to pass a comprehensive two-s
tage examination to ecome
a fellow of one of the five recognised colleges of surgeons in the UK and Irelan
d. Surgery is carried out
in specially designed operating theatres. Whereas it used to necessitate days an
d sometimes weeks of
inpatient hospital care, many patients are now treated as day patients, often un
der local anaesthesia,
eing admitted in the morning and discharged later in the day. More complex surg
ery, such as
transplantation and neurosurgery, usually necessitates patients eing nursed pos
t-operatively in
highdependency units (see INTENSIVE THERAPY UNIT (ITU)) efore eing transferred
to ordinary recovery
wards. Successful surgery requires close co-operation etween surgeons, physicia
ns and radiologists as well
as anaesthetists (see ANAESTHESIA), whose sophisticated techniques enale surgeo
ns to undertake long and
complex operations that were unthinkale 30 or more years ago. Surgical treatmen
t of cancers is usually
done in collaoration with oncologists. Successful surgery is also dependent on
the skills of supporting
staff comprising nurses and operating-theatre technicians and the availaility o
f up-to-date facilities.
Surrogate A term applied in medicine to a sustance used as a sustitute
for another. The term is also
applied to a woman who agrees to ecome pregnant and give irth to a child on th
e understanding that she
will give up the child to the parents who have contracted with her for the surro
gacy arrangement. When in
vitro fertilisation (IVF see under ASSISTED CONCEPTION) proved successful, it e
came possile to transfer
Sympathetic 687
a fertilised egg to a uterus of choice. Artificial insemination of the pot
ential surrogate mother
using sperm from the putative father is also practised. Surrogacy has thrown up a
host of ethical and
legal prolems which have yet to e satisfactorily resolved.
Susceptiility A reduced aility to comat an illness, usually an infect
ion. The patient may e in poor
general health, or immunisation or disease may have affected his or her defence
mechanisms. For example, a
person with AIDS is particularly susceptile to infection.
Suture A word used in oth an anatomical and a surgical sense. (1) Anato
mically, suture is a type of
immovale joint, found particularly in the SKULL, including the coronal suture (
etween the frontal and
parietal ones); the lamoidal suture (etween the parietal and occipital ones)
; and the sagittal suture
(etween the two parietal ones). (2) Surgically the word refers either to the t
echnique of closing a
wound, or to the material used. Stitching methods have een developed for gastro
intestinal, neurological,
dermatological and other forms of surgery, and include laser surgery and remova
le clips or staples. The
material used is generally divided into monofilament, twisted or raided. Asor
ale sutures used for
internal stitching include catgut, Vicryl and Dexon. Nonasorale sutures include
silk, nylon and
prolene. The type used and time of suture-removal depend upon the site and gener
al state of the patient.
Those patients on steroids who have a malignant or infective disorder heal slowl
y, and their sutures may
need to stay in for 14 days or more instead of the usual 58 days.
Swa A term applied to a small piece of gauze, lint or similar material
used for wiping out the mouth
of a patient or for drying out a wound. The term is also applied to a tuft of st
erilised cottonwool wrapped
round a wire and enclosed in a sterile glass tue used for otaining a sample fo
r example, from the
throat or from wounds for acteriological examination.
Swan-Ganz Catheter (See also CATHETERS.) A flexile tue with a doule l
umen and a small alloon at its
distal end. It is introduced into a vein in the arm and advanced until the end o
f the catheter is in the
right atrium (see HEART). The alloon is then inflated with air through one lume
n and this
enales the loodstream to propel the catheter through the right ventric
le to the pulmonary artery. The
alloon is deflated and the catheter can then record the pulmonary artery pressu
re. When the alloon is
inflated, the tip is isolated from the pulmonary artery and measures the left at
rial pressure. These
measurements are important in the management of patients with circulatory failur
e, as under these
circumstances the central venous pressure or the right atrial pressure is an unr
eliale guide to
fluidreplacement.
Sweat See PERSPIRATION.
Sweat Glands See SKIN.
Sweetread A traditional term applied to several glands used for food, i
ncluding the THYMUS GLAND of
young animals (neck sweetread), the PANCREAS (stomach sweetread), and the test
is (see TESTICLE).
Sycosis Barae (Barers itch.) A chronic staphylococcal folliculitis (inf
ection of the hair follicles
with staphylococci acteria see STAPHYLOCOCCUS) of the eard area in males, caus
ing a papulopustular
inflammation clearly centred on hair follicles. It must e distinguished from RI
NGWORM infection of the
face and hair follicles (tinea arae) and from pseudo-folliculitis due to ingro
wing hairs. Topical and
oral antistaphyloccoccal antiiotics are effective.
Sydenhams Chorea Also called St Vituss dance, this type of CHOREA is a dis
ease of the central nervous
system that occurs after RHEUMATIC FEVER up to six months later and is proaly
an inflammatory
complication of a -haemolytic streptococcal infection (see STREPTOCOCCUS). The pa
tient presents with
jerky, purposeless, involuntary movements of a lim and tongue, similar to the s
ymptoms of CEREBRAL PALSY.
Chorea is est treated as a transitory reversile form of cereral palsy. The di
sorder usually lasts 68
months and residual symptoms are rare.
Sympathetic A term applied to certain diseases or symptoms which arise i
n one part of the ody in
consequence of disease in some distant part. Inflammation may arise in one eye,
in consequence of injury to
the other, y the spread of
S
Syphilis
rise in intrathoracic pressure. This may happen after prolonged vigorous
coughing the socalled COUGH
SYNCOPE or when elderly men with prostatic hypertrophy strain to empty their la
dder. This is known as
micturition syncope. Syncope is particularly likely to occur when the arterial
lood pressure is unusually
low. This may result from overtreatment of HYPERTENSION with drugs or it may e
the result of diseases,
such as ADDISONS DISEASE, which are associated with low lood pressures. It is im
portant that syncope e
distinguished from EPILEPSY.
Syndactyly A congenital condition in which two or more fingers or toes a
re fused together to a varying
extent. The condition is popularly known as WEBBED FINGERS (or toes).
Syndrome A term applied to a group of symptoms occurring together regula
rly, and thus constituting a
disease to which some particular name is given: for example, CUSHINGS SYNDROME co
mprising oesity,
hypertension, purple striae and osteoporosis; or KORSAKOFFS SYNDROME, comprising
loss of appreciation of
time and place comined with talkativeness, forming signs of alcoholic delirium.
Synechiae Adhesions etween the iris (see EYE) and adjacent structures (
e.g. cornea, lens). They
usually arise as a result of inflammation of the iris.
Synergist (1) A muscle that works in concert with an AGONIST muscle to p
erform a certain movement. (2)
An agent, for example a drug, that acts with another to produce a result that is
greater than adding
together the separate effects of the two agents. Synergism in drug treatment may
e eneficial, as in the
case of comined LEVODOPA and SELEGILINE, a selective monoamine oxidase inhiito
r (see MONOAMINE OXIDASE
INHIBITORS (MAOIS), in the treatment of PARKINSONISM. It may e potentially dang
erous, however, as when
MAOIs oost the effects of BARBITURATES.
Synostosis The term applied to a union y ony material of adjacent one
s which are normally separate.
Synovectomy Surgical removal of the synovium (see SYNOVIAL
689
MEMBRANE) to treat troulesome SYNOVITIS. The operation is not normally
done until other treatments
have failed.
Synovial Memrane This forms the lining of the soft parts that enclose t
he cavity of a joint. (See
JOINTS.)
Synovitis Inflammation of the memrane lining a joint (see JOINTS). It i
s usually painful and
accompanied y effusion of fluid within the synovial sac of the joint. It is fou
nd in RHEUMATOID ARTHRITIS,
various injuries and inflammations of joints, and in the chronic form in TUBERCU
LOSIS. Treatment of
synovitis is with rest, splinting, ANALGESICS and NON-STEROIDAL ANTIINFLAMMATORY
DRUGS (NSAIDS). Infection
should e treated with ANTIBIOTICS. If the joint fails to respond, surgery (SYNO
VECTOMY) may e needed.
(See also JOINTS, DISEASES OF.)
Synovium See SYNOVIAL MEMBRANE.
Synthetic A term applied to sustances produced y chemical processes in
the laoratory or y
artificial uilding-up.
Syphilis A sexually transmitted or CONGENITAL disease (the latter variet
y is now rare). Because in most
cases the disease is acquired as a result of sexual intercourse with an infected
individual, syphilis is
classed as one of the SEXUALLY TRANSMITTED DISEASES (STDS). It normally affects
only human eings. Today,
around 40 million new cases are notified annually in the world, and this is pro
aly an underestimate. In
the UK the annual incidence of new cases of syphilis diagnosed in NHS genito-uri
nary medicine clinics has
risen from 8.8 to 9.7 per million of male population etween 1991 and 1999; amon
g women the figures were
4.0 to 4.5 per million. The infection is most common in homosexual men (see HOMO
SEXUALITY).
Causes The causative organism is the Treponema pallidum, a long, threadlike wavy organism with pointed
tapering ends. It is found in large numers in the sores in the primary stage of
the disease and in the
skin lesions in the secondary stage. Syphilis may e acquired from people alread
y suffering from the
disease, or it may e congenital. The acquired form is usually got y
S
690 Syringe
sexual intercourse, kissing or other intimate odily contact. The epithe
lium covering the general
surface of the skin seems to e an efficient protection, ut the infective mater
ial penetrates mucous
memranes. The acquired form of the disease is infectious from contact with sore
s, oth in its primary and
secondary stages; infants suffering from the congenital form are also highly inf
ectious. Accordingly,
anyone frequently handling such an infant is at risk of infection, although the
mother may handle the ay
with impunity.
S
Symptoms The acquired form of the disease is commonly divided into three
stages primary, secondary,
and tertiary (although the latter is much less common than it was 50 years ago).
The clinical
manifestations are varied and are sometimes confused with those of other disease
s. There are several
laoratory tests for confirming the diagnosis. The incuation period ranges from
ten to 90 days, although
most frequently it is around four weeks. Then, a small persistent ULCER appears
at the site of infection,
which is accompanied y a typical cartilaginous hardness of the tissues immediat
ely around and eneath it.
This, which is known as the primary sore (or chancre), may e very much inflamed
, or it may e so small as
to pass almost or quite unnoticed. A few days later, the lymphatic glands in its
neighourhood, and then
those all over the ody, ecome swollen and hard. This condition lasts for sever
al weeks efore the sore
slowly heals and the glands suside. After a variale period usually aout two m
onths from the date of
infection the secondary symptoms appear and resemle the symptoms of an ordinary
FEVER, with pyrexia,
loss of appetite, vague pains through the ody, and a faint red rash seen est u
pon the front of the chest.
People with syphilis are infectious in the primary and secondary stages ut not
in the latent or tertiary
stages. In untreated or inadequately treated cases, manifestations of the tertia
ry stage develop after the
lapse of some months or even years: this is known as the latent period. These co
nsist in the growth, at
various sites throughout the ody, of masses of granulation tissue known as gumm
as. These gummas may appear
as hard nodules in the skin, or form tumour-like masses in the muscles, or produ
ce thickening of ones.
They may develop in the rain and spinal cord, where their presence causes very
serious symptoms. Gummas
yield readily, as a rule, to appropriate treatment, and generally disappear spee
dily.
Still later, effects are apt to follow, such as disease of the arteries,
leading to ANEURYSM (see also
ARTERIES, DISEASES OF), to STROKE, and to mental deterioration (see MENTAL ILLNE
SS); also certain nervous
diseases, of which taes dorsalis and general paralysis are the chief. The conge
Systolic Pressure
ringes.
though literally meaning under the skin, is now used to descrie most sy
T Taes
This means, literally, a wasting disease, and is a traditional name appl
ied to various diseases such as
taes dorsalis (tertiary SYPHILIS) and TUBERCULOSIS accompanied y enlargement o
f glands (see GLAND).
Tactile Perceptile to, pertaining to or related to the sense of TOUCH.
Taenia A parasitic tapeworm that infects several animals including human
s (see TAENIASIS).
Taeniasis
Tacalcitol
A parasitic disorder caused y taeniae or tapeworms. In the case of infe
station with Taenia saginata,
the host may not have any symptoms and only ecome aware that he or she is infes
ted upon sight of the
tapeworm or rather, part of it in the stools (FAECES). In the case of Taenia sol
ium the outlook is more
serious ecause the eggs, when swallowed, are liale to migrate into the tissues
of the ody (as they do in
the pig) and cause hydatid cysts. If these occur in the muscles they may cause l
ittle troule ut, if they
occur in the rain or liver, they can prove very serious. Hydatid cysts often gr
ow to a great size, udding
off smaller cysts in their interior. The symptoms produced y a hydatid cyst dep
end mainly upon the effects
of its size and consequent pressure.
A recently introduced, once-daily topical preparation for the treatment
of plaque
Treatment of tapeworm infestation is the
Talet A solid, disc-like preparation made y compression of a powder an
d containing a drug or drugs
mixed usually with sugar and other material. Talets are widely used ecause of
their convenience and
accurate dosage.
TAB Vaccine A comined VACCINE administered to produce IMMUNITY against
typhoid and paratyphoid A and B
(see ENTERIC FEVER). (See also IMMUNISATION.)
PSORIASIS.
Tachycardia A rise in the heart rate aove the normal range at rest 60100
eats a minute sometimes
accompanied y irregularities in rhythm (ARRHYTHMIA). Sinus tachycardia may occu
r with exercise or
emotional excitement, ut it may e the result of a feverish illness. (See also
HEART, DISEASES OF.)
Tachyphylaxis Rapidly developing TOLERANCE to a drug.
Tachypnoea Unusually rapid reathing.
Target Cell
tive with the same condition. Clinically, there are two types of congeni
tal talipes equinovarus (CTEV):
a milder form resolving CTEV in which full correction to the normal position is
relatively easily
achieved; and a more severe type resistant CTEV which is harder to correct; and
the infant has reduced
calf-muscle ulk and anormally shaped ones.
Treatment should e started at irth with the foot corrected to an impro
ved position and then
maintained in plaster of Paris or strapping a procedure performed weekly or more
often. If the deformity
is not corrected y around six weeks of age, a decision has to e made aout whe
ther to carry out surgical
correction. If a deformity persists to maturity, a triple arthrodosis fusion of
three affected joints
may e required.
Talus The square-shaped one which forms the lower part of the ankle-joi
nt and unites the leg ones to
the foot.
Tamoxifen An OESTROGENS receptor antagonist namely, the drug locks the
action of oestrogen which
is the treatment of choice for reast cancer (see BREASTS, DISEASES OF) in postm
enopausal women in
conjunction with LUMPECTOMY or partial or complete MASTECTOMY. Around 30 per cen
t of patients in whom
reast cancer has spread to adjacent glands or eyond respond to this hormonal t
reatment. In patients with
tumours that are oestrogensensitive, the positive response to tamoxifen is 60 pe
r cent; those tumours that
are not oestrogen-sensitive are much less likely to respond to the drug. Tamoxif
en increases oth survival
rates and the period etween the diagnosis of the tumour and appearance of metas
tatic growth (see
METASTASIS) in tumours sensitive to it. The drug has fewer adverse effects than
most others used for
treating reast cancer. Patients in whom the cancer has spread to the one(s) ma
y suffer pain with
tamoxifen treatment. Tamoxifen is also used to treat INFERTILITY, eing taken on
certain days of the
menstrual cycle (see MENSTRUATION).
Tampon A plug of compressed gauze or cotton wool inserted into a wound o
r orifice to arrest leeding.
Also inserted into the VAGINA to asor the flow of lood during MENSTRUATION. I
nfected tampons may cause
TOXIC SHOCK SYNDROME,
a potentially dangerous uncommon reaction.
ut
693
fortunately
Teeth
695
applied in the evening and continued for up to six weeks. Tazarotene is
not suitale for those aged
under 18.
T-Cell Lymphoma See LYMPHOMA.
Tears See EYE
Lacrimal apparatus.
Technetium-99 An ISOTOPE of the artificial element technetium. It emits
gamma rays and is used as a
tracer in uilding up a scintigraphic radioactive image of organs such as the r
ain.
Teeth Hard organs developed from the mucous memranes of the mouth and e
medded in the jawones, used
to ite and grind food and to aid clarity of speech.
Structure Each tooth is composed of enamel, dentine, cement, pulp and pe
riodontal memrane. ENAMEL is
the almost translucent material which covers the crown of a tooth. It is the mos
t highly calcified material
in the ody, 9697 per cent eing composed of calcified salts. It is arranged from
millions of long,
six-sided prisms set on end on the dentine (see elow), and is thickest over the
iting surface of the
tooth. With increasing age or the ingestion of arasive foods the teeth may e w
orn away on the surface, so
that the dentine ecomes visile. The outer sides of some teeth may e worn away
y ad tooth-rushing
technique. DENTINE is a dense yellowish-white material from which the ulk and t
he asic shape of a tooth
are formed. It is like ivory and is harder than one ut softer than enamel. The
crown of the tooth is
covered y the hard protective enamel and the root is covered y a one-like su
stance called cement. Decay
can erode dentine faster than enamel (see TEETH, DISORDERS OF Caries of the teet
h). CEMENT or cementum is
a thin one-like material which covers the roots of teeth and helps hold them in
the one. Fires of the
periodontal memrane (see elow) are emedded in the cement and the one. When t
he gums recede, part of the
cement may e exposed and the cells die. Once this has happened, the periodontal
memrane can no longer e
attached to the tooth and, if sufficient cement is destroyed, the tooth-support
will e so weakened that
the tooth will ecome loose. PULP This is the inner core of the tooth and is
Vertical section through incisor tooth.
composed of a highly vascular, delicate firous tissue with many fine ne
rve-fires. The pulp is very
sensitive to temperature variation and to touch. If the pulp ecomes exposed it
will ecome infected and
usually cannot overcome this. Root-canal treatment or extraction of the tooth ma
y e necessary. PERIODONTAL
MEMBRANE This is a layer of firous tissue arranged in groups
rround and support the root
of a tooth in a one socket. The fires are interspersed with
nerves. Loss of the
memrane leads to loss of the tooth. The memrane can release
fires to allow the tooth
to move when it erupts, or (to correct dental deformities) is
hodontic springs.
of fires which su
Arrangement and form Teeth are present in most mammals and nearly all ha
ve two sets: a temporary or
milk set, followed y a permanent or adult set. In some animals, like the toothe
d whale, all the teeth are
similar; ut in humans there are four different shapes: incisors, canines (eye-t
eeth), premolars
(icuspids), and molars. The incisors are chisel-shaped and the canine is pointe
d. Premolars have two cusps
on the crown (one medial to the other) and molars have at least four cusps. They
are arranged together in
an arch in each jaw and the
T
696 Teeth
The permanent teeth of the left side of upper and lower jaws.
cusps of opposing teeth interdigitate. Some herivores have no upper ant
erior teeth ut use a pad of
gum instead. As each arch is symmetrical, the teeth in an upper and lower quadra
nt can e used to identify
the animal. In humans, the quadrants are the same: in other words, in the child
there are two incisors, one
canine and two molars (total teeth 20); in the adult there are two incisors, one
canine, two premolars and
three molars (total 32). This mixture of tooth-form suggests that humans are omn
ivorous. Anatomically the
crown of the tooth has mesial and distal surfaces which touch the tooth next to
it. The mesial surface is
the one nearer to the centre line and the distal is the further away. The iting
surface is called the
incisal edge for the anterior teeth and the occlusal surface for the posteriors.
T
Development The first stage in the formation of the teeth is the appeara
nce of a downgrowth of
EPITHELIUM into the underlying
mesoderm. This is the dental lamina, and from it ten smaller swellings i
n each jaw appear. These ecome
ell-shaped and enclose a part of the mesoderm, the cells of which ecome specia
lised and are called the
dental papillae. The epithelial cells produce enamel and the dental papilla form
s 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 resor a
nd the permanent teeth are
then ale to push the crowns out and erupt themselves. If this process is distur
ed, the permanent teeth
may e displaced and appear in an anormal position or e impacted. Eruption of
teeth is in a definite
order and at a fixed time, although there may e a few months leeway in either di
rection which is of no
significance. Excessive delay is found in some congenital disorders such as CRET
INISM. It may also e
associated with local anormalities of the jaws such as cysts, malformed teeth a
nd supernumerary teeth. The
usual order of eruption of deciduous teeth is: Middle incisors Lateral incisors
First molars Canines
(eye-teeth) Second molars
68 months 810 months 1216 months 1620 months 2030 months
The usual order of eruption of permanent teeth is: First molars Middle i
ncisors Lateral incisors
Canines First and second premolars Second molars Third molars (wisdom teeth)
Teeth of a six-year-old child. The permanent teeth are coloured lack.
67 years 68 years 79 years 912 years 1012 years 1113 years 1721 years
Teeth, Disorders of
697
have receded. This pain is often associated with temperature-change or s
weet foods. Expert dental
advice should e sought early, efore the decay is extensive. If a large cavity
is accessile, temporary
relief may e otained y inserting a small piece of cotton wool soaked, for exa
mple, in oil of cloves.
Alveolar ascess, dental ascess or gumoil This is an ABSCESS caused y
an infected tooth. It may e
present as a large swelling or cause trismus (inaility to open the mouth). Trea
tment is drainage of the
PUS, extraction of the tooth and/or ANTIBIOTICS.
Caries of the teeth or dental decay is very
The permanent teeth of the upper (top) and lower (ottom) jaws.
Teeth, Disorders of Teething, or the process of eruption of the teeth in
infants, may e accompanied y
irritaility, salivation and loss of sleep. The child will tend to ru or touch
the painful area. Relief
may e otained in the child y allowing it to chew on a hard oject such as a t
oy or rusk. Mild ANALGESICS
may e given if the child is restless and wakens in the night. A serious pitfall
is to assume that an
infants symptoms of ill-health are due to teething, as the cause may e more seri
ous. Fever and fits (see
SEIZURE) are not due to teething. Toothache is the pain felt when there is infla
mmation of the pulp or
periodontal memrane of a tooth (see TEETH Structure). It can vary in intensity
and may e recurring. The
commonest cause is caries (see elow) when the cavity is close to the pulp. Once
the pulp has ecome
infected, this is likely to spread from the apex of the tooth into the one to f
orm an ascess (gumoil
see elow). A lesser ut more long-lasting pain is felt when the dentine is unpr
otected. This can occur
when the enamel is lost due to decay or trauma or ecause the gums
common in the more affluent countries and is most common in children and
young adults. Increasing
awareness of the causes has resulted in a considerale improvement in dental hea
lth, particularly in recent
years; this has coincided with a rise in general health. Now more than half of f
ive-year-old children are
caries-free and of the others, 10 per cent have half of the remaining carious ca
vities. Since the start of
the National Health Service, the emphasis has een on preventive dentistry, and
now edentulous patients are
mainly found among the elderly who had their teeth removed efore 1948. The caus
e of caries is proaly
acid produced y oral acteria from dietary carohydrates, particularly refined
sugar, and this dissolves
part of the enamel; the dentine is eroded more quickly as it is softer (see TEET
H Structure). The exposed
smooth surfaces are usually protected as they are easily cleaned during normal e
698 Teeth-Grinding
Irregularity of the permanent teeth may e due to an anormality in the
growth of the jaws or to the
early or late loss of the deciduous set (see TEETH Development). Most frequently
it is due to an
imalance in the size of the teeth and the length of the jaws. Some improvement
may take place with age,
ut many will require the help of an orthodontist (specialist dentist) who can c
orrect many malocclusions
y removing a few teeth to allow the others to e moved into a good position y
means of springs and
elastics on various appliances which are worn in the mouth.
Dental ascess is an infection that arises in
accident or inflammation of the GUM. Teeth loosened y trauma may e rep
laced and splinted in the
socket, even if knocked right out. If the loosening is due to periodontal diseas
e, the prognosis is less
favourale.
or around a tooth and spreads to involve the one. It may occur many yea
rs after a low has killed the
pulp of the tooth, or more quickly after caries has reached the pulp. At first t
he pain may e mild and
intermittent ut eventually it will ecome severe and a swelling will develop in
the gum over the apex of
the tooth. A radiograph of the tooth will show a round clear area at the apex of
the tooth. Treatment may
e y painting the gum with a mild counter-irritant such as a tincture of aconit
e and iodine in the early
stages, ut later rootcanal therapy or apicectomy may e required. If a swelling
is present, it may need to
e drained or the offending teeth extracted and antiiotics given.
