The British

Medical Association
-
AZ
FAMILY
MEDICAL
ENCYCLOPEDIA
BMA CONSULTING MEDICAL EDITOR
Dr. Michael Peters
 BRITISH MEDICAL ASSOCIATION
Chairman of the Council Mr. James Johnson
Treasurer Dr. David Pickersgill
Chairman of Representative Body Dr. George Rae

MEDICAL EDITORS AND CONSULTANTS

BMA Consulting Medical Editor Dr. Michael Peters MB BS
Medical Consultants Dr. Wendy Abrams MB BS MRCGP DRCOG; Ian Beider BDS (U.Lond)
Dr. Sue Davidson MB BS MRCP MRCGP DRCOG,
Dr. Penny Preston MB ChB MRCGP
Dr. Frances W. Williams MA MBBChir MRCP MRCPCH DTM&H

DORLING KINDERSLEY
Senior Managing Editor Martyn Page • Project Editor Teresa Pritlove
Editors Ann Baggaley, Joanna Benwell, Dawn Henderson, Katie John,
Alyson Lacewing, Mary Lindsay, Maugan Lloyd, Nikki Sims • Editorial assistance Kathryn Wilkinson
Managing Art Editors Louise Dick, Marianne Markham • Senior Designer Ian Spick
Designers Phillip Lord, Andrew O’Brien • Design Assistants Iona Hoyle, Francis Wong
DTP Design Julian Dams • Production Wendy Penn, Kirsti Rippon • Illustrators Patrick Mulrey,
Andrew O’Brien, Richard Tibbits • Picture Research Carolyn Clerkin, Diana Morris
Category Publisher Corinne Roberts • Art Director Bryn Walls

DORLING KINDERSLEY INDIA

Managing Editor Ira Pande • Editors Sudhanshu Gupta, K. J. Ravi, Ranjana Saklani • Managing Art
Editors Shuka Jain, Aparna Sharma • Illustrations Project Co-ordinator Malavika Talukder
Illustrations Umesh Aggarwal, Rajesh Chhibber,Vinod Harish, Nain Singh Rawat, Pankaj Sharma, Sunil
Sharma, Balwant Singh, Ashwani Tyagi • DTP Co-ordinator Pankaj Sharma • DTP Design Ajay Verma

PREVIOUS EDITIONS
DORLING KINDERSLEY
Senior Managing Editor Martyn Page • Managing Editor Ruth Midgley • Editors Andrea Bagg, Dr. Stephen
Carroll, Robert Dinwiddie, Gail Lawther, Mary Lindsay, Richenda Milton-Thompson, Ricki Ostrov, Teresa Pritlove,
Jillian Somerscales, Tony Whitehorn • Additional editorial assistance Maria Adams, Simon Adams, Donald
Berwick, Deirdre Clark, Jean Cooke, Mike Darton, Elizabeth Galfalvi, Claire Isaac, Ann Kramer, Cathy Meeus,
Terence Monaighan, Theodore Rowland-Entwistle, Ruth Swan, Rena Taylor, Pat White, Kay Wright • Senior
Managing Art Editor Bryn Walls • Managing Art Editors Chez Picthall, Denise Brown • Art Editors Melissa Gray,
Caroline Murray, Anne Renel • Designers Sandra Archer, Peter Cross, Tina Hill, Gail Jones, Sarah Ponder, Tracy
Timson, Lydia Umney • Additional design assistance Peter Blake, Carol Briggs, Thomas Keenes, Chris Scollens
Illustrators Karen Cochrane, Paul Cooper, Sandra Doyle, Tony Graham, Will Giles, Brian Hewson, Chris Jenkins,
Kevin Jones, Janos Marffy, Kevin Marks, Coral Muller, Frazer Newman, Nick Oxloby, Lynda Payne, Sandra Ponder,
Patricia Sempron, Mark Surridge, John Temperton, John Woodcock • DTP Design Jason Little • Picture Research
Sandra Schneider, Sharon Southren • Production Elizabeth Cherry, Eunice Paterson, Hilary Stephens, Michelle
Thomas • Indexer Kay Wright • Editorial Directors Amy Carroll, Jackie Douglas
 PREVIOUS EDITIONS
Medical Editor Dr. Tony Smith MA BM BCh