Discoloration of the teeth may e intrinsic
Injuries to teeth are common. The more
or extrinsic: in other words, the stain may e in the calcified structur
e or stuck on to it. Intrinsic
staining may e due to JAUNDICE or the antiiotic tetracycline. Extrinsic stain
may e due to tea, coffee,
toacco, pan (a mixture of chuna and etel nuts wrapped in a leaf ), ironcontain
ing medicines or excess
fluoride.
minor injuries include crazing and the loss of small chips of enamel, an
d the major ones include a
roken root and avulsion of the entire tooth. A specialist dental opinion should
e sought as soon as
possile. A tooth that has een knocked out can e re-implanted if it is clean a
nd replaced within a few
hours. It will then require splinting in place for 46 weeks.
Loosening of the teeth may e due to an
Gingivitis or inflammation of the gum may occur as an acute or chronic c
ondition. In the acute form it
is often part of a general infection of the mouth, and principally occurs in chi
ldren or young adults
resolving after 1014 days. The chronic form occurs later in life and tends to e
progressive. Various
microorganisms may e found on the lesions, including anaeroes. Antiseptic mout
hwashes may help, and once
the painful stage is past, the gums should e thoroughly cleaned and any calculu
s removed. In severe
conditions an antiiotic may e required.
T
PEPSIA. Treatment is largely aimed at stailising the condition rather t
han curing it.
Periodontal disease is the spread of gingivitis (see aove) to involve t
he periodontal memrane of the
tooth; in its florid form it used to e called pyorrhoea. In this, the memrane
ecomes damaged y the
inflammatory process and a space or pocket is formed into which a proe can e e
asily passed. As the pocket
ecomes more extensive, the tooth loosens. The loss of the periodontal memrane
also leads to the loss of
supporting one. Chronic inflammation soon occurs and is difficult to eradicate.
Pain is not a feature of
the disease ut there is often an unpleasant odour (halitosis). The gums leed e
asily and there may e DYSPrevention of dental disease As with other disorders, prevention is ett
er than cure. Children should
e taught at an early age to keep their teeth and gums clean and to avoid refine
d sugars etween meals. It
is etter to finish a meal with a drink of water rather than a sweetened drink.
Fluoride in some of its
forms is useful in the reduction of dental caries; in some parts of the UK natur
al water contains fluoride,
and in some areas where fluoride content is low, artificial fluoridation of the
water supply is carried
out. Overcrowding of the teeth, ovious maldevelopment of the jaw and persistent
thumsucking into the
teens are all indications for seeking the advice of an orthodontist. Generally,
adults have less troule
with decay ut more with periodontal disease and, as its onset is insidious, reg
ular dental inspections are
desirale.
Teeth-Grinding See also BRUXISM.
Teeth-grinding occurs in children during sleep and is of no significance
unless really persistent.
During the day it may e an attention-seeking device. There is no treatment for
it. In adults it is usually
associated with stress or
Temperature
anxiety, ut may e due to some local condition in the mouth such as an
unsatisfactory filling. It may
also e caused y certain drugs, including fenfluramine and LEVODOPA. If not con
trolled, it produces
excessive wear of the enamel covering of the teeth. Treatment consists of allevi
ation of any condition in
the mouth and any anxiety and stress.
Teething See under TEETH, DISORDERS OF.
Teichopsia This refers to zigzag lines that patients with MIGRAINE often
experience as a visual AURA
preceding an attack.
Teicoplanin A glycopeptide antiiotic (see ANTIBIOTICS) which acts again
st aeroic and anaeroic
grampositive (see GRAMS STAIN) acteria. Like the similar drug, VANCOMYCIN, it is
given in the prophylaxis
and treatment of ENDOCARDITIS and other serious infections caused y grampositiv
e cocci, including
STAPHYLOCOCCUS, which have developed resistance to other antiiotics. Its long d
uration of action means
that it need e given only once a day. Teicoplanin can e given intramuscularly
or intravenously. Its use
should e carefully monitored as there is a range of adverse effects.
Telangiectasis Anormal dilatation of ARTERIOLES and venules (see VENULE
). In the skin it is seen in
spider NAEVUS and ROSACEA particularly.
Telemedicine A road term used to descrie medicine at a distance throug
h a communications link.
Although distance education has een used successfully for some time, more recen
tly distance diagnosis and
treatment have een successfully piloted. In teleradiology, radiographic images
are transmitted to a
distant site for interpretation y a radiologist. A telepathologist can look dow
n, and in some cases
control, a microscope located several hundred miles away. In a teleconsultation,
the doctor and patient are
in different places, joined y a communications link such as medical videoconfer
encing. In its simplest
form, this kind of telemedicine uses the telephone; more recently, full-colour t
wo-way video and audio
links have een used. Telesurgery, comining televisual and rootic techniques,
is also under development.
Telemedicine is useful for remote locations, such as the Antartic, or on oard s
hips, or aero699
planes, where it may e difficult or impossile to get a doctor to the p
atient. It can also speed up
the referral process, reduce unnecessary referrals and improve communication et
ween professionals. It has
potential value in pilot projects of hospital at home care.
Temazepam A enzodiazepine anxiolytic (see BENZODIAZEPINES; ANXIOLYTICS)
700 Temple
which the temperature falls, perspiration breaks out, the pulse rate
ls, and breathing becomes
quieter. This crisis is often preceded by an increase in symptoms, including
epicritical rise in
temperature. Body temperature is usually measured on the Celsius scale, on a
rmometer reading from 35 C
to 433 C. Measurement may be taken in the mouth (under the tongue), in the
the external ear canal
or (occasionally in infants) in the rectum. (See also THERMOMETER.)
fal
an
the
armpit,
Terbinafine
victim is often under the impression that he or she has received a blow.
This is accompanied by loss of
function, and a gap may be felt in the tendon.
Partial Rupture is also accompanied by pain, but there is no breach of c
ontinuity or complete loss of
function. Treatment of a complete rupture usually means surgical repair followed
by immobilisation of the
tendon in plaster of Paris for six weeks. Partial rupture usually responds to ph
ysiotherapy and
immobilisation, but healing is slow.
Tendon Transfer Reconstructive surgery in which the TENDON from an unimp
ortant muscle is removed and
used to repair or replace a damaged tendon of a major muscle.
Tendovaginitis Also called tenovaginitis: inflammation of a TENDON and o
f the sheath enveloping it.
Tenesmus A symptom of disease affecting the lower part of the large INTE
STINE, such as DYSENTERY, piles
(HAEMORRHOIDS) or tumour. It consists of a constant sense of heavy discomfort ab
out the lower bowel and
desire to defaecate, coupled with straining when doing so, with the passage of m
ucus and often blood.
Tennis Elbow The medical name for this condition is epicondylitis. The c
ondition is characterised by
pain and tenderness on the outside of the elbow and is the result of inflammatio
n in the TENDON that
attaches the muscles which extend the elbow to the HUMERUS bone. Epicondylitis c
an be the result of playing
a lot of tennis or other racquet sports, gardening, do it yourself work, or any ac
tivity that constantly
pulls the tendon at its point of attachment. Lifting heavy objects aggravates th
e condition. Treatment is
resting the arm, ANALGESICS and/or NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS
). Sometimes ULTRASOUND
therapy may promote healing, but persistent severe pain may necessitate the loca
l injection of
CORTICOSTEROIDS. Rarely, surgery may be recommended to release the tendon.
TenoA prefix denoting some relation to a TENDON.
Tenosynovitis Also called tenositis: inflammation of a TENDON.
701
Tenotomy An operation in which one or more tendons (see TENDON) are divi
ded, usually with the object of
remedying some deformity.
Tenovaginitis See TENDOVAGINITIS.
TENS See TRANSCUTANEOUS STIMULATION (TENS).
ELECTRICAL
NERVE
Tentorium A wide flap of DURA MATER forming a partition between the cere
brum and cerebellum (see BRAIN)
and supporting the former.
Teratogenesis The production of physical defects in the FETUS. A drug ma
y interfere with a mechanism
that is essential for growth, and result in arrested or distorted development of
the fetus and yet cause
no disturbance in adults, in whom these growth processes have ceased. Whether an
d how the EMBRYO is
affected depends on what stage of development it has reached when the drug is gi
ven. The age of early
differentiation that is, from the beginning of the third week to the end of the
tenth week of pregnancy
is the time of greatest susceptibility. After this time the likelihood of CONGEN
ITAL malformation resulting
from drug treatment is less, although the death of the fetus can occur at any ti
me as a result of drugs
crossing the PLACENTA or as a result of their effect on the placental circulatio
n. Although the risks are
nil or very small with most drugs, no medication should be given to a pregnant w
oman, particularly during
the first few months of pregnancy, unless it is absolutely essential for her hea
lth or that of her unborn
child. Alcohol is regarded as medication in this context.
Teratoma A tumour that consists of partially developed embryonic tissues
. The most common sites of this
tumour are the ovary (see OVARIES) and the TESTICLE.
Terbinafine An antifungal drug given systemically. Used in the treatment
of dermatophyte infections of
the nails and RINGWORM infections (tinea pedis, cruris and corporis) which have
not responded to topical
antifungal preparations.
T
702 Terbutaline
Terbutaline A beta2 adrenoreceptor agonist that acts as a BRONCHODILATOR
(see also
BETAADRENOCEPTOR-BLOCKING DRUGS). As an aerosol (see INHALANTS), it is of partic
ular value in the treatment
of mild to moderate attacks of ASTHMA; it is also available in oral and parenter
al forms, as well as
subcutaneous, intramuscular, or slow intravenous injection.
Tertian Fever The name applied to that type of MALARIA in which the feve
r reappears every other day.
Testicle Every man has two testicles or testes which are the sexual glan
ds. In the fetus, they develop
in the abdomen, but before birth they descend into a fold or pouch of skin known
as the SCROTUM. Each
testicle consists of up to 1,000 minute tubes lined by cells from which the sper
matozoa (see SPERMATOZOON)
are formed. Around 45 million spermatozoa are produced per gram of testicle per d
ay. These tubes
communicate with one another near the centre of the testicle, and are connected
by a much coiled tube, the
EPIDIDYMIS, with the ductus, or VAS DEFERENS, which enters the abdomen and passe
s on to the base of the
bladder. This duct, after joining a reservoir known as the seminal vesicle, open
s, close to the duct from
the other side of the body, into the URETHRA where it passes through the PROSTAT
E GLAND. Owing to the
convolutions of these ducts leading from the testicles to the urethra, and their
indirect route, the
passage from testicle to urethra is over 6 metres (20 feet) in length. In additi
on to producing
spermotozoa, the testicle also forms the hormone TESTOSTERONE which is responsib
le for the development of
male characteristics.
Testicle, Diseases of T The SCROTUM may be affected by various skin dise
ases, particularly eczema (see
DERMATITIS) or fungal infection. A HERNIA may pass into the scrotum. Defective d
evelopment of the testicles
may lead to their retention within the abdomen, a condition called undescended t
esticle.
Hydrocoele is a collection of fluid distending one or both sides of the
scrotum with fluid. Treatment
is by withdrawal of the fluid using a sterile syringe and aspiration needle. Hyp
ogonadism Reduced activity
of the testes or ovaries (male and female gonads). The result is impaired develo
pment of the secondary
sexual characteristics (growth of the genitals, breast and adult hair di
stribution). The cause may be
hereditary or the result of a disorder of the PITUITARY GLAND which produces GON
ADOTROPHINS that stimulate
development of the testes and ovaries.
Varicocoele is distension of the veins of the spermatic cord, especially
on the left side, the causes
being similar to varicose veins elsewhere (see VEINS, DISEASES OF). The chief sy
Tetanus
Injuries A severe blow may lead to
703
and symptoms of collapse, usually relieved by rest in bed; however, a HA
EMATOMA may develop.
wound, which is absorbed through the motor nerves into the spinal cord w
here it renders the nerves
excitable and acutely sensitive to mild stimuli.
Testis
Symptoms Most
SHOCK
See EMBRYO TRANSFER.
commonly appearing within four to five days of the wound, the patients sy
mptoms may be delayed for
several weeks by which time the wound may have healed. Initially there is muscle
stiffness around the
wound followed by stiffness around the jaw, leading to lockjaw, or trismus. This
extends to the muscles of
the neck, back, chest, abdomen, and limbs, leading to strange, often changing, c
ontorted postures,
accompanied by frequent seizures often provoked by quite minor stimuli such as a
sudden noise. The
patients breathing may be seriously affected, in severe cases leading to ASPHYXIA
; the temperature may
rise sharply, often with sweating; and severe pain is common. Mental clarity is
characteristic adding to
the patients anxiety. In severe infections death may be from asphyxia, PNEUMONIA,
or general exhaustion.
More commonly, the disease takes a chronic course, leading to gradual recovery.
Outcome depends on several
factors, chiefly the patients immune status and age, and early administration of
appropriate treatment.
Tetanus may occur in newborn babies, particularly when birth takes place in an u
nhygienic environment. It
is particularly common in the tropics and developing countries, with a high mort
ality rate. Local tetanus
is a rare manifestation, in which only muscles around the wound are affected, th
ough stiffness may last for
several months. STRYCHNINE poisoning and RABIES, although similar in some respec
ts to tetanus, may be
easily distinguished by taking a good history.
Tetanus
Prevention and treatment The incidence
Also called LOCKJAW, this is a bacterial infection of the nervous system
. Increased excitability of the
SPINAL CORD results in painful and prolonged spasms of the voluntary muscles thr
oughout the body, rapidly
leading to death unless treated.
of tetanus in the United Kingdom has been almost abolished by the introd
uction of tetanus vaccine (see
IMMUNISATION). Children are routinely immunised at two, three and four months of
age, and boosters are
given later in life to at-risk workers, or those travelling to tropical parts. T
reatment should be started
as soon as possible after sustaining a potentially dangerous wound. An intraveno
us injection of antitoxin
should be given immediately, the wound thoroughly cleaned and PENICILLIN adminis
tered. Expert nursing is
most important. Spasms may be minimised by reducing unexpected stimuli, and diaz
epam (see BENZODIAZEPINES;
TRANQUILLISERS) is helpful. Intravenous feeding
See TESTICLE.
Test Meal (1) The name given to a gastric-function test, involving injec
tion of HISTAMINE a powerful
stimulator of gastric juice, or pentagastin. After the stimulant has been inject
ed, the digestive juices
are withdrawn through a stomach tube (inserted through the nose and throat) and
their volume and chemistry
measured. A similar test is used to assess the working of the PANCREAS. (2) The
second meaning (also called
test feed) applies to a diagnostic procedure for congenital PYLORIC STENOSIS, wh
ereby a paediatrician feels
over the babys abdomen while he or she is feeding. The pyloric mass can be felt a
s a firm swelling with
the consistency of a squash ball, which comes and goes under the examiners finger
s.
Testosterone The principal male sex hormone secreted by the testes. It h
as also been prepared
synthetically and has the formula C19H28O2. In true male HYPOGONADISM it has the
power of restoring male
sexual characteristics. (See also ANDROGEN.)
Test-Tube A tube of thin glass closed at one end, which is used for obse
rving chemical reactions or for
bacterial culture.
Test-Tube Baby
Causes The disease is caused by the bacillus Clostridium tetani, found g
enerally in earth and dust and
especially in places where animal manure is collected. Infection usually follows
a wound, especially a
deeply punctured or gunshot wound, with the presence of some foreign body. It is
a hazard in war and also
among farmers, gardeners and those in the construction industry. The bacillus de
velops a toxin in the
T
704 Tetany
should be started immediately if the patient cannot swallow. Aspiration
of bronchial secretions and
antibiotic treatment of pneumonia may be necessary.
Tetany A condition characterised by SPASM of muscle, usually caused by a
fall in blood CALCIUM levels.
This results in hyperexcitability of muscles which may go into spasm at the slig
htest stimulus. This is
well demonstrated in two of the classical signs of the disease: Chvosteks sign, i
n which the muscles of
the face contract when the cheek is tapped over the facial nerve as it emerges o
n the cheek; and Erbs
sign, in which muscles go into spasm in response to an electrical stimulus which
normally causes only a
contraction of the muscle. Tetany occurs in newborn babies, especially if they a
re premature, and in
infants; as a result of RICKETS, excessive vomiting, or certain forms of NEPHRIT
IS. It may also be due to
lack of the active principle of the PARATHYROID glands. Overbreathing may also c
ause it. Treatment consists
of the administration of calcium salts, and in severe cases this is done by givi
ng calcium gluconate
intravenously or intramuscularly. High doses of vitamin D are also required.
Tetrabenazine A drug used mainly to control disorders of movement in HUN
TINGTONS CHOREA and similar
disorders. It probably acts by reducing DOPAMINE at the NERVE endings, thus slow
ing neural transmissions.
Tetracyclines
T
A group of broad-spectrum ANTIBIOTICS which include oxytetracycline, tet
racycline, doxycycline,
lymecycline, minocycline, and demeclocycline. All the preparations are virtually
identical, being active
against both gram-negative and gram-positive bacteria (see GRAMS STAIN). Derived
from cultures of
streptomyces bacteria, their value has lessened owing to increasing resistance t
o the group among bacteria.
However, they remain the treatment of choice for BRUCELLOSIS, LYME DISEASE, TRAC
HOMA, PSITTACOSIS, Q FEVER,
SALPINGITIS, URETHRITIS and LYMPHOGRANULOMA INGUINALE, as well as for infections
caused by MYCOPLASMA,
certain rickettsiae (see RICKETTSIA) and CHLAMYDIA. Additionally they are used i
n the treatment of ACNE,
but are not advised in children under 12 as they may produce permanent discolora
tion of the teeth.
Tetracyclines must not be used if a
woman is pregnant as the infants deciduous teeth will be stained.
Tetralogy of Fallot The most common form of cyanotic congenital heart di
sease. The tetralogy consists
of stenosis of the pulmonary valve (see PULMONARY STENOSIS); a defect in the sep
tum separating the two
ventricles (see VENTRICLE); the AORTA over-riding both ventricles; marked HYPERT
Thiamine
not regrow. Treatment is the administration of CHELATING AGENTS. (See al
so POISONS.) The radio-isotope
(see ISOTOPE) thallium201 is used as a tracer during special imaging studies of
blood flow through the
heart muscle in the diagnosis of myocardial ischaemia (see HEART, DISEASES OF.)
Theca A sheath-like structure enclosing an organ or part.
Thenar Eminence The projecting mass at the base of the thumb: what is po
pularly known as the ball of
the thumb.
Theophylline An alkaloid (see ALKALOIDS) structurally similar to CAFFEIN
E, and found in small amounts
in tea. Its main use is for the relief of BRONCHOSPASM, where beta-2 adrenocepto
r stimulants have failed.
It is given intravenously in combination with the stabilising agent ethylenediam
ine (as aminophylline) for
the treatment of severe ASTHMA or paroxysmal nocturnal DYSPNOEA. Formerly used i
n the treatment of left
ventricular failure, it has been largely superseded by more effective DIURETICS.
When indicated,
aminophylline should be given by very slow intravenous injection; acute overdose
may cause convulsions and
cardiac ARRHYTHMIA.
705
changes in temperature in a record known as a thermogram. Unfortunately,
such hot areas of skin are
caused by a number of other conditions; this is therefore a diagnostic method th
at can be used only as a
rough screening procedure.
Thermoluminescent Dosimeter A commonly used device for measuring peoples
exposure to RADIATION. It
contains activated sodium fluoride which luminesces in proportion to the radiati
on dose to which it is
exposed.
Thermometer An instrument for measuring a persons body TEMPERATURE. A tra
ditional clinical thermometer
comprises a glass capillary tube sealed at one end with a MERCURY-filled bulb at
the other. The mercury
expands (rises) and contracts (falls) according to the temperature of the bulb,
which may be placed under
the tongue or arm or in the rectum. Calibration is in degrees Celsius or Fahrenh
eit. Modern thermometers
use an electric probe linked to a digital read-out display, providing an instant
reading. Hospitals now
have electronic devices that maintain constant monitoring of patients temperature
s, pulse rates and blood
pressure.
Thermometer Scales See TEMPERATURE.
Therapeutic Index
Thermoreceptor
In anticancer therapy, this is the ratio of a dose of the treatment agen
t that damages normal cells to
the dose necessary to produce a determined level of anticancer activity. The ind
ex shows the effectiveness
of the treatment against the cancer.
The end of a sensory NERVE that reacts to changes in temperature. Such r
eceptors are widely distributed
in the SKIN as well as the mucous membranes of the mouth and throat.
Therapeutics The general name applied to different methods of treatment
and healing.
Therapy The treatment of injury or disease.
ThermoA prefix implying some relation to heat.
Thermography A method of detecting the amount of heat produced by differ
ent parts of the body. This is
done with an infra-red sensitive photographic film. High blood flow in an area s
hows up as a heat zone and
thus tumours such as breast cancer can be identified. The process records such
Thiabendazole The drug of choice for adults infected with the intestinal
parasite Strongyloides
stercoralis (see STRONGYLOIDIASIS). Its side-effects, including ANOREXIA, nausea
, vomiting, diarrhoea,
abdominal pain, itching and drowsiness, are more troublesome in elderly patients
.
Thiamine The British Pharmacopoeia name for vitamin B1. Also known as AN
EURINE, it is found in the
husks of cereal grains. Its deficiency may be produced by too careful milling of
rice, or by a diet of
white bread to the exclusion of brown bread and other cereal sources of this vit
amin. The resulting disease
is a form of NEURITIS with muscular weakness and heart failure known as BERIBERI
. The best sources of this
vitamin are wholemeal flour, bacon, liver, egg-yolk, yeast
T
706 Thiazides
and the pulses. The
upon the total food intake,
has been estimated to be in
ncreased during pregnancy
to 2 mg daily as a minimum.
Thromboembolism
Thoracocentesis The withdrawal of fluid from the pleural cavity. (See AS
PIRATION.)
cavity into which the nose, mouth, gullet, and larynx all open. (See als
o TONSILS; NOSE.)
Throbbing
Thoracoplasty
See PULSATION.
The operation of removing a varying number of ribs so that the underlyin
g lung collapses. It was
formerly done to treat pulmonary
Thrombin
TUBERCULOSIS.
707
See COAGULATION.
Thromboangiitis Obliterans
Thorax Another name for the CHEST. Also the title of a medical journal r
ead by chest physicians.
Thought Disorders Thought is a mental activity by which people reason, s
olve problems, form judgements
and communicate with each other by speech, writing and behaviour. Disturbances o
f thought are reflected in
how a person communicates: the normal logic of thought is broken up and a person
may randomly move from one
subject to another. SCHIZOPHRENIA is a mental illness characterised by thought d
isorder. Confusion,
DEMENTIA, DEPRESSION and MANIA are other conditions in which thought disorders m
ay be a marked feature.
(See also MENTAL ILLNESS.)
Also known as Buergers disease, this is an inflammatory disease involving
the blood vessels and nerves
of the limbs, particularly the lower limbs. TOBACCO is an important cause. Pain
is the outstanding symptom,
accompanied by pallor of the affected part; intermittent CLAUDICATION caused by
a reduction in blood supply
is common. Sooner or later ulceration and GANGRENE tend to develop in the feet o
r hands when AMPUTATION of
the affected part may be necessary. There is no specific treatment, but, if seen
in the early stages,
considerable relief may be given to the patient. Regular walking exercise is hel
pful and affected
individuals should not smoke.
Thrombocyte See PLATELETS.
Threadworm
Thrombocytopenia
See ENTEROBIASIS.
A fall in the number of PLATELETS (thrombocytes) in the blood caused by
failure of production or
excessive destruction of platelets. The result is bleeding into the skin (PURPUR
A), serious bleeding after
injury and spontaneous bruising. (See also IDIOPATHIC THROMBOCYTOPENIC PURPURA (
ITP).)
Threonine One of the essential or indispensable
AMINO
ACIDS.
Threshold The degree of stimulation, or electrical depolarisation, neces
sary to produce an action
potential in a nerve-fibre (see NEURON(E); NERVE). Stimulation below this level
elicits no conducted
impulse, and supramaximal stimulation will elicit the same response as a thresho
ld stimulus.
Thrill A tremor or vibration felt on applying the hand to the surface of
the body. It is felt
particularly over the region of the heart in conditions in which the valve openi
ngs are narrowed or an
ANEURYSM is present.
Throat In popular language, this is a vague term applied indifferently t
o the region in front of the
neck, to the LARYNX or organ of voice, and to the cavity at the back of the mout
h. The correct use of the
word denotes the PHARYNX or
Thrombocytopenic See THROMBOCYTOPENIA.