MEDICAL REVIEWERS
Mr. John Ballantyne CBE, FRCS, Professor Arnold E. Bender Lewis MB, FFARCS, Mr. C.D.R. Lightowler FRCS, Dr. G. Keith
DSc, PhD, Dr. Brendan M. Buckley DPhil, FRCP(I), Professor Morris MD, FRCP, Dr. Graham Peter Mulley DM,FRCP, Dr.
James Calnan FRCS, FRCP, Dr. Dewi Davies MD, FRCP, Dr. A.K. R.T.D. Oliver MD, FRCP, Dr. Alex Paton MD, FRCP, Dr. T.
Dixon MD, FRCR, Dr. James Owen Drife MD, FRCS(Ed), Mr. Richards MRCP, MRCGP, Dr. J.A. Savin MD, FRCP, Dr. Leonard
Edgar Gordon MSc, DDS, Professor Terry J. Hamblin DM, Sinclair FRCP, DCH, Dr. R.N.T. Thin MD, FRCP, Mr. Patrick D.
FRCP, Dr. Anthony John Holland MPhil, MRCP, Dr. Helen M. Trevor-Roper MD, FRCS, Mr. Robert H. Whitaker MD, FRCS,
Kingston MD, MRCP, Professor W.R. Lee, MD, FRCP, Dr. E.B. Dr. George Bernard Wyatt FRCP, DCH