Thromboembolism The formation of a thrombus (BLOOD CLOT) in one part of
the circulatory system from
which a portion becomes detached and lodges in another blood vessel, partially o
r completely obstructing
the blood flow (an EMBOLISM). Most commonly a thrombus is formed in the veins of
the leg DEEP VEIN
THROMBOSIS (DVT) and the embolism lodges in the pulmonary (lung) circulation. PU
LMONARY EMBOLISM is a
potentially fatal condition and requires urgent anticoagulant treatment (see ANT
ICOAGULANTS) and sometimes
surgery. Extended periods lying in bed or prolonged sitting in a confined positi
on such as a car or
aeroplane can cause DVT; venous thromboses in the legs may occur after surgery a
nd preventive anticoagulant
treatment
T
708 Thrombolysis
with HEPARIN and warfarin is often used. Similar treatment is needed if
a thrombus develops.
STREPTOKINASE is also used to treat thromboembolism.
Thrombolysis The breakdown of a BLOOD CLOT by enzymic activity (see ENZY
ME). Naturally occurring
enzymes limit the enlargement of clots, and drugs for example, STREPTOKINASE may
be given to dissolve
clots (e.g. following a coronary THROMBOSIS see under HEART, DISEASES OF). The d
rug needs to be given
within 612 hours to be effective in reducing the death rate, so prompt diagnosis
and transfer to hospital
is essential: a short door-to-needle time. An unwanted effect may be increased ris
k of bleeding,
especially in the elderly. It has been used in trials in patients with PULMONARY
EMBOLISM and with
peripheral arterial disease, but its value in these conditions is uncertain.
Thrombolytic Agents These are compounds with the property of breaking up
blood clots in the circulatory
system (see BLOOD CLOT; THROMBUS; THROMBOSIS; FIBRINOLYTIC DRUGS).
Thrombophlebitis Inflammation of the veins combined with clot formation.
(See BLOOD CLOT; VEINS,
DISEASES OF.)
Thromboplastin Also known as thrombokinase, this is an ENZYME formed in
the preliminary stages of the
COAGULATION of blood. It converts the inactive PROTHROMBIN into the enzyme THROM
BIN.
Thrombosis
T
The formation of a BLOOD CLOT within the vessels or heart during life. T
he process of clotting within
the body depends upon the same factors as that of clotting of blood outside the
body, involving the
fibrinogen and calcium salts circulating in the blood, as well as blood PLATELET
S. The indirect cause of
thrombosis is usually some damage to the smooth lining of the blood vessels brou
ght about by inflammation,
or the result of ATHEROMA, a chronic disease of the vessel walls. The blood is a
lso specially prone to clot
in certain general conditions such as ANAEMIA, the ill-health of wasting disease
s like cancer, and in
consequence of the poor circulation of old age. Thrombosis may occur in the vess
els of the brain and thus
causes STROKE in people whose arteries are much diseased.
Thrombosis of a coronary artery of the heart is a very serious condition
which affects, as a rule,
middle-aged or elderly people. (See also ARTERIES, DISEASES OF; COAGULATION; HEA
RT, DISEASES OF Coronary
thrombosis; VEINS, DISEASES OF.)
Thromboxane A substance produced in the blood PLATELETS which induces ag
Thymocyte A cell that develops in the THYMUS GLAND, probably from a stem
cell of bone marrow. It is a
precursor of T-lymphocytes originating in the gland (see LYMPHOCYTE).
Thymoma A tumour of the THYMUS GLAND. Such tumours are rare and are clas
sified according to the variety
of thymus tissue from which they develop. Epithelial thymomas grow slowly and ra
rely spread. If the tumour
arises from LYMPHOID TISSUE, it may progress to a generalised non-Hodgkins LYMPHO
MA. Another variety is a
thymic TERATOMA which is normally benign in women but malignant in men. Thymomas
may affect the working of
the immune system (see IMMUNITY), increasing the likelihood of infection. They a
re also associated with
MYASTHENIA GRAVIS an autoimmune disorder; removal of the gland may cure the diso
rder.
712 Thyroidectomy
weight and develop constipation. The skin becomes dry and yellow due to
the presence of increased
carotene. Hair becomes thinned and brittle and even baldness may develop. Swelli
ng of the soft tissues may
give rise to a CARPAL TUNNEL SYNDROME and middle-ear deafness. The diagnosis is
confirmed by measuring the
levels of thyroid hormones in the blood, which are low, and of the pituitary TSH
which is raised in primary
hypothyroidism.
Thyrotoxicosis A disorder of the thyroid gland in which excessive amount
s of thyroid hormones are
secreted into the bloodstream. Resultant symptoms are tachycardia, tremor, anxie
ty, sweating, increased
appetite, weight loss and dislike of heat. (See hyperthyroidism above.)
Treatment consists of the administration of
Thyroidectomy
thyroxine. Although tri-iodothyronine is the metabolically active hormon
e, thyroxine is converted to
tri-iodothyronine by the tissues of the body. Treatment should be started cautio
usly and slowly increased
to 02 mg daily the equivalent of the maximum output of the thyroid gland. If too
large a dose is given
initially, palpitations and tachycardia are likely to result; in the elderly, he
art failure may be
precipitated.
Surgical removal of the THYROID GLAND. Partial thyroidectomy removal of
part of the gland is
sometimes done in patients with hyperthyroidism (see under THYROID GLAND, DISEAS
ES OF) when drug treatment
has failed to control the disorder.
Congenital hypothyroidism Babies may
Thyrotoxicosis
be born hypothyroid as a result of having little or no functioning thyro
id-gland tissue. In the
developed world the condition is diagnosed by screening, all newborn babies havi
ng a blood test to analyse
TSH levels. Those found positive have a repeat test and, if the diagnosis is con
firmed, start on thyroid
replacement therapy within a few weeks of birth. As a result most of the ill-eff
ects of cretinism can be
avoided and the children lead normal lives.
See under THYROID GLAND, DISEASES OF.
Thyroiditis Inflammation of the thyroid
T
removed surgically or destroyed using radioactive iodine.
Tinnitus
bone are usually compound ones. The thigh bone abuts on the larger upper
end of the tibia at the
knee-joint, whilst below, the tibia and fibula together enter into the ankle-joi
nt, the two bosses or
malleoli at the ankle belonging, the inner to the tibia, the outer to the fibula
.
Tic A repetitive, usually involuntary SPASM that varies from being the s
imple twitch of a muscle for
example, affecting an eyelid to complex coordinated actions. About 20 per cent o
f children suffer from
tic which normally lasts several months. Emotional stress is a common cause (see
GILLES DE LA TOURETTES
SYNDROME).
Tic Douloureux Another name for TRIGEMINAL NEURALGIA due to some affecti
on of the fifth cranial nerve,
and characterised by pain situated somewhere about the temple, forehead, face, o
r jaw and sometimes by
SPASM in the muscles of the affected region.
Ticks Ticks are blood-sucking arthropods which are responsible for trans
mitting a wide range of
diseases to humans, including ROCKY MOUNTAIN SPOTTED FEVER, African tick typhus,
LYME DISEASE and fivre
boutonneuse (see TYPHUS FEVER). Apart from being transmitters of disease, they c
ause intense itching and
may cause quite severe lesions of the skin. The best repellents are dimethyl pht
halate and
diethyltoluamide. Once bitten, relief from the itching is obtained from the appl
ication of calamine lotion.
Tick-bites are an occupational hazard of shepherds and gamekeepers. (See also BI
TES AND STINGS.)
Ticlopidine A recently introduced antiplatelet drug, which decreases clu
mping of blood PLATELETS and
thus inhibits the formation of clots (see BLOOD CLOT; THROMBUS). It is used to p
revent episodes in patients
with a history of symptomatic ischaemic disease such as STROKE and INTERMITTENT
CLAUDICATION. The drug
should be started under hospital supervision.
TIE See TRANSIENT ISCHAEMIC ATTACKS OR EPISODES (TIA, TIE).
Timolol Maleate A beta-adrenoceptor-blocking drug which is of value in t
he treatment of ANGINA
PECTORIS, myocardial infarction (see HEART, DISEASES OF)
713
and HYPERTENSION. It is also used in the treatment of GLAUCOMA. (See als
o ADRENERGIC RECEPTORS.)
Tincture An alcoholic solution used in PHARMACY, generally of some veget
able substance.
Tinea See RINGWORM.
Tinnitus A noise heard in the EAR without any external cause. It often a
ccompanies DEAFNESS, and
severely deaf patients find tinnitus as troubling as if not more so than the dea
fness. Tinnitus is
described as objective if it is produced by sound generated within the body by vas
cular tumours or
abnormal blood flows. In patients with conductive hearing loss, tinnitus may be
the consequence of the
blocking of outside noises so that their own bodily activities become audible. E
ven normal people
occasionally suffer from tinnitus, but rarely at a level which prompts them to s
eek medical advice. Present
knowledge of the neurophysiological mechanisms is that the noise arises high in th
e central nervous
system in the subcortical regions of the BRAIN. The resting level of spontaneous
neuronal activity in the
hearing system is only just below that at which sound enters a persons consciousn
ess a consequence of
the fine-tuning of normal hearing; so it is not, perhaps, surprising that normal
ly unheard neuronal
activity becomes audible. If a patient suffers sensorineural deafness, the body
may reset the awareness
threshold of neural activity, with the brain attempting greater sensitivity in a
n effort to overcome the
deafness. The condition has a strong emotional element and its management calls
for a psychological
approach to help sufferers cope with what are, in effect, physically untreatable
symptoms. They should be
reassured that tinnitus is not a signal of an impending stroke or of a disorder
of the brain. COGNITIVE
BEHAVIOUR THERAPY can be valuable in coping with the unwanted noise. Traditional
ly, masking sounds,
generated by an electrical device in the ear, were used to help tinnitus suffere
rs by, in effect, making
the tinnitus inaudible. Even with the introduction of psychological retraining t
reatment, these maskers may
still be helpful; the masking-noise volume, however, should be kept as low as po
ssible or it will interfere
with the retraining process. For patients with very troublesome tinnitus, length
y counselling and
retraining
T
Tomography
100,000 premature deaths a year in the United Kingdom alone. In addition
to the deaths caused by
cigarette smoking, it is also a major cause of disability and illness in the for
m of myocardial infarction
(see HEART, DISEASES OF), PERIPHERAL VASCULAR DISEASE, and EMPHYSEMA. Tobacco-sm
oking is also a serious
hazard to the FETUS if the mother smokes. Furthermore, passive smoking inhalatio
n of other peoples
tobacco smoke has been shown to be a health hazard to non-smokers.
Composition In addition to vegetable fibre, tobacco leaves contain a lar
ge quantity of ash, the nature
of this depending predominantly upon the minerals present in the ground where th
e tobacco plant has been
grown. Of the organic constituents, the brown fluid alkaloid known as NICOTINE i
s the most important. The
nicotine content of different tobacco varies, and the amount absorbed depends up
on whether or not the
smoker inhales. Nicotine is the substance that causes a person to become addicte
d to tobacco smoking (see
DEPENDENCE). Tobacco smoke also contains some 16 substances capable of inducing
cancer in experimental
animals. One of the most important of these is benzpyrene, a strongly carcinogen
ic hydrocarbon. As this is
present in coal tar pitch, it is commonly referred to in this context as tar. Ot
her constituents of tobacco
smoke include pyridine, ammonia and carbon monoxide. Nicotine addiction is a lif
e-threatening but treatable
disorder, and nicotine-replacement treatment is available on NHS prescription. T
his includes the provision
of bupropion trade name Zyban . The availability of this drug which should be used
with caution as it
has unwelcome side-effects in some people and the introduction of specialist smo
kingcessation services to
provide behavioural support to people who wish to stop smoking should result in
a reduction in
tobacco-related diseases. Given the critical position of nicotine in leading peo
ple to become addicted to
smoking, it is anomalous that there are no effective government regulations cove
ring the sales of tobacco.
Because it is not a food, tobacco is not regulated by the Food Standards Agency;
it is not classified as a
drug so is not controlled by legislation on medicines. Furthermore, despite bein
g a consumer product,
tobacco is exempt from the Consumer Protection Act (1987) and other government s
afety regulations. So the
NHS is left to try to ameliorate the serious health consequences lung cancer, ca
rdiovascular disease,
peripheral vascular disease, chronic bronchitis, and emphysema of a sub715
stance for which there are no effective preventive measures except the w
illpower of the individual
smoker or non-smoker. (Escalating taxation of tobacco seems to have been circumv
ented as a deterrent by the
rising incidence of smuggling cigarettes into Britain.) Action on Smoking and He
alth (ASH) is a small
charity founded by the Royal College of Physicians in 1971 that attempts to aler
t and inform the public to
the dangers of smoking and to try to prevent the disability and death which it c
auses.
Tobramycin An aminoglycoside antibiotic used to treat serious infections
such as MENINGITIS and
PERITONITIS as well as those affecting bones, joints and lungs. It is given by i
njection, sometimes in
conjunction with penicillin. It has a range of side-effects including damage to
the balance and hearing
mechanisms as well as to the kidney.
Toes See CORNS AND BUNIONS; SKIN
Nail.
Tolazomide See SULPHONYLUREAS.
Tolbutamide A sulphonamide derivative, or sulphonylurea (see SULPHONYLUR
EAS), which lowers the level of
the blood sugar in DIABETES MELLITUS. As it is rapidly excreted from the body, i
t has to be taken twice
daily. Like CHLORPROPAMIDE, it may induce undue sensitivity to alcohol.
Tolerance This occurs when the response to a particular amount of a drug
or physiological messenger
decreases, so that a larger dose must be given to produce the same response as b
efore. It is particularly
common with certain drug dependencies (see DEPENDENCE): for example, with MORPHI
NE or HEROIN.
Toluene Also called methylbenzene: a product of the distillation of coal
tar widely used as a solvent
in the manufacture of paint and rubber and plastic cements.
Tomography A technique using X-RAYS or ULTRASOUND to build up a focused
image of a slice through the
body at a given level. By producing a series of such slices at different depths,
a threedimensional image
of the body structures can be built up.
T
716 -tomy
-tomy A suffix indicating an operation by cutting.
Tongue The tongue is made up of several muscles, is richly supplied with
blood vessels and nerves, and
is covered by highly specialised MUCOUS MEMBRANE. It consists of a free part kno
wn as the tip, a body, and
a hinder fixed part or root. The under-surface lies upon the floor of the mouth,
whilst the upper surface
is curved from side to side, and still more from before backwards so as to adapt
it to the roof of the
mouth. At its root, the tongue is in contact with, and firmly united to, the upp
er edge of the LARYNX; so
that in some persons who can depress the tongue readily the tip of the EPIGLOTTI
S may be seen projecting
upwards at its hinder part.
Structure The substance of the tongue consists almost entirely of muscle
s running in various
directions. The tongue also has numerous outside attachments: one muscle on each
side unites it to the
lower jaw-bone just behind the chin, and this muscle serves to protrude the
tongue from the mouth; other muscles, which retract the tongue, attach i
t to the hyoid bone, the
larynx, the PALATE, and the styloid process on the base of the SKULL. The mucous
membrane on the
undersurface of the tongue is very thin. In the middle line, a fold of mucous me
mbrane, the frenum, passes
from the under-surface to the floor of the mouth; when this frenum is attached t
oo far forwards towards the
tip of the tongue, the movements of the organ are impeded the condition being kn
own as tongue-tie. On the
upper surface or dorsum of the tongue, the mucous membrane is thicker, and in it
s front two-thirds is
studded with projections or papillae, most of which are conical. Some of them en
d in long filaments, and
are then known as filiform papillae. On the tip, and towards the edges of the to
ngue, small, red, rounded
fungiform papillae are seen, which act as end-organs for the sense of taste as d
o circumvallate papillae,
each of which is surrounded by a trench along which open numerous taste-buds. Th
ese taste-buds are also
found in the fungiform papillae, scattered over
T
(Left) Tongue from above showing different areas of taste discrimination
. (Right) Vertical section
through surface of tongue showing taste-bud ( x 400).
Tonsillitis
the throat, FAUCES, and palate. Five nerves, originating from the fifth,
seventh, ninth, tenth and 12th
cervical nerves supply the tongue.
Functions The chief uses of the tongue are:
push the food between the teeth for tomastication, and then mould it int
o a bolus preparatory to
swallowing;
the organ of the sense of taste, and as an asorgan provided with a delic
ate sense of touch; and
a part in the production of speech. to(Seeplay VOICE AND SPEECH.) It is
usual to classify any taste
as: sweet, bitter, salt and acid, since finer distinctions are largely dependent
upon the sense of smell.
The loss of keenness in taste brought about by a cold in the head, or even by ho
lding the nose while
swallowing, is well known. Sweet tastes seem to be best appreciated by the tip o
f the tongue, acids on its
edges, and bitters at the back. There are probably different nerve-fibres and en
d-organs for the different
varieties of taste. Many tastes depend upon the ordinary sensations of the tongu
e. Like other sensations,
taste can be very highly educated for a time, as in tea-tasters and wine-tasters
, but this special
adaptation is lost after some years.
Tongue, Disorders of Conditions of the tongue At rest, the touches all t
he lower teeth and is slightly
arched from side to side. It has a smooth surface with a groove in the middle an
d an even but definite
edge. It is under voluntary control and the tip can be moved in all directions.
Ankyloglossia or tongue-tie
is a rare disorder in which the frenum or band connecting the lower surface of t
he tongue to the floor of
the mouth is so short or tight that the tongue cannot be protruded. Surgery can
remedy the defect. It is
easy to overdiagnose and is not a common cause of difficulty in feeding at birth
or speech defects in
infancy. Gross enlargement of the tongue can make speech indistinct or make swal
lowing and even breathing
difficult. This is known as macroglossia and may be such that the tongue is cons
tantly protruded from the
mouth. The cause may be CONGENITAL, as in severe cases of DOWNS (DOWN) SYNDROME,
or it may occur as a
result of ACROMEGALY or be due to abnormal deposits as in AMYLOIDOSIS. A marked
tremor of the tongue when
proTONGUE
717
truded may be seen in various neurological diseases, but may be caused b
y alcoholism. After a STROKE
involving the motor nerve centre, the control of one side of the tongue musculat
ure will be lost. This will
result in the protruded tongue pointing to the side of the body which is paralys
718 Tonsils
cases of sore throat, the tonsils are involved in the generalised inflamma
tion of the throat.
Causes Most commonly caused by the haemolytic STREPTOCOCCUS, its incidenc
e is highest in the winter
months. In the developing world it may e the presenting feature of DIPHTHERIA,
a disease now virtually
non-existant in the West since the introduction of IMMUNISATION. Symptoms The on
set is usually fairly
sudden with pain on swallowing, fever and malaise. On examination, the tonsils a
re engorged and covered
with a whitish discharge (PUS). This may occur at scattered areas over the tonsi
llar crypts (follicular
tonsillitis), or it may e more extensive. The glands under the jaw are enlarged
and tender, and there may
e pain in the ear on the affected side: although usually referred pain, this ma
y indicate spread of the
infection up the Eustachian tue to the ear, particularly in children. Occasiona
lly an ABSCESS, or quinsy,
develops around the affected tonsil. Due to a collection of pus, it usually come
s on four to five days
after the onset of the disease, and requires specialist surgical treatment.
Treatment Most cases need no treatment.
T
Therefore, it is advisale to take a throat swa to assess the nature of
any acterial treatment efore
starting treatment. Penicillin or erythromycin are the drugs of choice where et
ahaemolytic streptococci
are isolated, together with paracetamol or aspirin, and plenty of fluids. Remova
l of tonsils is indicated:
when the tonsils and adenoids are permanently so enlarged as to interfere with
reathing (in such cases the
adenoids are removed as well as the tonsils); when the individual is suject to
recurrent attacks of acute
tonsillitis which are causing significant deility, asence from school or work
on a regular asis (more
than four times a year); when there is evidence of a tumour of the tonsil. Recur
rent sore throat is not an
indication for removing tonsils.
Tonsils Two almond-shaped glands (see GLAND) situated one on each side o
f the narrow FAUCES where the
mouth joins the throat. Each has a structure resemling that of a lymphatic glan
d, and consists of an
elevation of the mucous memrane presenting 1215 openings, which lead into pits o
r lacunae. The mucous
covering is formed y the ordinary mucous memrane of the mouth, which also line
s the pits; and the main
sustance of the gland is composed of
loose connective tissue containing lymph corpuscles in its meshes, and p
acked here and there into
denser nodules or follicles. The tonsils play an important role in the protectiv
e mechanism of the ody
against infection.
Touch
Touch The sense that enales an individual to assess the physical charac
teristics of ojects for
example, their size, shape, temperature and texture. The sense of touch is consi
dered here along with other
senses associated with the skin and muscles. The cutaneous senses comprise:
Touch sense proper, y which we perceive a touch or stroke and estimate
the size and shape of odies
with which we come into contact, ut which we do not see.
Pressure sense, y which we judge the heaviness of weights laid upon the
skin, or appreciate the
hardness of ojects y pressing against them. Heat sense, y which we perceive t
hat an oject is warmer
than the skin.
Cold sense, y which we perceive that an oject touching the skin is col
d. Pain sense, y which we
appreciate pricks, pinches and other painful impressions.
Muscular sensitiveness, y which the painfulness of a squeeze is perceiv
ed. It is produced proaly y
direct pressure upon the nerve-fires in the muscles.
719
ated y only 1 mm; on the tips of the fingers they must e separated to
twice that distance, whilst on
the arm or leg they cannot e felt as two points unless separated y over 25 mm,
and on the ack they must
e separated y more than 50 mm. On the parts covered y hair, the nerves ending
around the roots of the
hairs also take up impressions of touch. Pressure is estimated proaly through
the same nerve-endings and
nerves that have to do with touch, ut it depends upon a difference in the sensa
tions of parts pressed on
and those of surrounding parts. Heat-sense, cold-sense and pain-sense all depend
upon different
nerveendings in the skin; y using various tests, the skin may e mapped out int
o a mosaic of little areas
where the different kinds of impressions are registered. Whilst the tongue and f
inger-tips are the parts
most sensitive to touch, they are comparatively insensitive to heat, and can eas
ily ear temperatures which
the cheek or elow could not tolerate. The muscular sense depends upon the senso
ry organs known as
musclespindles, which are scattered through the sustance of the muscles, and th
e sense of locality is
dependent partly upon these and partly upon the nerves which end in tendons, lig
aments and joints.
Disorders of the sense
n in which there is excessive
sensitiveness to any stimulus,
mere touch or gentle
handling causes acute pain, it
diseases of the SPINAL CORD
immediately aove the level of
y which we test the weight of an oject held in the hand, or gauge the
amount of energy expended on an
effort.
Sense of locality, y which we can, without looking, tell the position a
nd attitude of any part of the
ody.
Common sensation,
which is a vague term used to mean composite sensations produced y seve
ral of the foregoing, like
tickling, or creeping, and the vague sense of well-eing or the reverse that the
mind receives from
internal organs. (See the entry on PAIN.) The structure of the end-organs situat
ed in the skin, which
receive impressions from the outer world, and of the nerve-fires which conduct
these impressions to the
central nervous system, have een descried under NERVOUS SYSTEM. (See also SKIN
.) Touch affects the
Meissners or touch corpuscles placed eneath the epidermis; as these differ in cl
oseness in different
parts of the skin, the delicacy of the sense of touch varies greatly. Thus the p
oints of a pair of
compasses can e felt as two on the tip of the tongue when separT
Tracheostomy
similar causes. Usually a viral condition, treatment may e unnecessary (see CRO
UP). A rare condition,
acterial tracheitis, is more dangerous as the patient produces large amount of
thick, sticky SPUTUM which
may lock the airway causing respiratory failure and collapse. Treatment is y i
nsertion of an endotracheal
tue under general anaesthesia (see ENDOTRACHEAL INTUBATION), removing the secre
tions and using high-dose
antiiotics.
Tracheostomy
(1) Thin strips of ony tissue occurring in cancellous BONE sometimes ca
lled spongy one. (2) A and
of CONNECTIVE TISSUE passing from the outer part of an organ to the interior, se
parating the organ into
discrete chamers.
Also known as tracheotomy. The operation in which the TRACHEA or windpip
e is opened from the front of
the neck, so that air may e directly drawn or passed into the lower AIR PASSAGE
S. The opening is made
through the second and third rings of the trachea.