CONTRIBUTORS
Vivienne Owen Ankrett MRCGP, DRCOG, Igor Anrep LRCP, FRCPE, FRCGP, Paul W. Lambden FDS RCS, MB, Richard
MRCS, Ann Ashworth PhD, Alan Bailey MB, MRCP, Julian Lamerton MRCS, LRCP, R.S. Ledward FRCS, FRCOG, Colin
Barth MB, MRCP, Margaret A. Barrie FRCP, DRCOG, R.J. Berry John Leonard FRCGP, DCH, S.G. Lim BDS, E.S. Lin FFARCS,
FRCP, FRCR, A.K. Bhalla MD, MRCP, Charles Eric Blank PhD, Peter C. Lindsay MA, MB, Jane MacDougall MB, MRCOG,
MB, Geoffrey Blundell, Susan Bosanko, Arthur William Shelia Macey, Norma MacMillan, T.E. Martin MB, John A.
Boylston MD, MRCPath, Amanda Bridges, Peter Bromwich Matthews MD, FRCP, Francis Matthey MB, MRCP, J.Q.
MB, MRCOG, W.B.J. Broom MB, N.F. Burnett Hodd FBCO, Matthias MD, FRCP, Kenneth A. McLean MB, MRCP, P.W.D.
DCLP, E.P. Cameron MCh, FRCS, Rosalind Carr MB, DRCOG, Meerstadt MRCP, DCH, Debbie Mills, P.J.A. Molitor MB,
Nicola Jane Carroll, N.R. Carroll BDS, LDSRCS, Simon StC. FRCS, Alex J. Munro, MSc, MRCP, Nabil M. Mustapha MB,
Carter MB, FRCS, Michael D. Chard MB, MRCP, Lyn Cheater, FRCS, Paul Myers MRCGP, DObstRCOG, David S. Nairn MB,
Julian Chomet MSc, Neil Citron MChir, FRCS, A.M. de Lacy FRCS, Margaret Nanson MA, MB, C.G.H. Newman FRCP,
Costello MB, MRCP, Richard Dawood FRCR, DTM & H, DCH, Kenneth Arthur Newton FRCP, FRCR, A.N. Nicolaides
J.J. Dawson MS, FRCS, Jonathan H. Dean, Jane Deverson, John MS, FRCS, Mark Noble PhD, N.P. Norwell DA, MRCGP, P.M.
H. Dubois, Andrew Duncombe MB, MRCP, Patrick Durston Owens MB, Malcolm Padwick MB, MRCOG, A.M. Peters MD,
FASI, REMT, Adrian Eddleston DM, FRCP, Martin Brian MRCPath, Michael Peter Powell MB, FRCS, W.D.W. Rees MD,
Edwards BDS, FDSRCS, Anne Eldred MB, MRCGP, Christopher MRCP, Anthony John Richards FRCP, DPhysMed, M.B. Richter
John Ellis FRCP, DTM & H, M.G. Falcon FRCS, FCOphth, Ivor FRACP, PhD, Amanda Jane Roberts MB, M. Rogers BPharm,
L. Felstein MB, P.H. Fentem MB, MRCP, Colin Ferguson MB, MRPharmS, DipInfSc, MIInfSc, N.D. Rothnie MB, FRCS,
FRCS, Loraine Fergusson, Richard E. Field FRCSE, Michael W. Rosalind J.D. Rothnie MB, DObstRCOG, Robert Royston,
Flowers MB, FRCS, Michael D. Flynn MB, MRCP, John Foley Quentin Sattentau PhD, Peter Saul MRCGP, DCH, Glenis K.
MD, FRCP,T.J. Fowler DM, FRCP, Roger Gabriel MB, FRCP, Scadding MD, MRCP, D.F. Scott FRCP, DPM, Christina M.
Ruth Garland, Michael Glasspool FRCS, DO, Max Glatt FRCP, Scott-Moncrieff MB, MFHom, Mike Seymour MB, FRCS,
FRCPsych, J. Graham MB, MRCGP, Roger F. Gray MB, FRCS, Sarah-Jane Seymour MB, J.F.L. Shaw ChM, FRCS, Caroline
Brian Glenville MB, FRCS, Alison Hadley SRN, HV, John W. M. Shreeve MB,Valerie Sinason, Albert Singer DPhil, FRCOG,
Harcup SBStJ, MRCGP, Richard Harding AFOM RCP, DAv T.M. Skerry BVetMed, MRCVS, Arlene Sobel, Michael Spira
Med, David Haslam MRCGP, DObstRCOG, Roderick J. Hay MB,Venetia Stent MB, MRCGP, Richard Stern MD, FRCPsych,
DM, FRCP, Kenneth W. Heaton MD, FRCP, John A. Henry MB, Susan Sturrock, Paul Sweny MD, FRCP, M.F. Sturridge MS,
FRCP, Anthony David Heyes PhD, Ann Hill PhD, K.E.F. Hobbs FRCS, Margaret Elizabeth Taylor BDS, MB, A. Theodossi MD,
ChM, FRCS, David Honeybourne MD, MRCP, Judith Hooper MRCP, Malcolm Keith Thompson DObstRCOG, FRCGP,
DObstRCOG, MRCGP, Graham Robert Vivian Hughes MD, Michael Townend MB, G.D.W. Towse,Trevor H. Turner MB,
FRCP, Alex T. Inglis BDS, FDSRCS, J. Jenner MD, MRCP, Lydia MRCPsych, H.A. Waldron MD, FFOM, Rae Ward, Michael
Jones MB, MRCP, Jack Joseph MD, FRCOG, Adrian D. Joyce Anthony Waugh MB, DipVen, Moya de Wet, Saffron Ann
MB, FRCS, Patricia A. Judd PhD SRD, Arthur Kaufman MSc, Whitehead PhD, Marcia Wilkinson DM, FRCP, Ian Williams
ABPsS, Patrick Kesteven FRCAP, FRCPA, R.B. Kinder MB, MRCGP, DRCOG, Pamela Wood, W. Keith Yeates MD, FRCS,
FRCS, Ronald L. Kleinman MB, DObstRCOG, J.D.E. Knox Robert M.Youngson DTM & H, FCOphth
 ABDOMEN