Trace Elements
Reasons for operation The cause of
Chemical elements that are distriuted throughout the tissues of the od
y in very small amounts and are
essential for the nutrition of the ody. Nine such elements are now recognised:
coalt, copper, fluorine,
iodine, iron, manganese, molydenum, selenium and zinc.
laryngeal ostruction should e treated ut, if ostruction is acute and
endangering the patients
life, urgent intervention is necessary. In most cases the insertion of an endotr
acheal tue either through
the nose or mouth and down the pharynx through the larynx to ypass the ostruct
ion is effective (see
ENDOTRACHEAL INTUBATION). If not, tracheostomy is performed. The majority of tra
cheostomies performed
nowadays are for patients in intensive-therapy-unit situations. These patients r
equire airway intervention
for
Tracer A compound introduced into the ody, the progress of which can su
sequently e followed and
information otained aout the odys metaolic activities. Radioactive tracers ar
e
T
722 Trachoma
prolonged periods to facilitate artificial ventilation which is performe
d y means of a mechanical
ventilator. The presence of a tue passing through the larynx for a prolonged pe
riod of time is associated
with long-term damage to the larynx, and therefore any patients requiring prolon
ged intuation usually
undergo a tracheostomy to prevent further damage. Endotracheal intuation is als
o the preferred method of
airway-intervention for acute inflammatory disorders of the upper airway (as opp
osed to tracheostomy);
tracheostomy in these cases is performed only in the emergency situation if faci
lities for endotracheal
intuation are not availale or if they are unsuccessful. Tracheostomy may also
e performed for large
tumours which ostruct the larynx until some form of treatment is instituted. Si
milarly it may e needed in
conditions wherey the nerve supply to the larynx has een jeopardised, impairin
g its protective function
of the upper airway and its respiratory function.
Tracheostomy tues When the trachea has een opened y an incision throu
gh the skin etween the
Adams apple and the clavicles; another through the THYROID GLAND followed y a sm
all vertical incision in
the trachea a metal or plastic tue is inserted to maintain the opening. There i
s always an outer tue
which is fixed in position y tapes passing round the neck, and an inner tue wh
ich slides freely out of
and into the other, so that it may e removed at any time for cleansing, and is
readily coughed-out should
it happen to ecome locked y mucus.
T
ally inactive. The acterium is transmitted y flies and causes inflamma
tion of the conjunctiva and
cornea (see EYE) with consequent scarring. The active disease is treated with te
tracycline talets and eye
drops; cure is usually satisfactory. In theory, trachoma should e easy to elimi
nate. The World Health
Organisation, which aims to do this y 2020, is using a fourpronged strategy to
tackle the disease. This
comprises: surgery to correct deformed eyelids efore lindness occurs. antiiot
ics to kill Chlamydia.
regular face-washing to stop acterial spread. environmental improvements for ex
ample, etter sanitation
and ruish disposal to eliminate the acteria.
Traction The application of a pulling force to the distal part of a frac
ture in order to allow the
fracture to heal with the one in correct alignment. There are many different me
thods for applying
traction, usually involving weights and pulleys.
Tractotomy A neurological operation to relieve intractale PAIN. The tha
lamic tracts of the SPINAL CORD
contain the nerve-fires that signal pain. They travel from the source of the pa
in in an organ or tissue
such as skin or one via the cord to the rain stem and cortex (see BRAIN) where
the individual ecomes
conscious of the pain. The operation aims to sever these tracts within the medulla
olongata of the
rain.
After-treatment When the operation has
Training
een performed for some permanent ostruction, the tue must e worn per
manently; and the doule metal
tue is in such cases replaced after a short time y a soft plastic single one.
When the operation has
relieved some ostruction caused, say, y diphtheria, the tue is left out now a
nd then for a few hours,
and finally, at the end of a week or so, is removed altogether, after which the
wound quickly heals up.
See DIET; EXERCISE.
Trachoma Trachoma is a severe type of conjunctivitis (see under EYE, DIS
ORDERS OF). This chronic
contagious condition is caused y Chlamydia trachomatis, a acterium with viruslike characteristics. The
disease affects 150 million people worldwide and is common in developing countri
es, where it is the leading
cause of preventale lindness. It may e seen in immigrant populations in devel
oped countries, although it
is usuTrance A profound SLEEP from which a person
, ut which is not due to
organic disease. The power of voluntary movement is
nd even consciousness may
remain. It is a disturance in mental functions and
EPSY, AUTOMATISM and petit
mal EPILEPSY. A trance may e induced y HYPNOTISM.
Transfusion
Tranquillisers A tranquilliser is a popular name for a drug which induce
s a mental state free from
agitation and anxiety, and renders the patient calm. Tranquillisers are classifi
ed as major and minor. The
former are used to treat psychotic illness such as SCHIZOPHRENIA; the latter are
sedatives used to treat
anxiety and emotional upsets (see NEUROSIS) and are called antianxiety drugs or
ANXIOLYTICS. Major
tranquillisers or antipsychotic drugs are given to patients with psychotic disor
ders which disrupt their
normal lives (see PSYCHOSIS). They do not cure the patient, ut do help to contr
ol his or her symptoms so
that the person can live in the community and e admitted to hospital only for a
cute episodes. The drug
chosen depends upon the type of illness and needs of a particular patient as wel
l as the likely adverse
effects. Antipsychotic drugs modify the transmission of nerve-signals y making
rain cells less sensitive
to the excitatory neurotransmitter chemical called DOPAMINE. Among the antipsych
otic tranquillisers are
CHLORPROMAZINE, HALOPERIDOL, CLOZAPINE and flupenthixol. Anxiety is a consequenc
e of too much STRESS and
may occur without eing serious enough to need treatment. Clinically it arises w
hen the alance etween
certain chemicals in the rain is distured: this increases activity in the symp
athetic system, thus
provoking physical symptoms such as reathlessness, tachycardia, headaches and i
ndigestion. Anxiolytics
help to alleviate these symptoms ut do not necessarily cure the underlying caus
e. Two main classes of drug
relieve anxiety: BENZODIAZEPINES and eta lockers (see BETA-ADRENOCEPTORBLOCKIN
G DRUGS). The latter, which
include atenolol and propanolol, reduce the physical symptoms such as tachycardi
a and are useful in
circumstances for example, examinations known to cause anxiety attacks. They lo
ck the action of
NORADRENALINE, a key chemical of the sympathetic nervous system. Benzodiazepines
depress activity in that
part of the rain controlling emotion y stimulating the action of a chemical ca
lled gammaaminoutyric acid
(GABA). Among the enzodiazepines are chlordiazepoxide and diazepam. (See also M
ENTAL ILLNESS.)
Transcervical Resection of Endometrium (TCRE) An operation, usually done
under local anaesthetic, in
which the lining memrane of the UTERUS (wom) is excised using a type of LASER
or DIATHERMY surgery that
utilises a hysterescope (a variety of ENDOSCOPE) through
723
which the operator can visualise the inside of the uterus. The operation
is done to treat MENORRHAGIA
(heavy lood loss during MENSTRUATION) and its introduction has reduced the need
to perform HYSTERECTOMY
for the condition.
Transcutaneous Electrical Nerve Stimulation (TENS) A method of electrica
724 Transfusion
announced that it would no longer accept donations from anyone who had r
eceived a lood transfusion
since 1980 ecause of the remote possiility that they might have een infected
with the PRION which
causes nvCJD. A standard transfusion ottle has een developed, and whole lood
may e stored at 26 C for
three weeks efore use. Transfusions may then e given of whole lood, plasma,
lood cells, or PLATELETS,
as appropriate. Stored in the dried form at 421 C, away from direct sunlight, huma
n plasma is stale for
five years and is easily reconstituted y adding sterile distilled water. The Na
tional Blood Authority
prepares several components from each donated unit of lood: whole lood is rare
ly used in adults. This
permits each product, whether plasma or various red-cell concentrates, to e sto
red under ideal conditions
and used in appropriate clinical circumstances say, to restore lood loss or to
treat haemostatic
disorders. Transfusion of lood products can cause complications. Around 5 per c
ent of transfused patients
suffer from a reaction; most are mild, ut they can e severe and occasionally f
atal. It can e difficult
to distinguish a transfusion reaction from symptoms of the condition eing treat
ed, ut the safe course is
to stop the transfusion and start appropriate investigation. In the developed wo
rld, clinicians can expect
to have access to high-quality lood products, with the responsiility of provid
ing lood resting with a
specially organised transfusion service. The cause of most fatal haemolytic tran
sfusion reactions is a
clerical error due to faulty laelling and/or failure to identify the recipient
correctly. Hospitals should
have a strict protocol to prevent such errors.
T
Artificial lood Transfusion with lood from donors is facing increasing
prolems. Demand is rising;
suitale lood donors are ecoming harder to attract; the processes of taking, s
toring and cross-matching
donor lood are time-consuming and expensive; the shelflife is six weeks; and th
e risk of adverse reactions
or infection from transfused lood, although small, is always present. Artificia
l lood would largely
overcome these drawacks. Several companies in North America are now preparing t
his: one product uses
purified HAEMOGLOBIN from humans and another from cows. These provide oxygen-car
rying capacity, are
unlikely to e infectious and do not provoke immunological rejections. Yet anoth
er product, called
Oxygene, does not contain any animal or human lood products; it comprises salt w
ater
and a sustance called perfluron, the molecules of which store oxygen a
nd asor caron dioxide more
effectively than does haemogloin. Within 24 hours of eing transfused into a pe
rsons loodstream,
perfluron evaporates and is harmlessly reathed out y the recipient. Artificia
l lood is especially
valuale in that it contains no unwanted proteins that can provoke adverse immun
ological reactions.
Furthermore, it is disease-free, lasts for up to three years and is no more expe
nsive than donor lood. It
could well take the place of donor lood within a few years.
Autologous transfusion is the use of an individuals own lood, provided i
n advance, for transfusion
during or after a surgical operation. This is a valuale procedure for operation
s that may require large
transfusions or where a person has a rare lood group. Its use has increased for
several reasons: fear of
infection such as HIV and hepatitis. shortages of donor lood and the rising cos
t of units of lood.
sustantial reduction of risk of incompatile transfusions. In practice, lood t
ransfusion in the UK is
remarkaly safe, ut there is always room for improvement. So, in the 1990s, a U
K inquiry on the Serious
Hazards of Transfusion (SHOT) was launched. It estalished (1998) that of 169 re
cently reported serious
hazards following lood transfusion, 81 had involved a lood component eing giv
en to the wrong patient,
while only eight were the result of viral or acterial infections. There are thr
ee ways to use a patients
own lood in transfusion: (1) predeposit autologous donation (PAD) taking lood
from a patient efore
operation and transfusing this lood ack into the patient as required during an
d after operation. (2)
acute normovalaemic haemodilution (ANH) diluting previously withdrawn lood and
thus increasing the
volume efore transfusion. (3) perioperative cell salvage (PCS) the use of centr
ifugal cell separation on
lood saved during an operation, particularly spinal surgery where lood loss ma
y e considerale. The
government has urged NHS trusts to consider the introduction of PCS as a possil
e adjunct or alternative to
anked-lood transfusion. In one centre (Nottingham), PCS has een used in the f
orm of continuous
autologous transfusion for several years with success.
Transplantation
Exchange transfusion is the method of treatment in severe cases of HAEMO
LYTIC DISEASE OF THE NEWBORN.
It consists of replacing the whole of the ays lood with Rh-negative lood of t
he correct lood group
for the ay.
Transient Ischaemic Attacks or Episodes (TIA, TIE) Episodes of transient
ISCHAEMIA of some part of the
cereral hemispheres or the rain stem (see BRAIN) lasting anything from a few m
inutes to several hours and
followed y complete recovery. By definition, the ischaemic episode must e less
than 24 hours. These
episodes may e isolated or they may occur several times in a day. The cause is
ATHEROMA of the carotid or
verteral arteries (see ARTERIES, DISEASES OF) and the emolisation (see EMBOLIS
M) of PLATELETS or
CHOLESTEROL. These attacks present with strokes (see STROKE) that rapidly recove
r.
Translocation The term used to descrie an exchange of genetic material
etween CHROMOSOMES. It is an
important factor in the etiology, or causation, of certain congenital anormalit
ies such as, for example,
DOWNS (DOWN) SYNDROME. It is one of the main anormalities sought for in AMNIOSCO
PY.
Transplantation Transplantation of tissues or organs of the ody are def
ined as an allotransplant, if
from another person; an autotransplant, if from the patient him or herself for e
xample, a skin graft (see
GRAFT; SKIN-GRAFTING); and a xenotransplant, if from an animal. The pioneering s
uccess was achieved with
transplantation of the kidney in the 1970s; this has een most successful when t
he transplanted kidney has
come from an identical twin. Less successful have een live transplants from oth
er lood relatives, while
least successful have een transplants from other live donors and cadaver donors
. The results, however, are
steadily improving. Thus the one-year functional survival of kidneys transplante
d from unrelated dead
donors has risen from around 50 per cent to over 80 per cent, and survival rates
of 80 per cent after three
years are not uncommon. For a well-matched transplant from a live related donor,
the survival rate after
five years is around 90 per cent. And, of course, if a transplanted kidney fails
to function, the patient
can always e switched on to some form of DIALYSIS. In the United Kingdom the su
pply of cadaveric (dead)
kidneys for transplantation is only aout half that necessary to meet the demand
.
725
Other organs that have een transplanted with increasing success are the
heart, the lungs, the liver,
one marrow, and the cornea of the eye. Heart, lung, liver and pancreas transpla
ntations are now carried
out in specialist centres. It is estimated that in the United Kingdom, approxima
opposite to that of the genitalia and the secondary sex characteristics. Suject
s may e helped y
counselling, drug therapy and in some circumstances an operation to change their
physical sexual
characteristics. Trans-sexuals or their families wanting help and guidance shoul
d contact the Gender
Identity Consultancy.
Transudation The passage of liquid called the transudate through a memr
ane: for example, the
passage of lood through the wall of a capillary vessel.
Transurethral Resection The use of a special CYSTOSCOPE (a resectoscope)
inserted through the URETHRA
to resect the PROSTATE GLAND or ladder tumours. (See also RESECTION.)
Transverse An anatomical description of a line, plane or structure at ri
ght-angles to the long axis of
an organ or the ody.
Transvestitism Also called transvestism. The term given to a psycho-sexu
al condition in which there is
a repetitive compulsion to dress in the clothes of the opposite sex to achieve O
RGASM.
UGS.
Trendelenerg Position
Traumatology Branch of SURGERY specialising in the treatment of wounds a
nd disailities arising from
injuries.
Travel Medicine Many countries have reciprocal health arrangements with
Britain under which British
visitors may receive emergency treatment free or at reduced cost. Information a
out these arrangements is
availale from any local DSS office. General and specific advice for travellers
on such matters as
immunisations needed can e otained from their general practitioner, through tr
avel agents or one of the
high street travel health shops. Travellers are advised to consult a doctor if the
y develop an illness
after an overseas visit: some tropical disorders may take days or even weeks to
produce symptoms.
Travel Sickness Sickness induced y any form of transport, whether y se
a, air, motor-car or train.
(See also MOTION (TRAVEL) SICKNESS.)
Travellers diarrhoea is an all-toocommon affliction of the traveller, whi
ch asks in a multiplicity of
names: for example, Aden gut, Aztec two-step, Basra elly, Delhi elly, Gippy tu
mmy, Hong Kong dog,
Montezumas revenge, Tokyo trots, turista. It is caused y a variety of micro-orga
nisms, usually E. coli.
Some people seem to e more prone to it than others, although for no good cause.
Ovious preventive
measures include the avoidance of salads, unpeeled fruit and ice cream, and neve
r drinking unoiled or
unottled water. If diarrhoea occurs, co-phenotrope and loperamide are often use
d to reduce the frequency
of owel movements in adults. Prophylactic antiacterial drugs are not advisale
.
Tremor A fine involuntary movement. Tremors may e seen in projecting pa
rts like the hands, head and
tongue, or they may involve muscles. Coarse tremors, which prevent a person from
drinking a glass of water
without spilling it, are found in MULTIPLE SCLEROSIS (MS) and in CHOREA; somewha
t finer tremors, which
produce tremling of the hands or tongue when they are stretched out, are caused
y alcoholism (see
ALCOHOL) and other forms of poisoning, y PARKINSONISM, and y the weakness whic
h follows some acute
disease or characterises old age. A fine tremor of the outstretched fingers is a
characteristic of
thyrotoxicosis (see under THY727
ROID GLAND, DISEASES OF); very fine tremors, visile in the muscles of f
ace or lims and known as
firillary tremors, are present in general paralysis of the insane (see SYPHILIS
), and in progressive
muscular atrophy or wasting palsy. Tremors may occur at rest and disappear on mo
vement as in Parkinsonism,
728 Trepanning
and emarrasses reathing, raising the legs y themselves is etter.
Trepanning An operation in which a portion of the CRANIUM is removed. Or
iginally the operation was
performed with an instrument resemling a carpenters race and known as the treph
ine or trepan, which
removes a small circle of one; ut now this instrument is only used, as a rule,
for making small openings,
whilst, for wider operations, gouge forceps, circular saws driven y electric mo
tor, or wire saws are used.
Trepanning is used in cases of fracture, with splintering of the skull; the oper
ation is performed to
remove fragments of one and any foreign odies, like a ullet, which may have e
ntered. In compression of
the rain with unconsciousness following an injury, the skull is trephined and a
ny lood clots removed, or
torn vessels ligatured. The operation may also e done for an ABSCESS within the
skull and for other
conditions where operative access to the rain is required.
Trephining See TREPANNING.
Treponema The name of a genus of spirochaetal microorganisms which consi
st of slender spirals and which
progress y means of ending movements. Treponema pallidum (formerly called Spir
ochaeta pallida) is the
causative organism of SYPHILIS.
Triage
T
Derived from the French word for sorting, triage is a universal term appli
ed to methods of allocating
treatment prioritisations for casualties from disasters or in warfare. The proce
dure helps a medical team
to treat casualties who, although adly injured, can e saved; to defer those wh
ose treatment is less
urgent; and to provide care and comfort for those with fatal injuries. Triage is
now operated in accident
and emergency departments y a triage nurse who allocates a degree of priority so
that patients are seen
in order of severity rather than according to their time of arrival.
the skin and joints y local injection.
Triceps A muscle of the posterior upper arm which acts to extend the for
earm. So-named ecause it
originates from three heads.
Trichiasis A condition in which the eyelashes ecome ingrown. (See EYE,
DISORDERS OF.)
Trichiniasis See TRICHINOSIS.
Trichinosis Trichinosis, or trichiniasis, is a disease caused y eating
meat infected with the
parasitic nematode worm, Trichinella spiralis. Although it infects more than 100
Trigeminal Neuralgia
Trigger Finger
Trinitrophenol
Also called snapping finger. This is the condition in which, when the fi
ngers are straightened on
unclenching the fist, one finger usually the ring or middle finger remains ent.
The cause is oscure.
In severe cases treatment consists of opening up the sheath surrounding the tend
on of the affected finger.
When confined to the thum, the condition is known as trigger thum.
See PICRIC ACID.
Trigger Thum See TRIGGER FINGER.
Triglyceride A LIPID or neutral FAT comprising GLYCEROL and three fattyacid molecules. Triglycerides
are manufactured in the ody from the digested products of fat in the diet. Fats
are stored in the ody as
triglycerides.
Trigone The ase of the URINARY BLADDER etween the openings of the two
ureters (see URETER) and of the
URETHRA.
Triplets See MULTIPLE BIRTHS.
Triple Vaccine Also known as DPT vaccine, this is an injection that prov
ides IMMUNITY against
DIPHTHERIA, pertussis (whooping-cough) and TETANUS. It is given as a course of t
hree injections at around
the ages of two, three and four months. A ooster dose of diphtheria and tetanus
is given at primary-school
age. Certain infants those with a family history of EPILEPSY, or who have neurol
ogical disorders or who
have reacted severely to the first dose should not have the pertussis element of
DPT. (See MMR VACCINE;
IMMUNISATION.)
Trismus Another name for TETANUS.
Trocar An instrument provided with a sharp three-sided
Truss
point fitted inside a tue or cannula, and used for puncturing cavities
of the ody in which fluid has
collected.
Trochanter The name given to two ony prominences at the upper end of th
e thigh-one (FEMUR). The
greater trochanter can e felt on the outer side of the thigh; the lesser trocha
nter is a small prominence
on the inner side of this one.
Trochlear Nerve The fourth cranial nerve (arising from the BRAIN), which
acts upon the superior olique
muscle of the EYE.
Trophic A term applied to the influence that nerves exert with regard to
the healthiness and
nourishment of the parts to which they run. When the nerves ecome diseased or i
njured, this influence is
lost and the muscles waste, while the skin loses its healthy appearance and is l
iale to reak down into
ulcers (see ULCER).
Tropholast The outer layer of the fertilised OVUM which attaches the ov
um to the wall of the UTERUS
(or wom) and supplies nutrition to the EMBRYO.
Trophozoite A stage in the life of the parasite Plasmodium, that is the
cause of MALARIA. It has a
ringshaped ody and single nucleus and grows in the lood cell, after which it d
ivides to form a schizont.
Tropical Diseases Technically, those diseases occurring in the area of t
he gloe situated etween the
Tropic of Cancer and the Tropic of Capricorn: pertaining to the sun. They includ
e many exotic infections
many of them parasitic in origin which fall under the umrella of TROPICAL MEDICI
NE. However, disease
in the tropics is far roader than this and includes numerous other infections,
many of them with a viral
or acterial asis: for example, the viral hepatidises, streptococcal and pneumo
coccal infections, and
tuerculosis. The prevalence of other diseases, such as rheumatic cardiac diseas
e, cirrhosis, heptocellular
carcinoma (hepatoma), and various nutrition-related prolems, is also much increas
ed in most areas of the
tropics. With people from developed countries increasingly travelling to worldwi
de destinations for
usiness and holiday, the
731
importation of tropical diseases to temperate climates should e orne in
mind when people fall ill.
The following diseases and conditions are treated under their separate dictionar
y entries: ANCYLOSTOMIASIS;
BERIBERI; BLACKWATER FEVER; CHOLERA; DENGUE; DRACONTIASIS; DYSENTERY; ELEPHANTIA
SIS; FILARIASIS; HEAT
STROKE; LEISHMANIASIS; LEPROSY; LIVER, DISEASES OF; MALARIA; ORIENTAL SORE; PLAG
732 Trypanosoma
thetic techniques mean that most people can have their hernias surgicall
y repaired.
Trypanosoma A genus of microscopic parasites, several of which are respo
nsile for causing SLEEPING
SICKNESS and some allied diseases.
Trypanosomiasis See SLEEPING SICKNESS.
Trypsin The chief protein ENZYME of the pancreatic secretion. Secreted
y the PANCREAS as trypsinogen
(an inactive form), it is converted in the duodenum y another enzyme, enteropep
tidase. It changes proteins
into peptones and forms the main constituent of pancreatic extracts used for dig
estion of food. (See
PEPTONISED FOODS.)
Tryptophan (1) One of the nine indispensale (essential) AMINO ACIDS. Li
ke other amino acids,
tryptophan is needed y the ody to synthesise the proteins necessary for its gr
owth and functioning. The
description indispensale previously the adjective used was essential is applied
ecause the ody is
unale to manufacture these amino acids, which have to e otained from food or
drink. (2) A drug that has
helped some patients with resistant DEPRESSION. Used as a supporting drug with o
ther treatment, tryptophan
was withdrawn ecause of side-effects; it has, however, een reintroduced for us
e in hospital for patients
for whom no alternative treatment is suitale. (See also MENTAL ILLNESS.)
Tsetse Fly
T
An African fly of the genus Glossina. One or more of these is responsil
e for carrying the trypanosome
which causes SLEEPING SICKNESS and thus spreads the disease among cattle and fro
m cattle to humans.
Tsutsugamushi Also called Japanese river fever, this is a disease of the
typhus group. (See TYPHUS
FEVER.)
Tual Pregnancy Also known as ECTOPIC PREGNANCY. Implantation of the EMB
RYO in one of the FALLOPIAN
TUBES, rather than in the lining of the UTERUS. The patient usually complains of
pain etween six and ten
weeks gestation and, if the Fallopian tue is not removed, there may e rupture w
ith potentially
life-threatening haemorrhage.