A
which also covers the organs, such as tion, a physical examination, laboratory
A the pancreas and kidneys, that are fixed
to the back wall. Folds of peritoneum
tests, and imaging procedures such as
ultrasound scanning. The investigation
also cover the mobile organs, such as may also involve a laparoscopy (internal
the stomach and intestines. examination using a rigid or flexible
viewing tube) or a laparotomy (surgical
abdomen, acute exploration of the abdomen). Treatment
The medical term for persistent, severe depends on the underlying cause.
abdominal pain, of sudden onset, that is
usually associated with spasm of the abdominal
abdominal muscles, vomiting, and fever. Relating to the abdomen.
abdomen CAUSES
The region of the body between the The most common cause of an acute abdominal hysterectomy
chest and the pelvis.The abdominal cav- abdomen is peritonitis (inflammation of The surgical removal of the uterus
ity is bounded by the ribs and the membrane that lines the abdomen); (womb) through an incision in the
diaphragm above, and by the pelvis underlying causes include appendicitis, abdomen (see hysterectomy).
below, with the spine and abdominal abdominal injury, or perforation of an
muscles forming the back, side, and internal organ as a result of disorders abdominal pain
front walls. The abdominal cavity con- such as diverticular disease (the presence Discomfort in the abdominal cavity.
tains the liver, stomach, intestines, of small, protruding pouches in the Symptoms accompanying abdominal
spleen, pancreas, and kidneys. In the intestinal wall) or peptic ulcer. pain may include belching, nausea, vom-
lower abdomen, enclosed by the pelvis, SYMPTOMS iting, rumbling and gurgling noises,
are the bladder, rectum, and, in women, Acute abdomen commonly begins as a and flatulence (wind).
the uterus and ovaries. vague pain in the centre of the abdomen CAUSES
STRUCTURE that gradually localizes to a particular Mild abdominal pain is common and is
The spine, pelvis, and ribs provide region of the body, depending on the often due to excessive alcohol intake,
attachments for the layers of muscle condition. For example, pain is felt on eating unwisely, or an attack of diar-
that make up the abdominal walls. the right side of the body in appendicitis. rhoea. Pain in the lower abdomen is
There is a layer of fat between these DIAGNOSIS AND TREATMENT common during menstruation but may
muscles and the skin. The inner surface An acute abdomen requires urgent medi- occasionally be due to a gynaecological
of the abdominal muscles is covered by cal investigation usually comprising disorder such as endometriosis (in which
a thin membrane, the peritoneum, detailed questioning about the condi- fragments of uterine lining are present
in abnormal sites within the abdomen).
Cystitis (inflammation of the bladder) is
LOCATION OF THE ABDOMEN another common cause of pain or dis-
comfort in the lower abdomen. Bladder
The abdomen is bounded by the lower ribs at the top and the
pelvis below. The illustration shows the position of the abdominal
distension due to urinary obstruction
organs in an adult woman. may also cause abdominal pain.
Abdominal colic is the term used for
pain that occurs every few minutes as
Line of one of the internal organs goes into
diaphragm
muscular spasm. Colic is an attempt by
the body to overcome an obstruction
Muscle Peritoneum such as a stone or an area of inflamma-
tion. The attacks of colic may become
Skin Stomach more severe and may be associated with
Liver Spleen vomiting (see abdomen, acute).
A peptic ulcer, which is associated
Gallbladder Adrenal with an increase in the amount of acid
gland
formed in the stomach, often produces
Kidney Kidney recurrent gnawing pain. Other possible
Pancreas causes of abdominal pain are infection,
Large intestine such as pyelonephritis (infection of the
Small intestine (colon) kidneys) and pelvic inflammatory disease
(infection of the internal female repro-
Caecum Rectum ductive organs), and ischaemia (a lack
Appendix of blood supply), as occurs when a
Ovary volvulus (twisting of the intestine) obs-
Fallopian tube tructs blood vessels. Tumours affecting
Uterus an abdominal organ can cause pain.
Bladder Abdominal pain may also have a psy-
chological cause, such as anxiety.