Tuercle The term is used in two distinct senses. As a descriptive term
in anatomy, a tuercle means a
small elevation or roughness upon a BONE, such as the tuercles of the ris. In
the pathological sense, a
tuercle is a small mass, arely visile to the naked eye, formed in some organ
as the starting-point of
TUBERCULOSIS. The name of tuercle acillus was originally given to the micro-or
ganism that causes this
disease, ut was susequently changed to Mycoacterium tuerculosis. The term tu
ercular should strictly
e applied to anything connected with or resemling tuercles or nodules, and th
e term tuerculous to
anything pertaining to the disease tuerculosis.
Tuerculide The term given to any skin lesion which is the result of inf
ection with the tuercle
acillus, or Mycoacterium tuerculosis as it is now known.
Tuerculin Tuerculin is the name originally given y Koch in 1890 to a
preparation derived from the
tuercle acillus, or Mycoacterium tuerculosis as it is now known, and intende
d for the diagnosis or
treatment of TUBERCULOSIS.
Varieties is the heat-concentrated filtrate from a fluid medium on which
the human or ovine type of
Mycoacterium tuerculosis has een grown for six weeks or more.
OLD TUBERCULIN (OT)
TUBERCULIN PURIFIED PROTEIN DERIVATIVE (TUBERCULIN PPD) is the active pr
inciple of OT (see aove), and
is prepared from the fluid
medium on which the Mycoacterium tuerculosis has een grown. It is sup
plied as a liquid, a powder, or
as sterile talets. The liquid contains 100,000 units per millilitre, and the dr
y powder contains 30,000
units per milligram. It is distriuted in sterile containers sealed so as to exc
lude micro-organisms. It is
more constant in composition and potency than OT.
Uses The asis of the tuerculin reaction is that any person who has ee
n infected with the
Mycoacterium tuerculosis gives a reaction when a small amount of tuerculin is
injected into the skin. A
negative reaction means either that the individual has never een infected with
the tuercle acillus, or
that the infection has een too recent to have allowed of sensitivity developing
. There are various methods
of carrying out the test, of which the following are the most
Tuerculosis
commonly used. The Mantoux test is the most satisfactory of all, and has
the advantage that the size of
the reaction is a guide to the severity of the tuerculous infection: it is perf
ormed y injecting the
tuerculin into the skin on the forearm. The Heaf multiple puncture test is reli
ale: it is carried out
with the multiple puncture apparatus, or Heaf gun. The Vollmer patch test, using
an impregnated filter
paper, is useful in children ecause of the ease with which it can e carried ou
t.
Tuerculosis Tuerculosis results form infection with Mycoacterium tue
rculosis. The lungs are the
site most often affected, ut most organs in the ody can e involved in tuercu
losis. The other common
sites are LYMPH NODES, ones, gastrointestinal tract, kidneys, skin and MENINGES
. The weight loss and
wasting associated with tuerculosis efore treatment was availale led to the d
iseases popular name of
consumption. Enlargement of the glands in the neck, formerly called scrofula, wa
s known also as the kings
evil from the supersition that a touch of the royal hand could cure the condition
. Lupus vulgaris (see
under LUPUS) is another of the skin manifestations of the disease. The typical p
athological change in
tuerculosis involves the formation of clusters of cells called granulomas (see
GRANULOMA) with death of
the cells in the centre producing CASEATION. It is estimated that there are 78 mi
llion new cases of
tuerculosis worldwide each year, with 23 million deaths. The incidence of tuerc
ulosis in developed
countries has shown a steady decline throughout the 20th century, mainly as a re
sult of improved nutrition
and social conditions and accelerated y the development of antituerculous chem
otherapy in the 1940s.
Since the mid-1980s the decline has stopped, and incidence has even started to r
ise again in inner-city
areas. In 2002, 7,239 cases of tuerculosis were notified in the UK compared wit
h 6,442 a decade earlier;
more than 390 deaths in 2003 were attriuted to the disease. Factors involved in
this rise are immigration
from higher-prevalence areas, poorer social conditions and homelessness in some
uran centres and the
association with HIV infection and drug ause. The incidence of tuerculosis is
also rising in many
developing countries ecause of the emergence of resistant strains of the tuerc
le acillus (see elow). In
the UK recently there have een serious outreaks in a handful of uran-ased sc
hools.
Nature of the disease Tuerculosis has
733
een recognised from earliest times. Evidence of the condition has een
found in Egyptian mummies; in
the fourth century BC Hippocrates, the Greek physician, called it phthisis ecau
se of the lung involvement;
and in 1882 Koch announced the discovery of the causative organism, the tuercle
acillus or Mycoacterium
tuerculosis. The symptoms depend upon the site of the infection. General sympto
ms such as fever, weight
loss and night sweats are common. In the most common form of pulmonary tuerculo
sis, cough and
lood-stained sputum (haemoptysis) are common symptoms. The route of infection i
s most often y inhalation,
although it can e y ingestion of products such as infected milk. The results o
f contact depend upon the
extent of the exposure and the susceptiility of the individual. Around 30 per c
ent of those closely
exposed to the organism will e infected, ut most will contain the infection wi
th no significant clinical
illness and only a minority will go on to develop clinical disease. Around 5 per
cent of those infected
will develop postprimary disease over the next two or three years. The rest are
at risk of reactivation of
the disease later, particularly if their resistance is reduced y associated dis
ease, poor nutrition or
immunosuppression. In developed countries around 5 per cent of those infected wi
ll reactivate their healed
tuerculosis into a clinical prolem. Immunosuppressed patients such as those in
fected with HIV are at much
greater risk of developing clinical tuerculosis on primary contact or from reac
tivation. This is a
particular prolem in many developing countries, where there is a high incidence
of oth HIV and
tuerculosis.
Diagnosis This depends upon identification of mycoacteria on direct sta
ining of sputum or other
secretions or tissue, and upon culture of the organism. Culture takes 46 weeks u
t is necessary for
differentiation from other nontuerculous mycoacteria and for drugsensitivity t
esting. Newer techniques
involving DNA amplification y polymerase chain reaction (PCR) can detect small
numers of organisms and
help with earlier diagnosis. Treatment This can e preventative or curative. Imp
ortant elements of
prevention are adequate nutrition and social conditions, BCG vaccination (see IM
MUNISATION), an adequate
pulic-health programme for contact tracing, and chemoprophylaxis. Radiological
screening
T
Tympanic Memrane
Tumour This literally means any swelling, ut the term does not usually
include temporary swellings
caused y acute inflammation. The consequences locally, however, of chronic infl
ammation for example,
TUBERCULOSIS, SYPHILIS and LEPROSY are sometimes classed as tumours, according t
o their size and
appearance.
Varieties Some are of an infective nature, as already stated; some arise
as the result of injury, and
several contriuting factors are mentioned under the heading of CANCER. Traditio
nally tumours have een
divided into enign (simple) and malignant. Even enign tumours can e harmful,
ecause their size or
position may distort or damage nerves, lood vessels or organs. Usually, however
, they are easily removed
y surgery. Malignant tumours or cancers are harmful and potentially lethal, not
just ecause they erode
tissues locally ut ecause many of them spread, either y direct growth or y se
eding to other parts
metastasising. Malignant tumours arise ecause of an uncontrolled growth of previo
usly normal cells.
Heredity, environmental factors and lifestyle all play a part in malignancy (see
also ONCOGENES). Symptoms
are caused y local spread and as a result of metastases. These cause serious lo
cal damage, for example, in
the rain or lungs, as well as disturing the odys metaolism. Unless treated wi
th CHEMOTHERAPY,
RADIOTHERAPY or surgery or a comination of these, malignant tumours are ultimat
ely fatal. Many, however,
can now e cured. The original site and type of a malignant tumour usually deter
mine the rate and extent of
spread. The type of cell and organ site determine the characteristics of a malig
nant tumour. The prognosis
(outlook) for a patient with a malignant tumour depends largely upon how soon it
is diagnosed. Staging
criteria have een developed to assess the local and metastatic spread of a tumo
ur, its size and also
likely sensitivity to the types of availale treatment. The aility to locate a
tumour and its metastases
accurately has vastly improved with the introduction of radionuclide and ULTRASO
UND scanning, CT scanning
and magnetic resonance imaging (MRI). Screening for cancers such as those in the
reast, cervix, colorectal
region and prostate help early diagnosis and usually improve treatment outcomes.
Tumours are now classed
according to the tissues of which they are uilt, somewhat as follows: simple tu
mours of normal tissue.
735
tumours or cysts, generally of simple hollow nature. tumours: (a) of cel
lular structure, malignant
resemling the cells of skin, mucous memrane, or secreting glands; () of conne
ctive tissue.
736 Tympanites
Tympanites Also known as meteorism. Distension of the abdomen due to the
presence of gas or air in the
INTESTINE or in the peritoneal cavity (see PERITONEUM). The abdomen when struck
with the fingers, gives
under these conditions a drumlike (tympanitic) note.
Tympanum Another name for the middle EAR.
Typhoid Fever See ENTERIC FEVER.
Typhus Fever An infective disease of worldwide distribution, the manifes
tations of which vary in
different localities. The causative organisms of all forms of typhus fever belon
g to the genus RICKETTSIA.
These are organisms which are intermediate between bacteria and viruses in their
properties, and measure
05 micrometre or less in diameter.
Louse typhus, in which the infecting rickettsia is transmitted by the lo
use, is of worldwide
distribution. More human deaths have been attributed to the louse via typhus, lo
useborne RELAPSING FEVER
and trench fever, than to any other insect with the exception of the MALARIA mos
quito. Louse typhus
includes epidemic typhus, Brills disease which is a recrudescent form of epidemic
typhus and TRENCH
FEVER. Epidemic typhus fever, also known as
T
exanthematic typhus, classical typhus, and louse-borne typhus, is an acu
te infection of abrupt onset
which, in the absence of treatment, persists for 14 days. It is of worldwide dis
tribution, but is largely
confined today to parts of Africa. The causative organism is the Rickettsia prow
azeki, so-called after
Ricketts and Prowazek, two brilliant investigators of typhus, both of whom died
of the disease. It is
transmitted by the human louse, Pediculus humanus. The rickettsiae can survive i
n the dried faeces of lice
for 60 days, and these infected faeces are probably the main source of human inf
ection.
Symptoms The incubation period is usually 1014 days. The onset is precede
d by headache, pain in the
back and limbs and rigors. On the third day the temperature rises, the headache
worsens, and the patient is
drowsy or delirious. Subsequently a characteristic rash appears on the abdomen a
nd inner aspect of the
arms, to
spread over the chest, back and trunk. Death may occur from SEPTICAEMIA,
heart or kidney failure, or
PNEUMONIA about the 14th day. In those who recover, the temperature falls by CRI
SIS at about this time. The
death rate is variable, ranging from nearly 100 per cent in epidemics among debi
litated refugees to about
10 per cent.
Murine typhus fever, also known as flea typhus, is worldwide in its dist
ribution and is found wherever
individuals are crowded together in insanitary, rat-infested areas (hence the ol
d names of jail-fever and
ship typhus). The causative organism, Rickettsia mooseri, which is closely relat
ed to R. prowazeki, is
transmitted to humans by the rat-flea, Xenopsyalla cheopis. The rat is the main
reservoir of infection;
once humans are infected, the human louse may act as a transmitter of the ricket
tsia from person to person.
This explains how the disease may become epidemic under insanitary, crowded cond
itions. As a rule, however,
the disease is only acquired when humans come into close contact with infected r
ats.
Symptoms These are similar to those of louse-borne typhus, but the disea
se is usually milder, and the
mortality rate is very low (about 15 per cent).
Tick typhus, in which the infecting rickettsia is transmitted by ticks,
occurs in various parts of the
world. The three best-known conditions in this group are ROCKY MOUNTAIN SPOTTED
FEVER, fivre boutonneuse
and tickbite fever.
Mite typhus, in which the infecting rickettsia is transmitted by mites,
includes scrub typhus, or
tsutsugamushi disease, and rickettsialpox. Rickettsialpox is a mild disease caus
ed by Rickettsia akari,
which is transmitted to humans from infected mice by the common mouse mite, Allo
dermanyssus sanguineus. It
occurs in the United States, West and South Africa and the former Soviet Union.
Treatment The general principles of treatment are the same in all forms
of typhus. consists of either
avoidance or destruction of the vector. In the case of louse typhus and flea typ
hus, the outlook has been
revolutionised by the introduction of efficient insecticides such as DICHLORODIP
HENYL TRICHLOROETHANE (DDT)
and GAMMEXANE. PROPHYLAXIS
Tyrosine
The value of the former was well shown by its use after World War II: th
is resulted in almost complete
freedom from the epidemics of typhus which ravaged Eastern Europe after World Wa
r I, being responsible for
30 million cases with a mortality of 10 per cent. Now only 10,00020,000 cases occ
ur a year, with around a
few hundred deaths. Efficient rat control is another measure which reduces the r
isk of typhus very
considerably. In areas such as Malaysia, where the mites are infected from a wid
e variety of rodents
scattered over large areas, the wearing of protective clothing is the most pract
ical method of prophylaxis.
CURATIVE TREATMENT was revolutionised by the introduction of CHLORAMPHENICOL and
the TETRACYCLINES. These
antibiotics altered the prognosis in typhus fever very considerably.
737
Tyramine A variety of the chemical compound amine, which is derived from
ammonia. A sympathomimetic
agent with an action which resembles that of ADRENALINE, tyramine occurs in mist
letoe, mature cheese,
beers, red wine and decaying animal matter. This adrenaline effect is potentiall
y dangerous for patients
taking MONOAMINE OXIDASE INHIBITORS (MAOIS) ANTIDEPRESSANT DRUGS because, when c
ombined with tyramine,
the blood pressure rises sharply. Such patients should avoid taking cheese, beer
s and red wine.
Tyrosine One of the AMINO ACIDS. Tyrosine is important in the production
of CATECHOLAMINES, MELANIN and
THYROXINE.
T
U UKCC
United Kingdom Central Council for Nursing, Midwifery and Health Visitin
g, now known as the Council for
Nursing and Midwifery. (See APPENDIX 7: STATUTORY ORGANISATIONS.)
UKTSSA United Kingdom Transplant Support Service Authority (see TRANSPLA
NT SUPPORT SERVICES AUTHORITY).
Ulcer Destruction of the skins surface tissues resulting in an open sore.
A similar breach may occur
in the surface of the mucous membrane lining body cavities for example, the stom
ach, duodenum or colon
(see COLITIS). Usually accompanied by pain and local inflammation, ulcers can be
shallow or deep, with a
crater-like shape. An ulcer may heal naturally, but on certain parts of the body
legs (venous ulcers, see
below) or bony protuberances (decubitus ulcers, see below) they can become chron
ic and difficult to
treat. When an ulcer heals, granulations (well-vascularised connective tissue) f
orm which become fibrous
and draw the edges of the ulcer together. Any damage to the body surface may dev
elop into an ulcer if the
causative agent is allowed to persist for example, contact with a noxious substa
nce or constant pressure
on an area of tissue with poor circulation. Treatment of skin ulcers is effected
by cleaning the area,
regular dry dressings and local or systemic ANTIBIOTICS depending upon the sever
ity of the ulcer.
Decubitus ulcer Also known as pressure or bed sore. Occurs when there is
constant pressure on and
inadequate oxygenation of an area of skin, usually overlying a bony protuberance
. Elderly or infirm people,
or individuals with debilitating, emaciating or neurological illnesses, are vuln
erable to the condition.
Longterm pressure from a bed, wheelchair, cast or splint is the usual cause. Los
s of skin sensation is a
contributory factor, and muscle and bone as well as skin may be affected.
Treatment The most important treatment is prevention, keeping the patien
ts back, buttocks, heels and other pressure-points clean and dry, and regularly chan
ging his or her position. If
ulcers do develop, repeated local DEBRIDEMENT, protective dressings and (in seri
ous cases) surgical
treatment are required, accompanied by an appropriate antibiotic if infection is
persistent.
Venous ulcer This occurs on the lower leg or ankle and is caused by chro
nic HYPERTENSION in the deep
leg VEINS, usually the consequences of previous deep vein thrombosis (DVT) see T
HROMBOSIS; VEINS,
DISEASES OF which has destroyed the valvular system in the vein(s). The ulcer is
usually preceded by
chronic OEDEMA, often local eczema (see DERMATITIS), and bleeding into the skin
that produces brown
staining. Varicose veins may or may not be present. Control of the oedema by com
pression and encouragement
Ultrasound
control the diarrhoea. Intravenous nutrition may be required. The anaemi
a is treated with iron
supplements, and with blood infusions if necessary. Blood cultures should be tak
en, repeatedly if the fever
persists. If SEPTICAEMIA is suspected, broad-spectrum antibiotics should be give
n. Surgery to remove part
of the affected colon may be necessary and an ILEOSTOMY is sometimes required. A
fter recovery, the patient
should remain on a low-residue diet, with regular follow-up by the physician, Me
salazine and SULFASALAZINE
are helpful in the prevention of recurrences. Patients and their relatives can o
btain help and advice from
the National Association for Colitis and Crohns Disease.
Ulcer Healing Drugs A variety of drugs with differing actions are availa
ble for the treatment of peptic
ulcer, the composite title covering gastric ulcer (see STOMACH, DISEASES OF) and
DUODENAL ULCER. Peptic
ulceration may also involve the lower OESOPHAGUS, and after stomach surgery the
junction of the stomach and
small intestine. The drugs used in combination are: The receptor antagonists, wh
ich reduce the output of
gastric acid by histamine H2receptor blockade; they include CIMETIDINE, FAMOTIDI
NE and RANITIDINE.
ANTIBIOTICS to eradicate Helicobacter pylori infection, a major cause of peptic
ulceration. They are
usually used in combination with one of the PROTON-PUMP INHIBITORS and include c
larithomycin, amoxacillin
and metronidazole. BISMUTH chelates. The prostaglandin analogue misoprostol has
antisecretory and
protective properties. Proton-pump inhibitors omeprazole, lansoprazole, pantapra
zole and rabeprazole, all
of which inhibit gastric-acid secretion by blocking the proton pump enzyme syste
m.
Ulna The inner of the two bones in the forearm. It is wide at its upper
end, and its olecranon process
forms the point of the elbow. In its lower part it is more fragile and liable to
be broken by a fall upon
the forearm while something is grasped in the hand. Chipping-off of the olecrano
n process is a not uncommon
result of falls upon the elbow. (See BONE, DISORDERS OF Bone fractures.)
Ulnar Nerve A major NERVE in the arm, it runs from the brachial plexus t
o the hand. The nerve controls
739
the muscles that move the fingers and thumb and conveys sensation from t
he fifth and part of the fourth
and from the adjacent palm. Muscle weakness and numbness in the areas supplied b
y the nerve is usually
caused by pressure from an abnormal outgrowth from the epicondyle at the bottom
of the humerus (upper-arm
bone).
Ultrafiltration Filtration carried out under pressure. Blood undergoes u
ltrafiltration in the KIDNEYS
to remove the waste products, urea and surplus water that constitute URINE.
Ultrasonography The use of ULTRASOUND to produce images of structures in
the body that can be viewed on
a television screen and transferred to photographic film.
Ultrasound Ultrasound, or ultrasonic, waves comprise very-high-frequency
sound waves above 20,000 Hz
that the human ear cannot hear. Ultrasound is widely used for diagnosis and also
for some treatments. In
OBSTETRICS, ultrasound can assess the stage of pregnancy and detect abnormalitie
s in the FETUS (see below).
It is a valuable adjunct in the investigation of diseases in the bladder, kidney
s, liver, ovaries, pancreas
and brain (for more information on these organs and their diseases, see under se
parate entries); it also
detects thromboses (clots) in blood vessels and enables their extent to be asses
sed. A non-invasive
technique that does not need ionising radiation, ultrasound is quick, versatile
and relatively inexpensive,
with scans being done in any plane of the body. There is little danger to the pa
tient or operator: unlike,
for example, XRAYS, ultrasound investigations can be repeated as needed. A contr
ast medium is not required.
Its reliability is dependent upon the skill of the operator. Ultrasound is repla
cing ISOTOPE scanning in
many situations, and also RADIOGRAPHY. Ultrasound of the liver can separate medi
cal from surgical JAUNDICE
in approximately 97 per cent of patients; it is very accurate in detecting and d
efining cystic lesions of
the liver, but is less accurate with solid lesions and yet will detect 85 per ce
nt of secondary deposits
(this is less than COMPUTED TOMOGRAPHY [CT] scanning). It is very accurate in de
tecting gall-stones (see
GALL-BLADDER, DISEASES OF) and more accurate than the oral cholecystogram. It is
useful as a screening test
for pancreatic disease and can differentiate carcinoma of the pancreas
U
Ultraviolet lamps produce UVR and are used to tan skin but, because of the risk
of producing skin cancer
(see SKIN, DISEASES OF), the lamps must be used with great caution.
Umbilical Cord The fleshy tube containing two arteries and a vein throug
h which the mother supplies the
FETUS with oxygen and nutrients. The cord, which is up to 60 cm long, ceases to
function after birth and is
clamped and cut about 25 cm from the infants abdominal wall. The stump shrivels an
d falls off within two
weeks, leaving a scar which forms the UMBILICUS. (See also PREGNANCY AND LABOUR.
)
Umbilicus The scientific name for the navel, a circular depression in th
e ABDOMEN that marks the areas
where the UMBILICAL CORD was attached when the fetus was in the uterus.
Uncinate Fit A type of temporal lobe EPILEPSY in which a patient has a h
allucination of smell or of
taste; it may also be the result of a tumour pressing on that part of the BRAIN
concerned with the
appreciation of smell and taste.
Unconscious A state of UNCONSCIOUSNESS or a description of mental activi
ties of which an individual is
unaware. The term is also used in PSYCHOANALYSIS to characterise that section of
a persons mind in which
memories and motives reside. They are normally inaccessible, protected by inbuil
t mental resistance. This
contrasts with the subconscious, where a persons memories and motives while tempo
rarily suppressed can
usually be recalled.
Unconsciousness The BRAIN is the organ of the mind. Normal conscious ale
rtness depends upon its
continuous adequate supply with oxygen and glucose, both of which are essential
for the brain cells to
function normally. If either or both of these are interrupted, altered conscious
ness results. Interruption
may be caused by three broad types of process affecting the brain stem: the reti
cular formation (a network
of nerve pathways and nuclei-connecting sensory and motor nerves to and from the
cerebrum, cerebellum,
SPINAL CORD and cranial nerves) and the cerebral cortex. The three types are dif
fuse brain dysfunction
for example, generalised metabolic
741
disorders such as URAEMIA or toxic disorders such as SEPTICAEMIA; direct
effects on the brain stem as a
result of infective, cancerous or traumatic lesions; and indirect effects on the
brain stem such as a
tumour or OEDEMA in the cerebrum creating pressure within the skull. Within thes
e three divisions are a
large number of specific causes of unconsciousness. Unconsciousness may be tempo
rary, prolonged or
indefinite (see PERSISTENT VEGETATIVE STATE (PVS)), depending upon the severity
of the initiating incident.
The patients recovery depends upon the cause and success of treatment, where give
n. MEMORY may be
affected, as may motor and sensory functions; but short periods of unconsciousne
ss as a result, say, of
trauma have little obvious effect on brain function. Repeated bouts of unconscio
usness (which can happen in
boxing) may, however, have a cumulatively damaging effect, as can be seen on CT
(COMPUTED TOMOGRAPHY) scans
of the brain. POISONS such as CARBON MONOXIDE (CO), drug overdose, a fall in the
oxygen content of blood
(HYPOXIA) in lung or heart disease, or liver or kidney failure harm the normal c
hemical working or
metabolism of nerve cells. Severe blood loss will cause ANOXIA of the brain. Any
of these can result in
altered brain function in which impairment of consciousness is a vital sign. Sud
den altered consciousness
will also result from fainting attacks (syncope) in which the blood pressure fal
ls and the circulation of
oxygen is thereby reduced. Similarly an epileptic fit causes partial or complete
loss of consciousness by
causing an abrupt but temporary disruption of the electrical activity in the ner
ve cells in the brain (see
EPILEPSY). In these events, as the brains function progressively fails, drowsines
s, stupor and finally
COMA ensue. If the cause is removed (or when the patient spontaneously recovers
from a fit or faint),
normal consciousness is usually quickly regained. Strokes (see STROKE) are somet
imes accompanied by a loss
of consciousness; this may be immediate or come on slowly, depending upon the ca
use or site of the strokes.
Comatose patients are graded according to agreed test scales for example, the GL
ASGOW COMA SCALE in
which the patients response to a series of tests indicate numerically the level o
f coma. Treatment of
unconscious patients depends upon the cause, and range from first-aid care for s
omeone who has fainted to
hospital intensivecare treatment for a victim of a severe head injury or massive
stroke.
U
glomerular filtration also leads to retention of SODIUM and water with resulting
OEDEMA, and to retention
of POTASSIUM resulting in HYPERKALAEMIA. The most important causes of uraemia ar
e the primary renal
diseases of chronic glomerular nephritis (inflammation) and chronic PYELONEPHRIT
IS. It may also result from
MALIGNANT HYPERTENSION damaging the kidneys and amyloid disease destroying them.
Analgesic abuse can cause
tubular necrosis. DIABETES MELLITUS may cause a nephropathy and lead to uraemia,
as may MYELOMATOSIS and
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE). Polycystic kidneys and renal tuberculosis ac
count for a small
proportion of cases.
Symptoms Uraemia is sometimes classed as acute that is, those cases in w
hich the symptoms develop in
a few hours or days and chronic, including cases in which the symptoms are less
marked and last over
weeks, months, or years. There is, however, no dividing line between the two, fo
r in the chronic variety,
which may be said to consist of the symptoms of chronic glomerulonephritis, an a
cute attack is liable to
come on at any time. Headache in the front or back of the head, accompanied ofte
n by insomnia and daytime
drowsiness, is one of the most common symptoms. UNCONSCIOUSNESS of a profound ty
pe, which may be
accompanied by CONVULSIONS resembling those of EPILEPSY, is the most outstanding
feature of an acute attack
and is a very dangerous condition. Still another symptom, which often precedes a
n acute attack, is severe
vomiting without apparent cause. The appetite is always poor, and the onset of d
iarrhoea is a serious sign.
Treatment The treatment of the chronic type of uraemia includes all the
measures which should be taken
by a person suffering from
Urinary Diversion
sticks which change colour in the presence of these substances. The pres
ence of microscopic HAEMATURIA
(blood in the urine) should be confirmed by microscopic examination of a fresh,
midstream urine specimen.
The specimen should also be sent for bacteriological culture to exclude or ident
ify infection. If protein
in the urine is suspected, a 24-hour collection of urine should be assessed. Cyt
ological examination will
identify abnormal or malignant cells in the urinary tract.
Urinary Bladder The urinary bladder is a highly distensible organ for st
oring URINE. It consists of
smooth muscle known as the detrusor muscle and is lined with urine-proof cells k
nown as transitional cell
epithelium. The bladder lies in the anterior half of the PELVIS, bordered in fro
nt by the pubis bone and
laterally by the side wall of the pelvis. Superiorly the bladder is covered by t
he peritoneal lining of the
abdomen. The bottom or base of the bladder lies against the PROSTATE GLAND in th
e male and the UTERUS and
VAGINA in the female.
Urinary Bladder, Diseases of Diseases of the URINARY BLADDER are diagnos
ed by the patients symptoms
and signs, examination of the URINE, and using investigations such as X-RAYS and
ULTRASOUND scans. The
interior of the bladder can be examined using a cystoscope, which is a fibreopti
c endoscope (see FIBREOPTIC
ENDOSCOPY) that is passed into the bladder via the URETHRA.
Cystitis Most cases of cystitis are caused by bacteria which have spread
from the bowel, especially
Escherichia coli, and entered the bladder via the urethra. Females are more pron
e to cystitis than are
males, owing to their shorter urethra which allows easier entry for bacteria. Ch
ronic or recurrent cystitis
may result in infection spreading up the ureter to the kidney (see KIDNEY, DISEA
SES OF).
745
bacterial growth, and an appropriate course of once a urine sample has b
een analysed in the laboratory
to confirm the diagnosis and determine what antibiotics the causative organism i
s likely to respond to.
ANTIBIOTICS
Stone or calculus The usual reason for the formation of a bladder stone
is an obstruction to the
bladder outflow, which results in stagnant residual urine ideal conditions for t
he crystallisation of the
chemicals that form stones or from long-term indwelling CATHETERS which weaken t
he natural mechanical
protection against bacterial entry and, by bruising the lining tissues, encourag
e infection.
Symptoms The classic symptom is a stoppage in the flow of urine during u
Urticaria
Causes Neurological injury, such as trauma to the spinal cord, may cause
bladder weakness, leading to
retention, although this is rare. Obstruction to outflow is more common: this ma
y be acute and temporary,
for example after childbirth or following surgery for piles (HAEMORRHOIDS); or c
hronic, for example, with
prostatic enlargement (see PROSTATE GLAND). Commonly seen in elderly men, this l
eads to reduced bladder
capacity, with partial emptying every few hours. Total retention is rare, but ma
y result from a stricture,
or narrowing, of the URETHRA (see also URETHRA, DISEASES OF AND INJURY TO) usual
ly the result of
infection or injury or to pressure from a large neighbouring tumour. Retention i
s generally treated by
regular use of a urethral catether (see CATHETERS), various types of which are a
vailable. Tapping of the
bladder with a needle passed above the pubis is rarely necessary, but may occasi
onally be required in cases
of severe stricture.
Urinometer A simple instrument designed for estimating the specific grav
ity of URINE a test that can
be helpful in diagnosing disorders of the URINARY TRACT.
Urobilinogen A chemical compound formed when bacteria in the intestine a
ct on BILIRUBIN. Some is
reabsorbed and returns to the LIVER and some is eliminated in the faeces.
Urocele A cystic swelling that develops in the SCROTUM when URINE escape
s from the URETHRA, usually
after injury. Prompt treatment is necessary and this is done by diverting the ur
ine by inserting a
suprapubic catheter (see CATHETERS) into the URINARY BLADDER, draining the cysto
cele and giving the
patients antibiotics. The injured urethra can be surgically repaired later.
Urodynamics The measurement of the pressures within the URINARY BLADDER
as well as the pressures of the
urethral sphincter. The technique is useful in the investigation of patients wit
h urinary incontinence.
Special equipment is needed to carry out the procedure.
Urogenital An adjective relating to the organs and tissues involved in t
he anatomically closely related
functions of excretion and reproduction.
747
Urography Examination of the URINARY TRACT by means of contrast medium X
-rays (see PYELOGRAPHY;
URETHROGRAPHY).
Urokinase Urokinase is an ENZYME obtained from URINE which dissolves blo
od clots. It is used to treat
THROMBOLYSIS in the EYE, in arteriovenous shunts (see SHUNT) and deep-vein THROM
BOSIS. It has the advantage
over other fibrinolytic drugs of not causing immunological reactions.
748 Uterus
Physical factors can cause urticaria. Heat, exercise and emotional stres
s may induce a singular pattern
with small pinhead weals, but widespread flares of ERYTHEMA, activated via the A
UTONOMIC NERVOUS SYSTEM
(CHOLINERGIC urticaria) may also occur. Rarely, exposure to cold may have a smii
lar effect (cold
urticaria) and anaphylactic shock following a dive into cold water in winter is o
ccasionally fatal. The
diagnosis of cold urticaria can be confirmed by applying a block of ice to the a
rm which quickly induces a
local weal. Transient urticaria due to rubbing or even stroking the skin is comm
on in young adults
(DERMOGRAPHISM or factitious urticaria). More prolonged deep pressure induces de
layed urticaria in other
subjects. IgE-mediated urticaria is part of the atopic spectrum (see ATOPY, and
SKIN, DISEASES OF
Dermatitis and eczema). Allergy to peanuts is particularly dangerous in young at
opic subjects.
Notwithstanding the many known causes, chronic urticaria of unknown cause is com
mon and may have an
autoimmune basis (see AUTOIMMUNE DISORDERS).
Treatment Causative
factors must be removed. Topical therapy is ineffective except for the u
se of calamine lotion, which
reduces itching by cooling the skin. Oral ANTIHISTAMINES are the mainstay of tre
atment and are remarkably
safe. Rarely, injection of ADRENALINE is needed as emergency treatment of massiv
e urticaria, especially if
the tongue and throat are involved, following by a short course of the oral ster
oid, prednisolone.
Angio-oedema is a variant of urticaria
U
where massive OEDEMA involves subcutaneous tissues rather than the skin.
It may have many causes but
bee and wasp stings in sensitised subjects are particularly dangerous. There is
also a rare hereditary form
of angio-oedema. Acute airway obstruction due to submucosal oedema of the tongue
or larynx is best treated
with immediate intramuscular adrenaline and antihistamine. Rarely, TRACHEOSTOMY
may be life-saving.
Patients who have had two or more episodes can be taught self-injection with a p
reloaded adrenaline
syringe.
Uterus A hollow, triangular organ, flattened from front to back, the low
er angle (or cervix)
commincates through a narrow opening (the os uteri) with the VAGINA. The uterus
or womb is where the
fertilised ovum (egg) normally
becomes embedded and in which the EMBRYO and FETUS develop. The normal u
terus weighs 3040 g; during
pregnancy, however, enormous growth occurs together with muscular thickening (se
e MUSCLE Development of
muscle). The cavity is lined by a thick, soft, mucous membrane, and the wall is
chiefly composed of muscle
fibres arranged in three layers. The outer surface, like that of other abdominal
organs, is covered by a
layer of PERITONEUM. The uterus has a copious supply of blood derived from the u
terine and ovarian
arteries. It has also many lymphatic vessels, and its nerves establish wide conn
ections with other organs
(see PAIN). The position of the uterus is in the centre of the PELVIS, where it
is suspended by several
ligaments between the URINARY BLADDER in front and the RECTUM behind. On each si
de of the uterus are the
broad ligaments passing outwards to the side of the pelvis, the utero-sacral lig
ament passing back to the
sacral bone, the utero-vesical ligament passing forwards to the bladder, and the
round ligament uniting the
uterus to the front of the abdomen.
Uterus, Diseases of Absence or defects of the uterus Rarely, the UTERUS
may be completely absent as a
result of abnormal development. In such patients secondary sexual development is
normal but MENSTRUATION is
absent (primary amennorhoea). The chromosomal make-up of the patient must be che
cked (see CHROMOSOMES;
GENES): in a few cases the genotype is male (testicular feminisation syndrome).
No treatment is available,
although the woman should be counselled. The uterus develops as two halves which
fuse together. If the
fusion is incomplete, a uterine SEPTUM results. Such patients with a double uter
us (uterus didelphys) may
have fertility problems which can be corrected by surgical removal of the uterin
e septum. Very rarely there
may be two uteri with a double vagina. The uterus of most women points forwards
(anteversion) and bends
forwards (anteflexion). However, about 25 per cent of women have a uterus which
is pointed backwards
(retroversion) and bent backwards (retroflexion). This is a normal variant and v
ery rarely gives rise to
any problems. If it does, the attitude of the uterus can be corrected by an oper
ation called a
ventrosuspension.
Endometritis The lining of the uterine cavity is called the ENDOMETRIUM.
It is this layer that is
partially shed cyclically in women of
hormone which between them regulate the cycle. For some time after the MENARCHE
or before the MENOPAUSE,
menstruation may be irregular. If irregularity occurs in a woman whose periods a
re normally regular, it may
be due to unsuspected pregnancy, early miscarriage or to disorders in the uterus
, OVARIES or pelvic cavity.
The woman should seek medical advice.
Fibroids (leiomyomata) are benign tumours arising from the smooth muscle
layer (myometrium) of the
uterus. They are found in 80 per cent of women but only a small percentage give
rise to any problems and
may then require treatment. They may cause heavy periods and occasionally pain.
Sometimes they present as a
mass arising from the pelvis with pressure symptoms from the bladder or rectum.
Although they can be shrunk
medically using gonadorelin analogues, which raise the plasma concentrations of
LUTEINISING HORMONE and
FOLLICLE-STIMULATING HORMONE, this is not a long-term solution. In any case, fib
roids only require
treatment if they are large or enlarging, or if they cause symptoms. Treatment i
s either myomectomy
(surgical removal) if fertility is to be retained, or a hysterectomy.
Uterine cancers tend to present after the age of 40 with abnormal bleedi
ng (intermenstrual or
postmenopausal bleeding). They are usually endometrial carcinomas. Eighty per ce
nt present with early
(Stage I) disease. Patients with operable cancers should be treated with total a
bdominal hysterectomy and
bilateral excision of the ovaries and Fallopian tubes. Post-operative RADIOTHERA
PY is usually given to
those patients with adverse prognostic factors. Pre-operative radiotherapy is st
ill given by some centres,
although this practice is now regarded as outdated. PROGESTOGEN treatment may be
extremely effective in
cases of recurrence, but its value remains unproven when used as adjuvant treatm
ent. In 2003 in England and
Wales, more than 2,353 women died of uterine cancer.
Disorders of the cervix The cervix (neck of the womb) may produce an exc
essive
U
Uvulopalatopharyngoplasty
surgery, an internal support called a pessary can be fitted and changed
periodically.
Hysterectomy Many serious conditions of the uterus have traditionally be
en treated by hysterectomy, or
removal of the uterus. It remains a common surgical operation in the UK, but is
being superseded in the
treatment of some conditions, such as persistent MENORRHAGIA, with endometrial a
blation removal of the
lining of the uterus using minimally invasive techniques, usually using an ENDOS
COPE and laser.
Hysterectomy is done to treat fibroids, cancer of the uterus and cervix, menorrh
agia, ENDOMETRIOSIS and
sometimes for severely prolapsed uterus. Total hysterectomy is the usual type of
operation: it involves the
removal of the uterus and cervix and sometimes the ovaries. After hysterectomy a
woman no longer
menstruates and cannot become pregnant. If the ovaries have been removed as well
and the woman had not
reached the menopause, hormone replacement therapy (HRT see MENOPAUSE) should be
considered. Counselling
helps the woman to recover from the operation which can be an emotionally challe
nging event for many.
Utricle (1) Part of the membraneous labyrinth within the vestibule of th
e EAR. (2) Prostatic utricle is
a small sac extending out of the male URETHRA into the matrix of the PROSTATE GL
AND.
751
Uvea Uvea is a term applied to the middle coat of the EYE, including the
iris, ciliary body and
choroid.
Uveitis An inflammation of the uveal tract (see EYE). Iritis is inflamma
tion of the iris; cyclitis,
inflammation of the ciliary body; and choroiditis, inflammation of the choroid.
The symptoms and signs vary
according to which part of the uveal tract is involved and tend to be recurrent.
The patient may experience
varying degrees of discomfort or pain, with or without blurring of vision. In ma
ny cases a cause is never
found. Some known associations include various types of arthritis, some bowel di
seases, virus illnesses,
tuberculosis, syphilis, parasites and fungi. Treatment is with anti-inflammatory
drops and occasionally
steroid tablets, plus drops to dilate the pupil.
Uvula The small mass of muscle covered by mucous membrane that hangs dow
n from the middle of the soft
PALATE on its posterior aspect. Its function is not certain and it seldom causes
problems.
Uvulopalatopharyngoplasty Surgery to excise the UVULA, part of the soft
PALATE and the TONSILS. It is
done to help people with severe SNORING problems but it does not always achieve
a cure.
Vacuole
school, and on travel abroad to countries where POLIOMYELITIS is ENDEMIC
.
Rabies vaccine was introduced by Pasteur in 1885 for administration, dur
ing the long incubation period,
to people bitten by a mad dog, in order to prevent the disease from developing.
(See RABIES.)
753
chick embryos injected with the living, attenuated strain (17D) of pantr
opic virus. Only one injection
is required, and immunity persists for many years. Re-inoculation, however, is d
esirable every ten years.
(See YELLOW FEVER.)
Haemophilus vaccine (HiB) This vaccine
Rubella vaccine, usually given with mumps and measles vaccine in one dos
e called MMR VACCINE, see
also above now provides protection against RUBELLA (German measles). It also pro
vides immunity for
adolescent girls who have not had the disease in childhood and so ensures that t
hey will not acquire the
disease during any subsequent pregnancy thus reducing the number of congenitally
abnormal children whose
abnormality is the result of their being infected with rubella via their mothers
before they were born.
was introduced in the UK in 1994 to deal with the annual incidence of ab
out 1,500 cases and 100 deaths
from haemophilus MENINGITIS, SEPTICAEMIA and EPIGLOTTITIS, mostly in pre-school
children. It has been
remarkably successful when given as part of the primary vaccination programme at
two, three and four months
of age reducing the incidence by over 95 per cent. A few cases still occur, eith
er due to other subgroups
of the organism for which the vaccine is not designed, or because of inadequate
response by the child,
possibly related to interference from the newer forms of pertussis 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 successful smallpox eradica
tion campaign it declared
the disease eradicated in 1980 there is now no medical justification for smallpo
x vaccination. Recently,
however, there has been increased interest in the subject because of the potenti
al threat from
bioterrorism. (See also VACCINATION.)
UK from 1998, this has dramatically reduced the incidence of meningitis
and septicaemia due to this
organism. Used as part of the primary programme in early infancy, it does not pr
of
the
VAGINA.
(See
LEUCORRHOEA.)
Vagotomy The operation of cutting the fibres of the VAGUS nerve to the s
tomach. It was once part of the
routine surgical treatment of DUODENAL ULCER, the aim being to reduce the flow o
r acidity of the gastric
juice. The operation is now performed on those patients who fail to respond to d
rug treatment. (See also
STOMACH, DISEASES OF Gastric ulcer).
Vagus The tenth cranial nerve. Unlike the other cranial nerves, which ar
e concerned with the special
senses, or distributed to the skin and muscles of the head and neck, this nerve
(as its name implies
Latin for wanderer), passes downwards into the chest and abdomen, supplying branch
es to the throat,
lungs, heart, stomach and other abdominal organs. It contains motor, secretory,
sensory and vasodilator
fibres.
Valgus This term means literally knock-kneed, and is a bending inward at
the knees (genu valgum), or at
the ankle, as occurs in FLAT-FOOT (pes planus).
Validity An indication of how much a clinical test or sign is an accurat
e indicator of the presence of
disease. Reduced validity may occur because (1) identical tests repeated on the
same person in similar
circumstances produce variable results; (2) the same observer gets different res
ults on successive
occasions intraobserver error; (3) different observers produce different results
.
Valine One of the essential (indispensable)
AMINO
ACIDS.
Valium The proprietary name for diazepam, a widely used anxiolytic drug
(see ANXIOLYTICS).
Valsalvas Manoeuvre This is carried out by closing the mouth, holding the
nose and attempting to blow
hard. The manoeuvre raises pressure in the chest and, indirectly, the abdomen an
d forces air from
Vas
755
the back of the nose down the EUSTACHIAN to the middle ear. This latter
effect can be used to clear the
tube during descent in an aircraft, when it sometimes becomes blocked or partial
ly blocked, producing
differential pressures on the two sides of each eardrum, usually accompanied by
temporary pain and
deafness. Valsalvas manoeuvre is involuntarily performed when a person strains to
open his or her bowels:
in these circumstances the passage of air to the lungs is blocked by instinctive
closure of the vocal cords
in the LARYNX. The resultant raised abdominal pressure helps to expel the bowel
contents. The manoeuvre is
also used in the study of cardiovascular physiology because the rise in pressure
in the chest restricts the
return of venous blood to the right atrium of the HEART. Pressure in the periphe
ral VEINS is raised and the
amount of blood entering and leaving the heart falls. This drop in cardiac outpu
t may cause the subject to
faint because the supply of oxygenated blood to the brain is reduced.
A test done on SERUM from patients with JAUNDICE to discover whether the
excess BILIRUBIN in the blood
which causes the jaundice is conjugated or unconjugated. If conjugated, this ind
icates that HAEMOLYSIS
is causing the jaundice; if unconjugated, disease of the LIVER or BILE DUCT is t
he likely diagnosis.
Valves
Vaporiser
These cup-like structures are found in the HEART, VEINS, and lymphatic v
essels (see LYMPH); they ensure
that the circulation of the blood and lymph goes always in one direction.
A device that via a narrow nozzle turns water or a drug into a fine spra
y, thus enabling medicine to be
taken by INHALATION. It is used, for example, in the treatment of ASTHMA.
Valvotomy
See STANDARD DEVIATION.
TUBES
An operation that opens a stenosed heart valve (see STENOSIS; HEART, DIS
EASES OF) and allows it to
function properly again. Various techniques are used, including a dilating instr
ument, a balloon or
open-heart surgery.
Valvular Disease See under HEART, DISEASES OF.
Valvuloplasty An operation to repair or reconstruct a defective heart va
lve (see VALVES). It may be
done as an open-heart procedure (with the patient temporarily connected to a HEA
Veins
of the blood vessels, and several of the substances produced by ENDOCRIN
E GLANDS in the body have these
effects: for example, ADRENALINE.
Vasopressin The fraction isolated from extract of the posterior PITUITAR
Y GLAND lobe which stimulates
intestinal activity, constricts blood vessels, and inhibits the secretion of URI
NE. It is also known as the
antidiuretic hormone (ADH) because of this last effect, and its only use in medi
cine is in the treatment of
DIABETES INSIPIDUS.
Vasovagal Attack The temporary loss of consciousness caused by an abrupt
slowing of the heartbeat. This
may happen following SHOCK, acute pain, fear, or stress. A common cause of faint
ing in normal people, a
vasovagal attack may be a consequence of overstimulation of the VAGUS nerve whic
h is involved in the
control of breathing and the circulation.
VD The abbreviation for venereal disease (see SEXUALLY TRANSMITTED DISEA
SES (STDS)). The word
venereal is derived from Venus, the Roman goddess of love.
Vector An animal that is the carrier of a particular infectious disease
(see INFECTION). A vector picks
up the infectious agent (bacterium see BACTERIA; also RICKETTSIA; VIRUS) from an
infected persons blood
or faeces and carries it in or on its body before depositing the agent on or int
o a new host. Fleas, lice,
mosquitoes and ticks are among common vectors of disease to humans. When a vecto
r is used by the infectious
agent to complete part of its life-cycle for example, the malarial agent PLASMOD
IUM conducts part of its
life-cycle in the mosquito the vector is described as biological. If the vector
simply carries the agent
but is not a host for part of its life-cycle, the vector is described as mechani
cal. Flies, for example,
may carry an infection such as bacterial dysentery from infected faeces to the f
ingers of another host.
Veganism A strict form of VEGETARIANISM. Vegans do not eat meat, dairy p
roduce, eggs or fish.
Vegetarianism Restriction of ones diet, for health, cultural or humanitar
ian reasons, to foods of
fruit or vegetable origin. Most vegetarians, while excluding
757
meat and fish from their diets, include foods of animal origin, such as
milk, cheese, eggs, and butter.
Such a diet should supply an adequate balance of nutrients, although people with
special dietary
requirements such as pregnant or feeding mothers, and very strict vegetarians ma
y require dietary
supplements (see APPENDIX 5: VITAMINS).
red swelling of the calf. Diagnosis may be confirmed by venogram (an X-ray taken
following 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 exe
rcises very soon after an
operation, even major surgery. People should avoid sitting for long periods, par
ticularly 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 t
he 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 within th
e vein becomes dislodged
and travels up the venous system to become lodged in the pulmonary arteries. Thi
s is known as PULMONARY
EMBOLISM. Treatment is directed at thinning the blood with ANTICOAGULANTS, initi
ally with heparin and
subsequently with WARFARIN for a period of time while the clot resolves. Blocked
superficial veins are
described as superficial thrombophlebitis, which produces
Ventricle
inflammation over the vein. It responds to antiinflammatory analgesics.
Occasionally heparin and
ANTIBIOTICS are required to treat associated thrombosis and infection.
759
The name of either of the two large vessels that open into the right atr
ium of the HEART. (See VEINS.)
public places. Special filters may be used to reduce the risk of airborn
e infections and allergies (see
ALLERGY), but poorly maintained and contaminated systems may result in outbreaks
of serious disorders, such
as LEGIONNAIRES DISEASE. Sterilisation of air is rarely required, but ultraviolet
light is sometimes used
to kill pathogenic organisms. (See also ASTHMA; BRONCHITIS; HUMIDIFICATION.)
Venepuncture
Ventilation, Artificial
The insertion of a needle into a vein (see VEINS), usually for the purpo
se of injecting a drug or
withdrawing blood for haematological or biochemical analysis. The usual site for
venepuncture in adults is
the median cubital vein in the forearm.