6
 ABDUCENT NERVE

TREATMENT (examination of a body cavity using a INVESTIGATION

For mild abdominal pain, self-treatment
measures, such as a wrapped hot-water
flexible viewing tube) in the form of
laparoscopy (viewing the abdominal cav-
Diagnosis of the underlying cause may
involve X-rays (see abdominal X-ray),
A
bottle or a milky drink, are often effec- ity), gastroscopy (viewing the stomach ultrasound scanning, laparotomy (surgical
tive. Pain due to peptic ulcer can be and duodenum), or colonoscopy (view- exploration of the abdomen) or laparos-
temporarily relieved by consuming ing the large intestine). copy (examination of the inside of the
food or by taking antacid drugs. abdomen using a rigid or flexible view-
Abdominal pain that is not relieved abdominal swelling ing tube). In ascites, some of the fluid
by vomiting, persists for more than six Enlargement of the abdomen, which in the abdomen may be drained for
hours, or is associated with sweating or may be due to a variety of causes. detailed examination.
fainting requires urgent medical atten- Abdominal swelling is a natural result
tion. Urgent attention is also necessary of obesity and enlargement of the uterus abdominal thrust
if pain is accompanied by persistent during pregnancy. A first-aid treatment for choking in
vomiting, vomiting of blood, or passing Some causes of abdominal swelling which a sharp upward pressure is
of bloodstained or black faeces. Abdom- are harmless. Wind in the stomach or applied to the upper abdomen, just
inal pain that is accompanied by intestine may cause uncomfortable, below the rib cage, to dislodge a for-
unexplained weight loss or changes in bloating distension. Distension as a eign body that is obstructing the airway.
bowel habits should always be investi- result of temporary water retention may The technique is also known as the
gated by a doctor. occur in some women just before men- Heimlich manoeuvre.
INVESTIGATION AND DIAGNOSIS struation. Other causes may be more
The doctor makes a diagnosis of serious. For instance, ascites (fluid accu- abdominal X-ray
abdominal pain based on a physical mulation in the abdominal cavity) may An X-ray examination of the abdominal
examination and a detailed description be a symptom of cancer or disease of contents. An abdominal X-ray is often
of the patient’s symptoms. Investigation the heart, kidneys, or liver; swelling one of the first steps in the investigation
of severe abdominal pain may also may also be due to intestinal obstruc- of acute abdominal disease.
include blood tests, imaging tests such as tion (see intestine, obstruction of) or an X-rays do not reveal the internal
ultrasound scanning, and endoscopy ovarian cyst. structure of organs, but they do show
their outlines. X-rays can therefore
show whether any organ is enlarged
DIAGNOSING ABDOMINAL PAIN and can detect swallowed foreign bod-
ies in the digestive tract. X-rays also
The doctor conducts a physical examination and listens to the patient’s description
of the pain. More investigations, such as blood tests, X-rays, or imaging tests show accumulations of fluid and gas:
(including ultrasound scanning), may be carried out. If the diagnosis is still in distended loops of bowel containing
doubt, endoscopic inspection of the stomach and duodenum (gastroscopy), large collections of fluid often indicate the
intestine (colonoscopy), or abdominal cavity (laparoscopy) may be performed. presence of an obstruction (see
intestine, obstruction of); gas outside the
Oesophageal reflux Gallbladder pain intestine indicates intestinal perforation.
A burning pain in A cramplike or steady
the chest that is pain under the right
Calcium, which is opaque to X-rays,
accompanied by ribs that is often is present in most kidney stones (see
regurgitation of accompanied by calculus, urinary tract) and in some
stomach acid and vomiting and fever. gallstones and aortic aneurysms; these
is often worse after can sometimes be detected on an
meals or when lying
down at night. abdominal X-ray.
Abdominal X-rays may need to be
Duodenal ulcer pain Appendicitis pain followed by procedures that provide
This pain often occurs in This pain starts around more information, such as ultrasound
the same small area and the navel before finally scanning, barium X-ray examinations (use
may be temporarily settling in the lower right of a contrast medium to detect dis-
relieved by eating or side of the abdomen.
taking antacids. orders of the gastrointestinal tract),
laparoscopy (internal examination of the
abdomen using a viewing instrument),
CT scanning or MRI (techniques that
produce cross-sectional or three-dimen-
Wind Pelvic organ sional images of body structures).
Excess wind in the inflammation
digestive system affects A constant diffuse pain,
a large area of the usually accompanied by abducent nerve
abdomen and can vaginal discharge or The sixth cranial nerve. The abducent
cause an uncomfortable, fever, that extends over nerve supplies the lateral rectus muscle
distended feeling. the lower abdomen.
of each eye, which is responsible for
moving the eyeball outwards. The abdu-
cent nerve originates in the pons (part
of the brainstem) and passes along the

7
 ABDUCTION

base of the skull, entering the back of ABO blood groups If this drug treatment is unsuccessful, a
A the eye socket through a gap between
the skull bones.
See blood groups. surgical termination will be required.
Until the 12th week, pregnancy may be
The abducent nerve may be damaged abort terminated by vacuum suction curettage
in fractures of the base of the skull, or A term meaning to terminate a preg- performed under either a general or a
by disorders, such as tumours, that dis- nancy, either spontaneously (see local anaesthetic (see anaesthesia, gener-
tort the brain. Such damage may give miscarriage) or through medical inter- al; anaesthesia, local). The cervix is
rise to double vision or a squint. vention (see abortion, induced). dilated with curved metal rods and a
thin plastic tube is inserted into the
abduction abortifacient uterus. The tube is connected to an
Movement of a limb away from the cen- An agent that causes abortion. In medical apparatus that sucks out the fetal and
tral line of the body, or of a digit away practice, abortion is induced using placental tissues.
from the axis of a limb. Muscles that prostaglandin drugs, often given in the Recovery is generally fast, although
carry out this movement are called form of vaginal pessaries. These cause strenuous activity should be avoided for
abductors. (See also adduction.) the softening and widening of the several days. There is usually some
cervix (neck of the uterus) and mus- bleeding, and occasionally mild cramps,
abductor cular contractions of the uterus. for up to a week. Menstrual periods
Any one of the muscles that carry out typically return four to six weeks after
the movement of abduction. abortion the termination. Sexual intercourse can
In medical usage, a term denoting either be resumed after two to three weeks.
aberrant spontaneous abortion (see miscarriage) Late abortion Between the 12th and
A term meaning abnormal; in medical or medically induced termination (see 15th weeks of pregnancy, either the
usage the word is often applied to a abortion, induced) of pregnancy. (See suction procedure used in early abor-
blood vessel or nerve that deviates from also complete abortion; habitual abortion; tion or the evacuation procedure may
its normal route. incomplete abortion; septic abortion.) be recommended. In the evacuation
procedure, which is routinely perfor-
abetalipoproteinaemia abortion, induced med after the 15th week, the uterus is
A rare, inherited genetic disorder of lipo- Medically induced termination of preg- forced to contract so that the fetus is
protein (a protein that combines with fats nancy. In the UK abortion can legally expelled, as in natural labour. Contrac-
or other lipids) metabolism. It is inher- be performed up to the 24th week of tions are induced by oral administration
ited in an autosomal recessive manner pregnancy. Legally, abortion may be of a dose of mifepristone, followed 36
and is characterized by malabsorption of performed if continuation of the preg- to 48 hours later by the introduction,
fats, acanthocytosis (distorted red blood nancy would constitute a greater risk to high into the vagina, of a prostaglandin
cells), retinopathy (disease of the retina), the woman’s life than the termination, hormone pessary. The prostaglandin
ataxia (incoordination and clumsiness), if the mental or physical health of the medication may need to be repeated for
slurred speech, muscle weakness, curva- woman or her existing children is at the contractions to be maintained.
ture of the spine, neuropathy (peripheral risk, or if there is a substantial risk of It usually takes from 12 to 24 hours
nerve disease), fatty stools, diarrhoea, serious handicap to the baby. for the fetus to be expelled using the
and failure to thrive in infancy. MEDICAL REASONS FOR ABORTION evacuation procedure, during which
Treatment with high doses of fat sol- A doctor may recommend an abortion time the woman is given analgesic drugs
uble vitamins (vitamin A, vitamin D, if the woman suffers from a life-threat- (painkillers). She usually remains in
vitamin E, and vitamin K) may slow the ening condition, such as severe heart hospital for up to 48 hours after com-
progression of certain abetalipopro- disease, chronic kidney disease, or can- pletion of the termination in order to
teinaemia-related problems such as cer, especially of the breast or cervix. be monitored for complications.
retinal degeneration. If a serious fetal abnormality is discov- COMPLICATIONS
ered, for example severe developmental If termination is performed by a quali-
ablation defects (such as anencephaly) or chromo- fied gynaecologist in a well-equipped
The removal or destruction of diseased somal abnormalities (such as Down’s clinic or hospital, complications are
tissue by excision (cutting away), syndrome), the parents may be offered rare. Infection, resulting in a condition
cryosurgery (freezing), radiotherapy, dia- the option of a termination. Abortion called septic abortion, or serious bleeding
thermy (burning), or laser treatment. may also be recommended if the mother occasionally occur. Repeated termina-
contracts rubella (German measles) dur- tions may increase the risk of
ablepharia ing early pregnancy. miscarriage occurring in subsequent
A birth defect in which the eyelids fail to HOW IT IS DONE pregnancies; but a single termination is
develop normally, leaving the eyeball Early abortion Up to the ninth week of unlikely to affect future fertility. (See
completely covered over. pregnancy termination may be induced also complete abortion; habitual abortion;
by treatment with a combination of two incomplete abortion.)
abnormality drugs, mifepristone and a prostaglandin
A physical deformity or malformation, drug. These end the pregnancy by abrasion
behavioural or mental problem, or vari- inducing the uterus to contract and Also called a graze, a wound on the sur-
ation from normal in the structure or expel the embryo and the placenta; the face of the skin that is caused by
function of a body cell, tissue, or organ. process usually takes at least 48 hours. scraping or rubbing.