The procedure, usually carried out in an operating theatre or intensivecare unit, in which a device
called a VENTILATOR takes over a persons breathing. This is done for someone who
is unable to breathe
normally. Damage to the respiratory centre of the brain as a result of head inju
ry, disease of the brain,
or an overdose of sedative or narcotic drugs may affect the respiratory centre.
Chest injuries, disease of
the lungs, nerve or muscle disorders or surgery of the chest or abdomen can also
affect breathing and
require the use of a ventilator to maintain normal breathing. Artificial ventila
tion can also be carried
out as an emergency by mouth-to-mouth resuscitation. (See also ANAESTHESIA; ARTI
FICIAL VENTILATION OF THE
LUNGS.)
Vena Cava
Venereal Diseases See SEXUALLY TRANSMITTED DISEASES (STDS).
Venesection Venesection, or blood-letting, may be employed for two purpo
ses. Most commonly, small
quantities of blood may be required for analysis, as an aid to diagnosis or cont
rol of various diseases.
For example, knowledge of the plasma glucose concentration is important in the d
iagnosis and management of
DIABETES MELLITUS, or blood may be required in order to test for infections such
as HIV or HEPATITIS. Blood
may be obtained by pricking a fingertip, or inserting a needle into a vein, depe
nding on the amount
required. Controlled bleeding of larger amounts may rarely be used in certain ca
BETA-ADRENOCEPTOR-BLOCKING DRUGS.
Vermicides Also called vermifuges, these are substances that
Verrucose This term means having a surface resembling verrucae (see WART
S). Certain skin diseases may
become verrucose.
Version The name given to an operation in OBSTETRICS which consists in t
urning the FETUS in the UTERUS
where the fetus is lying in an abnormal position which may make eventual deliver
y difficult. In particular,
version (which can take place spontaneously) may be done on a fetus between the
34th and 37th weeks of
pregnancy when its buttocks rather than its head are positioned at the cervical
end of the uterus. The
procedure carries a small risk of precipitating premature labour, and it is not
always successful, in which
case a breech delivery is attempted or, in difficult cases, a CAESAREAN SECTION
is performed. (See also
PREGNANCY AND LABOUR.)
Vertebra One of the irregularly shaped bones that together form the vert
ebral column. (See SPINAL
COLUMN.)
Vertebrobasilar Insuffiency Intermittent incidents of double vision, diz
ziness, weakness and speaking
difficulties caused by a reduced blood supply to parts of the BRAIN. The cause i
s usually obstruction in
the basilar, vertebral and other arteries at the base of the brain. The conditio
n is sometimes the
precursor of a STROKE.
Vertigo A condition in which the affected person loses the power of bala
ncing him or herself, and has a
false sensation as to his or her own movements or those of surrounding objects.
The power of balancing
depends upon sensations derived partly through the sense of touch, partly from t
he eyes, but mainly from
the semicircular canals of the internal EAR the vestibular
Vestibule
mechanism. In general, vertigo is due to some interference with this ves
tibular ocular reflex mechanism
or with the centres in the cerebellum and cerebrum (see BRAIN) with which it is
connected. Giddiness is
often associated with headache, nausea and vomiting.
Causes The simplest cause of vertigo is some mechanical disturbance of t
he body affecting the fluid in
the internal ear; such as that produced by moving in a swing with the eyes shut,
the motion of a boat
causing sea-sickness, or a sudden fall. (See also MOTION (TRAVEL) SICKNESS.) Ano
ther common positional
variety is benign paroxysmal positional vertigo (BPPV) caused by sudden change i
n the position of the head;
this causes small granular masses in the cupola of the posterior semicircular ca
nal in the inner ear to be
displaced. It may subside spontaneously within a few weeks but can recur. Someti
mes altering the position
of the head so as to facilitate return of the crystals to the cupola will stop t
he vertigo. The cause which
produces a severe and sudden giddiness is MENIRES DISEASE, a condition in which th
ere is loss of function
of the vestibular mechanism of the inner ear. An acute labyrinthitis inflammatio
n of the labyrinth of the
ear may result from viral infection and produce a severe vertigo lasting 25 days.
Because it often
occurs in epidemics it is often called epidemic vertigo. Vertigo is sometimes pr
oduced by the removal of
wax from the ear, or even by syringing out the ear. (See EAR, DISEASES OF.) A se
vere upset in the
gastrointestinal tract may cause vertigo. Refractive errors in the eyes, an atta
ck of MIGRAINE, a mild
attack of EPILEPSY, and gross diseases of the brain, such as tumours, are other
causes acting more directly
upon the central nervous system. Finally, giddiness may be due to some disorder
of the circulation, for
example, reduced blood supply to the brain produced by fainting, or by disease o
f the heart. Treatment
While the attack lasts, this
requires the sufferer to lie down in a darkened, quiet room. SEDATIVES h
ave most influence in
diminishing giddiness when it is distressing. After the attack is over, the indi
vidual should be examined
to establish the cause and, if necessary, to be given appropriate treatment. Ver
tigo and nausea linked to
Menires disease or following surgery on the middle ear can be hard to treat. HYOSC
INE, ANTI761
HISTAMINE DRUGS and PHENOTHIAZINES for example, prochlorperazine are oft
en effective in preventing
and treating these disorders. Cinnarizine and betahistine have been marketed as
effective drugs for
Menires disease; for acute attacks, cyclizine or prochlorperazine given by intramu
scular injection or
rectally can be of value. Research in America is exploring the use of virtual-re
Vision 763
tact. Serum from patients convalescent from the disease is a useful sour
ce of ANTIBODIES to the virus.
Viral Pneumonia Infection of the lung tissue by a VIRUS. Causes of this
type of pneumonia include
ADENOVIRUSES, COXSACKIE VIRUSES and influenza virus. Viral infections do not res
pond to ANTIBIOTICS and
treatment is symptomatic, with antibiotics used only if the patient develops sec
ondary bacterial infection.
In a previously healthy individual the viral infection is usually selflimiting,
but in vulnerable patients
the elderly or those with pre-existing disease it can be fatal.
Virilisation The masculinisation of women suffering from excessive produ
ction of the male hormone
ANDROGEN. The person develops temporal balding, a male body shape, increased mus
cular bulk, deepening of
the voice, an enlarged CLITORIS and HIRSUTISM. Virilisation may also occur in wo
men who take synthetic
androgens, a practice sometimes used (illegally) to increase physical strength a
nd endurance in sport.
Virilism The condition in which masculine characteristics develop in the
female; it is commonly the
result of an overactive suprarenal gland (see ADRENAL GLANDS), or of a tumour of
its cortex. It may also
result from an ANDROGEN-secreting ovarian tumour (see OVARIES, DISEASES OF) and
also from the POLYCYSTIC
OVARY SYNDROME. The overproduction of male-sex (androgen) hormones can produce e
xcess growth of hair, male
pattern hairline, stopping or disruption of MENSTRUATION, enlargement of the CLI
TORIS and conversion to a
masculine body shape.
through the pores of collodion filters. They are responsible for some of
the most devastating diseases
affecting humans: for example, INFLUENZA, POLIOMYELITIS, SMALLPOX and YELLOW FEV
ER. The virus of influenza
measures 80 nanometres, whereas the STAPHYLOCOCCUS measures 1,000 nanometres (1
nanometre = one
thousand-millionth of a metre). A single virus particle, known as a virion, comp
rises an inner core of
NUCLEIC ACID which is surrounded by one or two protective coverings (capsid) mad
e of protein. Sometimes the
capsid is enclosed by another layer called the viral envelope (also a protein st
ructure). The envelope
often disintegrates when the virus invades a cell. Viruses enter cells and then
indulge in a complex and
variable process of replication using some of the cells own structure. Viruses ma
y stay in a hosts
nucleus, being reactivated months or years later. There are more than a score of
large families of viruses,
from papoviruses, which cause WARTS, through HERPES viruses (cold sores, CHICKEN
POX, SHINGLES) and
orthomyxoviruses (influenza), to corona viruses (common cold) and retroviruses (
AIDS/HIV). Viral diseases
are more difficult to treat than those caused by bacteria: ANTIBIOTICS are ineff
ective but INTERFERON, a
Vivisection
corrected with glasses such as ASTIGMATISM, HYPERMETROPIA or MYOPIA. Vis
ual acuity is tested using a
Snellen chart when the patient tries to read letters of differing standard sizes
from 6 metres away. The
optician will prescribe lenses to correct any defects detected by vision tests.
Visual Acuity See VISION.
Visual Evoked Response Stimulation of the retina of the EYE with light c
auses changes in the electrical
activity of the cerebral cortex (see BRAIN). These changes can be measured from
outside the skull and can
give valuable information about the state of the visual pathway from the retinal
ganglion cells to the
occipital cortex. Not only can it determine that function is normal, it can also
help to diagnose some
causes of poor VISION.
Vital Capacity The amount of air that can be forcibly exhaled from the l
ungs after a deep inspiration.
(See RESPIRATION.)
Vital Centres Groups of neurons (see NEURON(E)), usually sited in the HY
POTHALAMUS and the BRAIN stem,
that are the control centres for various essential body functions. Examples are:
blood pressure, breathing,
heart rate and temperature control. The centres are part of the bodys reflex adju
stments to the outside
world and its internal environment and are essential in maintaining HOMEOSTASIS.
Vitallium
765
Vitamin A term applied to a group of substances which exist in minute qu
antities in natural foods, and
which are necessary to normal nutrition, especially in connection with growth an
d development. Some A, D,
E and K are fat-soluble and can be stored in the body. The remainder C, B12 and
other members of the B
complex are water-soluble and are quickly excreted. Most vitamins have now been
synthesised. When they
are absent from the food, defective growth takes place in young animals and chil
dren, and in adults various
diseases arise; whilst short of the production of actual disease, persistent dep
rivation of one or other
vitamin is apt to lead to a state of lowered general health. Certain deficiencie
s in DIET have long been
known to be the cause of SCURVY, BERIBERI, and RICKETS. A diet containing foods
such as milk, eggs, butter,
cheese, fat, fish, wholemeal bread, fresh vegetables and fruit should contain su
fficient vitamins. Details
of the various vitamins are given in APPENDIX 5: VITAMINS.
Vitiligo A disease in which small or large areas of skin lose their pigm
ent and become white because of
a reduction in the bodys production of MELANIN. The hair may be similarly affecte
d. Probably a consequence
In any given voice, the range of pitch seldom exceeds two and a half oct
aves. Typically, the small
larynx of childhood produces a shrill or treble voice; the rapid growth of the l
arynx around PUBERTY causes
the voice to break in boys. Changes in the voice also occur at other ages as a res
ult of the secondary
action of the SEX HORMONES. Generally speaking, the adult voice is bass and teno
r in men, contralto or
soprano in women. Timbre is due to differences in the larynx, as well as to volu
ntary changes in the shape
of the mouth.
Speech Rapid modifications of the voice, produced by movements of the PA
LATE, tongue and lips. Infants
hear the sounds made by others and mimic them; hence the speech centres in the B
RAIN are closely connected
with those of hearing.
Defects of speech
See below, and also SPEECH
DISORDERS. MUTISM, or absence
of the power to speak, may be due to various causes. LEARNING DISABILITY
that prevents the child from
mimicking the actions of others is most common; in other cases the child has nor
mal intelligence but some
neurological disorder, or disorder of the speech organs, is responsible. Alterna
tively, complete DEAFNESS
or early childhood ear disease may be the cause. STAMMERING is a highly individu
al condition, but is
basically a lack of coordination between the different parts of the speech mecha
nism. (See also main entry
on STAMMERING.) DYSPHASIA is the inability to speak or understand speech, most c
ommonly following brain
disease, such as STROKE. APHONIA or loss of voice may be caused by LARYNGITIS or
, rarely, a symptom of
conversion and dissociative mental disorders traditionally referred to as HYSTER
IA. It is generally of
short duration.
Volar A term relating to the palm or sole.
Volkmanns Contracture A rare condition in which, as a result of too great
a pressure from splint or
bandage in the treatment of a broken arm, the flexor muscles of the forearm cont
ract and thus obstruct free
flow of blood in the veins; the muscles then swell and ultimately become fibrose
d.
Voluntary Admission The term applied in the UK to the admission of a men
tally ill person to a
psychiatric unit with
768 Voyeurism
which the affected person suffers episodes of spontaneous bleeding simil
ar to that occurring in people
with HAEMOPHILIA. It may be associated with a lack of FACTOR VIII (see COAGULATI
ON) in the blood. The
disorder is inherited as an autosomal dominant gene (see GENETIC DISORDERS).
Vulvectomy
MASTURBATION.
Surgical excision of the external genitals (see VULVA). In simple vulvec
tomy the LABIA majora and
minora and the CLITORIS are surgically removed, usually to treat a non-malignant
growth. A more extensive
operation is radical vulvectomy in which there is wide excision of the two labia
and the clitoris along
with complete removal of all regional LYMPH NODES on both sides and the covering
skin. This procedure is
carried out to treat cancer of the vulva.
Vulva
Vulvo-Vaginitis
The external genitalia of the female. The LABIA majora and minora compri
sing folds of flesh, the
latter inside the former surround the openings of the VAGINA and URETHRA. The
Inflammation of the VULVA and VAGINA. It may be due to infection, and ma
y be a presenting feature of
late onset DIABETES MELLITUS. Trauma may sometimes be the cause.
Voyeurism The regular viewing of people who are naked or part-naked or w
ho are taking part in intimate
sexual activities. The voyeurs subjects are unaware that they are being watched.
The voyeur, nearly always
a man, usually becomes sexually excited and may induce ORGASM by
V
folds extend upwards as an arch over the CLITThe vulva also contains ves
tibular glands which provide
profuse mucoid secretions during sexual activity.
ORIS.
W
from the SKIN arising from the epidermis and caused by various subtypes
of human papilloma 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 number of people waiting for h
ospital admission, usually for
non-acute surgery. The size of the waiting list has come to be perceived over th
e past 20 years especially
by politicians as a measure of the Services effectiveness. To the individual pati
ent, however, what
matters is the waiting time how long they have to wait before admission. This figu
re along with the
time a patient has to wait for an outpatient appointment to see a consultant is
increasingly being
recognised as one important measurement of how well a hospital is serving its lo
cal communities.
Walk See GAIT.
Warfarin An anticoagulant (see ANTICOAGULANTS), usually given by mouth o
n a daily basis. The initial
dose depends upon the PROTHROMBIN or coagulation time; this should be determined
before starting treatment,
and then at regular intervals during treatment. It is indicated for the prophyla
xis of embolisation (see
EMBOLISM) in rheumatic heart disease and atrial fibrillation (see HEART, DISEASE
S OF); after prosthetic
heartvalve insertion; prophylaxis and treatment of venous thrombosis and PULMONA
RY EMBOLISM; and TRANSIENT
ISCHAEMIC ATTACKS OR EPISODES (TIA, TIE). When given in tablet form, its maximum
effect generally occurs
within about 36 hours, wearing off within 48 hours. Special caution is appropria
te in patients with disease
of the liver or kidneys or who have had recent surgery. Warfarin is contra-indic
ated throughout pregnancy
(especially the first and third trimesters), and in cases of PEPTIC ULCER, sever
e HYPERTENSION and
bacterial ENDOCARDITIS. The most important adverse effect is HAEMORRHAGE. Other
reported side-effects
include HYPERSENSITIVITY, rash, ALOPECIA, diarrhoea, unexplained drop in HAEMATO
CRIT readings, purple toes,
skin NECROSIS, JAUNDICE, liver dysfunction, nausea, vomiting and pancreatitis (s
ee PANCREAS, DISEASES OF).
(See also COAGULATION.)
Warts Warts (verrucae) are small, solid outgrowths
seen mainly in children and young adults on the backs of the fingers and
hands, and less often on the
knees, face or scalp. They may be single or numerous and range from 1 mm to 10 m
m or more in size.
Untreated, they often resolve spontaneously after weeks or months. They may be o
ccupationally contracted by
butchers and meat-handlers.
Plane warts (verruca plana) are small, flat-topped, yellowish papules se
en mainly on the backs of the
hands, wrists and face in young people. They may persist for years.
Digitate warts (verruca digitata) are finger- or thread-like warts up to
5 mm in length with a dark
rough tip. They tend to grow on the eyelids or neck.
Plantar warts (verruca plantaris) occur on the soles of the feet, most c
ommonly in older children,
adolescents and young adults. Spread by walking barefoot in swimming pools, chan
ging rooms, etc., these
warts may appear as minor epidemics in institutions, such as schools. They are f
lattened, yellow-white
discrete lesions in the sole or heel, tender when squeezed. Multiple black point
s in the wart are
thrombosed capillaries. Occasionally, aggregates of plantar warts form a mosaiclike plaque, especially in
chronically warm, moist feet.
Genital warts are sexually transmitted. In the male they occur on the sh
aft of the PENIS and on the
PREPUCE or around the anus. In women they occur around the entrance to the VAGIN
A and LABIA minora. Genital
warts vary from 12 mm pink papules to florid, cauliflower-like masses. Pregnancy
facilitates their
development.
Mucosal warts may develop on the mucous membranes of the mouth.
Laryngeal warts may be found in children whose mothers had genital warts
(see above) at the time of
delivery. Some subtypes of genital wart can infect the uterine cervix (see UTERU
S), causing changes which
may lead eventually to cancer.
770 Washing
Treatment
CRYOTHERAPY freezing with liquid nitrogen is the principal weapon agains
t all types of warts, but
curettage (scraping out the wart with a CURETTE) and cauterisation (see ELECTROC
AUTERY) or LASER therapy
may be required for resistant warts. Genital warts may respond to local applicat
ion of PODOPHYLLIN
preparations. Sexual partners should be examined and treated if necessary. Final
ly, treatment of warts
should not be more onerous or painful than the disease itself, since spontaneous
resolution is so common.
Washing See DISINFECTION.
Washing Out of the Stomach See GASTRIC LAVAGE.
Wassermann Reaction A test introduced for the diagnosis of SYPHILIS by e
xamination of the blood. It has
now been largely supplanted by other, more specific tests.
Wasting See ATROPHY.
Water Bed A bed with a water-filled mattress can help prevent bed sores
(see ULCER Decubitus ulcer)
in patients confined to bed for more than a few days. Its flexibility provides u
niform support for the
whole body. Air beds are now more often used: they are light and more comfortabl
e and the modern version,
called a ripple bed, has a little motor that fills and empties tubes in the matt
ress. The patients
circulation is stimulated and pressure is regularly changed on susceptible parts
of the body elbows,
buttocks and heels thus reducing the likelihood of pressure sores developing, pa
rticularly in the
elderly.
Waterbrash
W
Also called pyrosis. A symptom of indigestion; during the course of DIGE
STION, the mouth fills with
tasteless or sour fluid, which is generally saliva, but is sometimes brought up
from the stomach. This is
accompanied by a burning pain often felt at the pit of the stomach or in the che
st. The condition is a
symptom of excessive acidity of the stomach contents, due sometimes to an injudi
cious diet, and often
characteristic of a DUODENAL ULCER. (See also DYSPEPSIA.)
Water-Hammer Pulse The peculiarly sudden
PULSE
that is associated
with incompetence of the AORTIC VALVE of the heart.
weight. Lifeinsurance statistics have shown that maximal life expectancy is obta
ined if the average weight
at 2530 years is maintained throughout the rest of life. These insurance statisti
cs also suggest that it
is of advantage to be slightly over the average weight before the age of 30 year
s; to be of average weight
after the age of 40; and to be underweight from ages 3040. In the past it has bee
n usual, in assessing the
significance of an adults weight, to allow a 10 per cent range on either side of
normal for variations in
bodybuild. A closer correlation has been found between thoracic and abdominal me
asurements and weight.
Weights and Measures It is more than a hundred years since the metric sy
stem was legalised in Britain,
but it was not until 1969 that it became illegal to use any system of weights an
d measures other than the
metric system for dispensing prescriptions. A rationalisation of the metric syst
em is now used, known as
the International System of Units (SI see APPENDIX 6: MEASUREMENTS IN MEDICINE).
Weils Disease See LEPTOSPIROSIS.
Werners Syndrome A rare inherited condition in which the affected person
suffers from premature ageing
from adolescence onwards. His or her growth may be retarded, the skin become thi
n, and arterial disease,
DIABETES MELLITUS and leg ulcers (see ULCER) develop. Treatment is symptomatic.
Wernickes Encephalopathy Also called the Wernicke-Korsakoff syndrome, thi
s uncommon disorder is
characterised by mental confusion or DELIRIUM that occurs in combination with an
unsteady GAIT, nystagmus
(see under EYE, DISORDERS OF), and paralysis of the eye muscles and eventually P
SYCHOSIS. It is caused by a
deficiency of vitamin B1 (THIAMINE see APPENDIX 5: VITAMINS) which affects the b
rain and nervous system.
It occurs in alcoholic individuals and in patients with persistent vomiting. As
soon as the condition is
W
catarrhal stage largely in preventing spread to brothers and sisters but are of
no use during the
paroxysmal stage. Cough suppressants are not always helpful unless given in high
(and therefore potentially
narcotic) doses, and skilled nursing may be required to maintain nutrition, part
icularly if the disease is
prolonged, with frequent vomiting.
See AGGLUTINATION.
Wilms Tumour Also called nephroblastoma. This is the commonest kidney tum
our in infancy. It is a
malignant tumour, which occurs in around one per 10,000 live births. The surviva
l rate with modern
treatment (removal of the kidney followed by radiotherapy and chemotherapy) is n
ow around 80 per cent.
Wilsons Disease
Windpipe The popular name for the TRACHEA, which extends from the LARYNX
above to the point in the
upper part of the chest where it divides into the two large bronchial tubes, one
to each lung. It is about
10 cm (4 inches) in length and consists of a fibrous tube kept permanently open
by about 20 strong,
horizontally placed hoops of cartilage, each of which forms about two-thirds of
a circle, the two ends
being joined behind by muscle fibres. This fibrocartilaginous tube is lined by a
smooth mucous membrane,
richly supplied with mucous glands and covered by a single layer of ciliated epi
thelium. (See also AIR
PASSAGES.)
Winter Vomiting Disease Winter vomiting disease, or epidemic nausea and
vomiting, is a condition caused
by subtypes of the genus Norwalk-like virus and is characterised by nausea, vomi
ting, diarrhoea and
giddiness, which occurs during the winter. Outbreaks of it usually involve whole
families or may affect
communities like schools. The incubation period is 2448 hours, and attacks seldom
persist for more than 72
hours. In England and Wales in 2000, more than 1,600 infections were reported co
mpared to more than 16,400
cases of salmonella infections and 56,420 of CAMPYLOBACTER. However, in England
it is estimated that around
1,500 times more people are infected in the community than are reported. Humans
are the only
W
W
(UTERUS), such as the beating of the mothers heart, the bowel sounds of t
he baby and the like. The
claim is that the replaying of these brings back the peaceful music of the womb, t
o which they have
become conditioned, and thus sings them to sleep.
Unpleasant physical and mental symptoms that occur when a person stops u
sing a drug or substance on
which he or she is dependent (see DEPENDENCE). The symptoms include tremors, swe
ating, and vomiting which
are reversed if further doses are given. Alcohol and hard drugs, such as morphin
e, heroin, and cocaine, are
among the substances that induce dependence, and therefore withdrawal symptoms,
when stopped. Amphetamines
and nicotine are other examples.
Womb See UTERUS.
Womb Music The name given to the playing to crying babies of sounds comp
arable to those by which the
unborn babe is surrounded in the womb
Wounds A wound is any breach suddenly produced in the tissues of the bod
y by direct violence. An
extensive injury of the deeper parts without corresponding injury of the surface
is known as a bruise or
contusion.
Varieties These are classified according to the immediate effect produce
d: are usually inflicted with
some sharp instrument, and are clean cuts, in which the tissues are simply divid
ed without any damage to
surrounding parts. The bleeding from such a wound is apt to be very free, but ca
n be readily controlled.
PUNCTURE WOUNDS, or stabs, are inflicted with a pointed instrument. These wounds
are dangerous, partly
because their depth involves the danger of wounding vital organs; partly because
bleeding from a stab is
hard to control; and partly because they are difficult to sterilise. The wound p
roduced by the nickel-nosed
bullet is a puncture, much less severe than the ugly lacerated wound caused by a
n expanding bullet, or by a
ricochet, and, if no clothing has been carried in by the bullet, the wound is cl
ean and usually heals at
once. LACERATED WOUNDS are those in which tissues are torn, such as injuries cau
sed by machinery. INCISED
WOUNDS
Wry-Neck
Little bleeding may occur and a limb can be torn completely away without
great loss of blood. Such
wounds are, however, especially liable to infection. CONTUSED WOUNDS are those a
ccompanied by much bruising
of surrounding parts, as in the case of a blow from a cudgel or poker. There is
little bleeding, but
healing is slow on account of damage to the edges of the wound. Any of these var
ieties may become infected.
First-aid treatment The first aim is to check any bleeding. This may be
done by pressure upon the edges
of the wound with a clean handkerchief, or, if the bleeding is serious, by putti
ng the finger in the wound
and pressing it upon the spot from which the blood is coming. If medical attenti
on is available within a
few hours, a wound should not be interfered with further than is necessary to st
op the bleeding and to
cover it with a clean dry handkerchief or bandage. When expert assistance is not
soon obtainable, the wound
should be cleaned with an antiseptic such as CHLORHEXIDINE or boiled water and t
he injured part fixed so
that movement is prevented or minimised. A wounded hand or arm is fixed with a S
LING, a wounded leg with a
splint (see SPLINTS). If the victim is in SHOCK, he or she must be treated for t
hat. (See also APPENDIX 1:
BASIC FIRST AID.) Wrinkle A natural furrow in the skin commonly associated with
AGEING. Wrinkles are most
prominent on the face and other exposed body parts. Overexposure to sunlight cau
ses premature wrinkling.
Cosmetic preparations may temporarily improve excessive wrinkling, but a face li
ft, which stretches the
skin using surgery, can improve a persons face for up to five years.
Wrist The joint situated between the arm above and the hand below. The r
egion of the wrist contains
eight small carpal bones, arranged in two rows, each containing four bones. Thos
e in the row nearest the
forearm are from the outside inwards when looking at the palm of the hand the sc
aphoid, lunate,
triquetrum, and pisiform.
775
Those in the row nearest the hand are the trapezium, trapezoid, capitate
and hamate. These latter
articulate with the metacarpal bones in the hand and are closely bound to one an
other by short, strong
ligaments; and the wrist-joint is the union of the composite mass thus formed wi
th the RADIUS and ULNA in
the forearm. The wrist and the radius and ulna are united by strong outer and in
ner lateral ligaments, and
by weaker ligaments before and behind, whilst the powerful tendons passing to th
e hand and fingers
strengthen the wrist. The joint can move in all directions, and its shape and ma
ny ligaments mean that it
rarely dislocates although stretching or tearing of some of these ligaments is a
common accident,
constituting a sprain. (See JOINTS, DISEASES OF.) Inflammation of the tendon-she
X
Xenograft A transplant (see TRANSPLANTATION) from one animal to another
of a different species. It is
also known as a heterograft.
Xenotransplantation Xanthelasma Palpebrarum
These yellow smooth nodules of LIPID-laden cells occur in and around the
eyelids (see EYE). Blood
lipids are usually normal, but there is an association with hypercholesterolaemi
a (see CHOLESTEROL;
HYPERLIPIDAEMIA) in a minority of sufferers.
Xanthoma (Plural: xanthomata.) A deposit of fatty material in the skin,
subcutaneous fat and tendons.
The presence of a xanthoma may be the first sign that a person has primary or se
condary HYPERLIPIDAEMIA a
raised concentration of lipids (see LIPID) in the blood. This can lead to ATHERO
MA, and appropriate
clinical and laboratory examinations should be done to determine the diagnosis a
nd treatment. When fatty
deposits occur in various parts of the body skin, brain, cornea, internal organs
and tendons the
condition is called xanthomatosis. Treatment is of the underlying conditions, an
important aim being to
lower the concentrations of fats in the body. Xanthomata have a variety of manif
estations which may point
to the underlying cause. These include:
Eruptive Eruptive yellow papules on the buttocks.
Plane Yellow plaques or macules in the skin. Tuberous Nodules on the elb
ows or knees. Tendinous
Subcutaneous nodules fixed to tendons, particularly those on the back of the fin
gers and the ACHILLES
TENDON.
X Chromosome One of two SEX CHROMOSOMES. Every normal female body cell h
as a pair of X chromosomes. Men
have only one X chromosome and this is paired with a Y chromosome. The sex cells
in men and women each have
one X and one Y chromosome. Certain diseases are linked to the presence of an X
chromosome: these include
HAEMOPHILIA (see GENETIC DISORDERS). (See also GENES.)
of organs from one species to another for example, from pigs to humans.
The use of organs from
appropriately cloned animals was seen as a possible solution to the shortage of
human organs for
transplantation; however, research has shown that rejection remains a problem an
d there is also an
unresolved possibility that diseases might be transmitted across the species bar
rier. It seems likely that
STEM CELL research will provide a more realistic source of tissues for transplan
tation to replace diseased
organs in humans.
TRANSPLANTATION
Xeroderma The term means dry skin. Normal skin may become dry when expos
ed to very low ambient humidity
and is then vulnerable to irritation by soaps, detergents and other chemicals wh
ich cause chapping.
Dryness of the skin may also be a feature of skin disease, especially atopic ecz
ema (see ATOPY;
DERMATITIS). Genetically determined xeroderma is called ICHTHYOSIS.
Xeroderma Pigmentosum A rare disease in which DNA repair mechanisms fail
, rendering the skin especially
vulnerable to damage from ultraviolet light (see ULTRAVIOLET RAYS (UVR)). Extrem
e photosensitivity begins
in infancy; later, marked freckling occurs and premature CARCINOGENESIS in the s
kin usually leads to early
death. There may also be neurological complications.
Xerosis Abnormal dryness, especially of the eye.
Xerostomia Dryness of the mouth due to lack of SALIVA. Its most extreme
form occurs following
radiotherapy of the mouth, and in the condition known as Sjgrens syndrome. No sati
sfactory substitute for
natural saliva has been found though some find a methyl-cellulose substitute giv
es partial relief, as may a
glycerin mouthwash.
Xiphisternum See XIPHOID PROCESS.
Xiphoid Cartilage See XIPHOID PROCESS.
X-Rays
Xiphoid Process Also known as the xiphisternum or xiphoid cartilage, thi
s is the small oval-shaped
projection forming the lowest of the three parts of the STERNUM or breastbone.
X-Rays Also known as Rntgen rays, these were discovered in 1895 by Wilhel
m Conrad Rntgen. Their use
for diagnostic imaging (radiology) and for cancer therapy (see RADIOTHERAPY) is
now an integral part of
medicine. Many other forms of diagnostic imaging have been developed in recent y
ears, sometimes also
loosely called radiology. Similarly the use of chemotherapeutic agents in cancer h
as led to the term
oncology which may be applied to the treatment of cancer by both drugs and X-ray
s. The rays are part of the
electro-magnetic spectrum; their wavelengths are between 109 and 10 13 metres; in
behaviour and energy
they are identical to the gamma rays emitted by radioactive isotopes. Diagnostic
Xrays are generated in an
evacuated tube containing an anode and cathode. Electrons striking the anode cau
se emission of Xrays of
varying energy; the energy is largely dependent on the potential difference (kil
ovoltage) between anode and
cathode. The altered tissue penetration at different kilovoltages is used in rad
iographing different
regions, for example in breast radiography (2540 kV) or chest radiography (120150
kV). Most diagnostic
examinations use kilovoltages between 60 and 120. The energy of Xrays enables t
hem to pass through body
tissues unless they make contact with the constituent atoms. Tissue attenuation
varies with atomic
structure, so that aircontaining organs such as the lung offer little attenuatio
n, while material such as
bone, with abundant calcium, will absorb the majority of incident Xrays. This r
esults in an emerging Xray
pattern which corresponds to the structures in the region examined.
Radiography The recording of the resulting images is achieved in several
ways, mostly depending on the
use of materials which fluoresce in response to Xrays. CONTRAST XRAYS Many bod
y organs are not shown by
simple Xray studies. This led to the development of contrast materials which ma
ke particular organs or
structures wholly or partly opaque to Xrays. Thus, bariumsulphate preparations
are largely used for
examining the gastrointestinal tract: for example, barium swallow, barium meal,
barium followthrough (or
enteroclysis) and barium enema. Watersoluble
777
iodinecontaining contrast agents that ionise in solution have been deve
loped for a range of other
studies. More recently a series of improved contrast molecules, chiefly nonioni
sing, has been developed,
with fewer sideeffects. They can, for example, safely be introduced into the sp
inal theca for
myeloradiculography contrast Xrays of the spinal cord. Using these agents, it is
possible to show many
organs and structures mostly by direct introduction, for example via a catheter
(see CATHETERS). In
urography, however, contrast medium injected intravenously is excreted by the ki
dneys which are outlined,
together with ureters and bladder. A number of other more specialised contrast a
gents exist: for example,
for cholecystography radiological assessment of the gallbladder. The use of con
trast and the attendant
techniques has greatly widened the range of radiology. IMAGE INTENSIFICATION The
relative insensitivity of
fluorescent materials when used for observation of moving organs for example, th
e oesophagus has been
overcome by the use of image intensification. A faint fluorographic image produc
ed by Xrays leads to
electron emission from a photocathode. By applying a high potential difference,
the electrons are
accelerated across an evacuated tube and are focused on to a small fluorescent s
creen, giving a bright
image. This is viewed by a TV camera and the image shown on a monitor and someti
mes recorded on videotape
or cine. TOMOGRAPHY Xray images are twodimensional representations of threedime
nsional objects. Tomography
(Greek tomos a slice) began with Xray imaging produced by the linked movement o
f the Xray tube and the
cassette pivoting about a selected plane in the body: over and underlying struc
tures are blurred out,
giving a more detailed image of a particular plane. In 1975 Godfrey Hounsfield i
ntroduced COMPUTED
TOMOGRAPHY (CT). This involves (i) movement of an Xray tube around the patient,
with a narrow fan beam of
Xrays; (ii) the corresponding use of sensitive detectors on the opposite side o
f the patient; (iii)
computer analysis of the detector readings at each point on the rotation, with c
alculation of relative
tissue attenuation at each point in the crosssectional plant. This invention has
enormously increased the
ability to discriminate tissue composition, even without the use of contrast. Th
e tomographic effect
imaging of a particular plane is achieved in many of the newer forms of imaging:
ULTRASOUND, magnetic
resonance imaging (see MRI) and some forms of
X
778 Xylose
nuclear medicine, in particular positron emission tomography (PET SCANNI
NG). An alternative term for
the production of images of a given plane is crosssectional imaging. While the
production of Xray and
other images has been largely the responsibility of radiographers, the interpret
ation has been principally
carried out by specialist doctors called radiologists. In addition they, and int
erested clinicians, have
developed a number of procedures, such as arteriography (see ANGIOGRAPHY), which
involve manipulative
access for imaging for example, selective coronary or renal arteriography. The u
se of Xrays, ultrasound
or computerised tomography to control the direction and position of needles has
made possible guided
biopsies (see BIOPSY) for example, of pancreatic, pulmonary or bony lesions and
therapeutic procedures
such as drainage of obstructed kidneys (percutaneous nephrostomy), or of abscess
es. From these has grown a
whole series of therapeutic procedures such as ANGIOPLASTY, STENT insertion and
renalstone track
formation. This field of interventional radiology has close affinities with MINI
MALLY INVASIVE SURGERY
(MIS).
Radiotherapy, or treatment by Xrays The two chief sources of the ionisi
ng radiations used in
radiotherapy are the gamma rays of RADIUM and the penetrating Xrays generated b
y apparatus working at
various voltages. For superficial lesions, energies of around 40 kilovolts are u
sed; but for deep
X
seated conditions, such as cancer of the internal organs, much higher vo
ltages are required. Xray
machines are now in use which work at two million volts. Even higher voltages ar
e now available through the
development of the linear accelerator, which makes use of the frequency magnetro
n which is the basis of
radar. The linear accelerator receives its name from the fact that it accelerate
s a beam of electrons down
a straight tube, 3 metres in length, and in this process a voltage of eight mill
ion is attained. The use of
these very high voltages has led to the development of a highly specialised tech
nique which has been
devised for the treatment of cancer and like diseases. Protective measures are r
outinely taken to ensure
that the patients normal tissue is not damaged during radiotherapy. The operators
too have to take special
precautions, including limits on the time they can work with the equipment in an
y one period of time. The
greatest value of radiotherapy is in the treatment of malignant disease. In many
patients it can be used
for the treatment of malignant growths which are not accessible to surgery, whil
st in others it is used in
conjunction with surgery and chemotherapy.
Xylose A sugar containing five carbon atoms involved in the metabolic co
Y Yawning
An involuntary opening of the mouth, which is accompanied by marked dila
tation of the pharynx, a
characteristic distortion of the face and usually stretching of the limbs. The c
ause and function of
yawning are quite obscure. It is classically regarded as a sign of drowsiness or
boredom, but it it may be
the result of raised concentrations of CARBON DIOXIDE (CO2) in the blood the phy
siological aim being to
cut the amount of CO2 and raise the level of oxygen in the blood.
Yaws A nonvenereal spirochaetal infection caused by Treponema pertenue
; it was formerly widespread in
most tropical and subtropical regions amongst the indigenous population, florid
disease being more common
in children than adults. The term is of CaribIndian (native to northeastern So
uth America, the east coast
of Central America, and the lesser Antilles) origin. It is directly contagious f
rom person to person;
infection is also transmitted by flies, clothing, and living in unclean huts. Cl
inically, the primary stage
is characterised by a granulomatous lesion, or papule (framboesioma or mother yaw)
at the site of
infection usually the lower leg or foot; this enlarges, crusts, and heals sponta
neously. It appears some
28 weeks after infection, during which time fever, malaise, pains, and pruritus m
ay be present. In the
secondary stage, a granulomatous, papular, macular or squamous eruption occurs;
periostitis may also be
present. The late, or tertiary stage (which appears 510 years later), is characte
rised by skin plaques,
nodules, ulcers, hyperkeratosis (thickening of the skin of the hands and feet) a
nd gummatous lesions
affecting bones. Recurrence of infection in individuals suffering from a concurr
ent infection (e.g.
SYPHILIS or TUBERCULOSIS) renders the infection more serious. Diagnosis is by de
monstration of T. pertenue
in exudate from a suspected lesion. Treatment is with PENICILLIN, to which T. pe
rtenue is highly sensitive.
Extensive eradication campaigns (initiated by the WHO in 1949) have been carried
out in endemic areas;
therefore, the early stages of the infection are rarely counted; only tertiary s
tages come to the attention
of a physician. Failure of
surveillance can lead to dramatic local recurrences.
Y Chromosome One of two SEX CHROMOSOMES that is present in every male bo
dy cell where it is paired with
an X CHROMOSOME. The sex or germ cells in women as well as men contain one X and
one Y chromosome (see also
GENES).
Yeast This consists of the cells and spores of unicellular fungi belongi
ng to the family of
Saccharomycetaceae. The main species of yeast used in medicine is Saccharomyces
cerevisiae, which is used
in the fermentation industries, such as brewing. It is a rich source of the vita
min B complex (see APPENDIX
5: VITAMINS), but its use has largely been given up since the various components
of the vitamin B complex
became available as separate entities.
Yellow Fever An acute arbovirus (see ARBOVIRUSES) infection caused by a
flavivirus of the togavirus
family, transmitted from animals to humans by various species of forest mosquito
(jungle/sylvan yellow
fever), and from human to human by Ades aegypti (urban yellow fever). Mosquito tr
ansmission was shown by
Walter Reed and his colleagues in 1900. It is ENDEMIC in much of tropical Africa
and Central and South
America but does not occur in Asia. In the urban cycle, humans constitute the re
servoir of infection, and
in the jungle/sylvan variety, mammals especially subhuman primates are involved
in transmission.
Historically, yellow fever was enormously important, causing devastating epidemi
cs (see EPIDEMIC); it also
carried a high mortality rate in travellers and explorers. Differentiation from
other infections associated
with JAUNDICE was often impossible. Clinically, yellow fever is characterised by
jaundice, fever, chills,
headache, gastrointestinal haemorrhage(s), and ALBUMINURIA. The incubation perio
d is 36 (up to 10) days.
Differentiation from viral hepatitides, other viral haemorrhagic fevers, severe
Plasmodium falciparum
malaria, and several other infections is often impossible without sophisticated
investigative techniques.
Infection carries a high mortality rate. Liver histology (biopsy is contraindica
ted due to the haemorrhagic
diathesis) shows characteristic changes; a fulminating hepatic infection is ofte
n present. Acute
inflammation of the kidneys and an inflamed, congested gastric mucosa, often acc
ompanied by haemorrhage,
are also demonstrable;
780 Yersinia
myocardial involvement often occurs. Diagnosis is primarily based on vir
ological techniques;
serological tests are also of value. Yellow fever should be suspected in any tra
vellers from an endemic
area. Management consists of instituting techniques for acute hepatocellular (li
vercell) failure. The
affected individual should be kept in an isolation unit, away from mosquitoes wh
ich could transmit the
disease to a healthy individual. Formerly, laboratory infections were occasional
ly acquired from infected
blood samples. Prophylactically, a satisfactory attenuated VACCINE (17D) has bee
n available for around 60
years; this is given subcutaneously and provides an individual with excellent pr
otection for ten years;
international certificates are valid for this length of time. Every traveller to
an endemic area should be
immunised; this is mandatory for entry to countries where the infection is endem
ic.
Yersinia A genus of BACTERIA which includes the causative organism of PL
AGUE, Yersinia pestis.
Yin and Yang Basic concepts in traditional Chinese medicine and philosop
hy. Yang represents active,
positive masculine qualities. Yin embodies passive, negative feminine qualities.
Yoga A system of Hindu philosophy and physical
Y
discipline involving special breathing techniques and a series of prescr
ibed physical poses. These are
intended to relax the body and teach the individual mental and physical control.
Yoga is best learned from
experienced teachers, or those practising it may damage their backs.
Yoghurt Sour milk curdled with one of the LACTIC ACID producing bacilli,
such as Lactobacillus
acidophilus or Lactobacillus bulgaricus. It contains all the protein, fat, calci
um, and vitamins of the
original milk, and is therefore a nutritious food, but there is no evidence that
it has any unique
beneficial properties of its own. In countries where standards of hygiene are lo
w, it has the advantage of
having been sterilised by boiling and is therefore unlikely to be contaminated w
ith dangerous
microorganisms.
Yohimbine This substance is derived from the bark of Pausinystalia yohim
bie, a West African tree. Once
widely used as an aphrodisiac an action for which there is no good evidence, it
is now being used in the
treatment of certain cases of postural HYPOTENSION and for the treatment of IMPO
TENCE.
Yttrium90 An artificially produced ISOTOPE of the element Yttrium. The
isotope is radioactive and
emits beta rays which are utilised for the treatment of tumours.
Z Zalcitabine
A nucleoside REVERSE TRANSCRIPTASE INHIBIused in the treatment of HIV, i
n combination with other
antiretroviral drugs. Serious sideeffects include the risk of peripheral NEUROP
ATHY and of pancreatitis
(see PANCREAS, DISEASES OF).
TOR
Zanamivir An antiviral drug (trade name Relenza) which ameliorates the sy
mptoms of INFLUENZA. It is
licensed in the United Kingdom for treating the A or B varieties, 48 hours after
the onset of symptoms. In
otherwise healthy people it reduces the duration of symptoms by around 24 hours.
It is not yet known to
what extent zanamivir can prevent complications in highrisk patients such as the
elderly.
Zidovudine An antiviral drug used to treat AIDS (see AIDS/ HIV) and its
related conditions, such as
pneumocystis PNEUMONIA. The drug slows down the growth of human immunodeficiency
virus (HIV) but does not
cure the disease. It may be given intravenously or by mouth. Also called AZT, zi
dovudine has been in use
since 1987, and it works by blocking the ENZYME that stimulates HIV to grow and
multiply. It may cause
ANAEMIA so regular blood tests are necessary.
Zinc A metal, several salts of which are used in medicine for external a
pplication. It is essential for
growth and development in animals and plants. The average human body contains a
total of 1 2 grams, and
most human diets contain 1015 mg. In human beings, deficiency of zinc results in
lack of growth, slow
sexual development and ANAEMIA. Deficiency is also associated with a skin disord
er known as acrodermatitis
enteropathica.
Uses Zinc chloride is a powerful caustic and astringent which, combined
with zinc sulphate, is used as
an astringent mouthwash. Zinc sulphate is also used in the form of eyedrops in t
he treatment of certain
forms of conjunctivitis (see under EYE, DISORDERS OF). Zinc oxide, zinc stearate
, and zinc carbonate
are made up in dusting powders, in ointments, in paste bandages or suspe
nded in water as lotions for
the astringent action they exert upon abraded surfaces of the skin. Zinc and cas
tor oil ointment of the
British Pharmacopoeia is a welltried treatment for nappy rash. Zinc undecenoate
is used as an ointment and
as a dustingpowder in the treatment of RINGWORM.
ZollingerEllison Syndrome A rare disorder in which severe peptic ulcers
recur in the stomach and
duodenum (see DUODENAL ULCER; STOMACH, DISEASES OF). It is caused by a tumour in
the PANCREAS that produces
a hormone, GASTRIN, which stimulates the stomach and duodenum to produce excess
acid: this causes
782 Zymolysis
Fertilisation of the female ovum by the male sperm cell to form the zygo
te.
ovum. After passing down the Fallopian tube, when the zygote starts divi
ding, it becomes implanted in
the UTERUS and develops into an EMBRYO.
Z
Zymolysis The mechanism of fermentation initiated by an ENZYME during DI
GESTION.
APPENDIX 1: BASIC FIRST AID This appendix is designed to cover the basic princip
les involved in the
save someones life or lessen the potential harm of an accident. Firstaid treatme
nt in an emergency is
intended: to preserve life and stop the victims condition from deteriorating. to
help recovery and save
the victim from further harm. to make the casualty as comfortable as possible an
d reassure him/her and the
family. to assess the events surrounding the illness or accident so that relevan
t facts can be given to a
doctor, nurse or paramedical staff. No ill or badly injured person should be mov
ed without skilled
immediate danger from the surroundings (e.g. a fire). He or she should be kept w
arm; constricting clothing
should be loosened; and a clear airway should be established, with any false tee
th removed.
Bleeding This may occur from arteries, veins or capillary beds. The form
er is easily recognised as the
blood tends to spurt from the wound at the same rate as the pulse; with the latt
er two types the blood
tends to flow from the wound. Minor bleeding is usually treated in the home by t
he application of bandages,
etc. However, the basic principles of treatment for major haemorrhages may be ap
plied. Pressure should be
applied to the bleeding point, via gauze or a clean piece of cloth if available,
firmly enough to stop the
flow of blood. With the pressure applied, the wound should be raised above the l
evel of the heart. The
patient should then be transferred to a place where medical care is available. I
f the loss of blood is
severe enough for the victim to have become shocked (see SHOCK), he or she shoul
d be laid flat with the
legs raised, if possible. (See also HAEMORRHAGE.)
Burns and scalds Burns can be caused by
dry heat, severe cold, corrosive materials, radiation (including rays fr
om the sun) and friction (such
as results from a body sliding along a road surface after a motorcycle accident)
. Scalds are caused by hot
fluids or steam. Burns and scalds may be associated with other injuries caused,
say, by an escape from a
burning building, a road traffic accident or an explosion: casualties should the
refore be examined for
other injuries. Most burns and scalds affect the skin, and the area(s) and site(
s) of skin damaged are
important in assessing a victims condition. Muscles and other tissues may be dama
ged by burns, and
inhalation of smoke or fumes may damage the linings of the mouth, throat and lun
gs. Shock, sometimes
severe, is common the result of pain and loss of body fluids. All but the most m
inor burns should be seen
by a doctor, as it is difficult to assess the severity of the burn immediately a
fter it occurs. If the
person or his or her clothing is actually on fire, then the first move must be t
o smother the flames by
covering them with a blanket or coat, for example and patting out the flames witho
ut sustaining burns
yourself. Many burns, however, are caused by hot liquids, hot gases, flashes fro
m explosions or contact
with a very hot object so that the person is not actually on fire. The treatment
for all these burns is the
same to remove any clothing over the affected area, if possible, and to put the
affected area under cold
running water until the pain has stopped or the ambulance has arrived (the cold
water should be applied for
several minutes, as cooling of the tissues, particularly the deeper layers of th
e skin, will limit the
extent of the burn). The burn should be left exposed or covered with a piece of
clean wet linen (e.g. a
pillowcase), for the transfer to hospital. No lotions or potions should be appli