8
 ABSCESS, DENTAL

abrasion, dental (see breast abscess), groin, and gums escape; a tube may be left in place to
The wearing away of tooth enamel,
which is often accompanied by the ero-
(see abscess, dental). Rarer sites include
the liver (see liver abscess) and brain
allow continuous drainage (see drain,
surgical). Some abscesses burst and
A
sion of dentine (the layer beneath the (see brain abscess). drain spontaneously.
enamel) and cementum (the bonelike CAUSES AND INCIDENCE OUTLOOK
tissue that covers the tooth root). Dental Common bacteria, such as staphylo- Many abscesses subside following
abrasion is usually a result of brushing cocci, are the usual cause of abscesses, drainage alone; others subside after a
the teeth too vigorously. although fungal infections are another combination of drainage and drug
Abraded areas are often sensitive to cause. Amoebae (single-celled micro- treatment. Occasionally the presence of
hot, cold, or sweet food and drink; a organisms) are an important cause of an abscess within a vital organ damages
desensitizing toothpaste and/or protec- liver abscesses (see amoebiasis). Infec- enough surrounding tissue to cause
tion with a bonding agent (see bonding, tious organisms reach internal organs permanent loss of normal function, or
dental) or filling (see filling, dental) may via the bloodstream or penetrate to even death. (See also appendix abscess;
be necessary. tissues under the skin through an Bartholin’s abscess; bone abscess; caseous
infected wound or bite. abscess; cold abscess; hot abscess;
abrasive People with impaired immunity, such metastatic abscess; pelvic abscess; peri-
A substance that is used in dentistry for as those who are taking immuno- odontal abscess; peritonsillar abscess;
polishing and cleaning the teeth. suppressant drugs and those with HIV sterile abscess; subphrenic abscess; tuber-
(See also dentifrice.) infection or AIDS, are especially suscep- cular abscess.)
tible to abscesses.
abreaction abscess, dental
In psychoanalysis, the process of becom- Also called a periapical abscess, a pus-
ing consciously aware of painful filled sac in the tissue around the end of
feelings and memories that have previ- Epidermis the root of a tooth, usually caused by
ously been repressed (buried). The bacterial infection.
emotional discharge of such experi- CAUSE
ences is believed to have therapeutic A periapical abscess may occur when
benefits. The concept of abreaction Small abscess bacteria invade the pulp (the tissues in
originates in Freudian theory, in which the central cavity of a tooth), causing
the process ideally occurs as a result Sinus the pulp to die.This commonly happens
of catharsis (the open expression of as a result of dental caries (see caries,
emotions that are associated with for- Dermis dental), as the tooth’s enamel and den-
gotten memories). tine are destroyed allowing bacteria to
reach the pulp. Bacteria can also gain
abruption access to the pulp when a tooth is
The medical term for the separation of Large abscess injured. The infection in the pulp then
one structure from another. (See also spreads into the surrounding tissue to
placental abruption.) form an abscess.
An abscess that occurs when bacteria
abruptio placentae Subcutaneous
fatty tissue accumulate in pockets that form between
The medical term for the premature the teeth and gums is called a periodon-
separation of the placenta from the wall tal abscess. This type of abscess indicates
Cross section of a collar-stud abscess
of the uterus (see placental abruption) A small cavity in the epidermis, just beneath the
chronic periodontal disease, in which the
during pregnancy. skin’s surface, connects, via a sinus (channel), to periodontal membrane (attachment of
a larger cavity in deeper, subcutaneous tissue. tooth to bone) is damaged and, in sev-
abscess ere cases, the supporting bone eroded.
A collection of pus caused by infection SYMPTOMS SYMPTOMS
by microorganisms, usually bacteria. An abscess may cause pain, depending The affected tooth aches or throbs, and
Pus is formed from destroyed tissue on where it occurs. Most larger absces- biting or chewing is often painful. The
cells, from leukocytes (a type of white ses cause fever (sometimes with chills), gum around the tooth is tender and
blood cell) that have been carried to the sweating, and malaise. Abscesses may may be red and swollen. An untreated
area to fight infection, and from dead produce a sensation of intense pressure abscess may eventually erode a sinus (a
and live microorganisms. A lining, and those close to the skin may cause channel) through the jawbone to the
known as a pyogenic membrane, often redness and swelling. gum surface, where it forms a gumboil
forms around the abscess. TREATMENT (a swelling). If the gumboil bursts, pus
TYPES Antibiotic drugs are usually prescribed is discharged into the mouth, and the
An abscess may develop in any organ, to treat bacterial infections, antifungal pain usually lessens. As the abscess
and in the soft tissues beneath the skin, drugs are used to treat fungal infections, spreads through the surrounding tissues
sometimes as a collar-stud abscess, a and amoebicides are used for amoebia- and bones, glands in the neck and face
small cavity that connects to a larger sis. Most abscesses need to be drained may become swollen and symptoms of
cavity in deeper tissues. Common sites by making a cut in the lining of the infection, such as headache and fever,
of abscesses include the armpit, breast abscess cavity to allow the pus to may develop.

9
 ABSENCE

TREATMENT also occurs in people with carcinomas side of the skull) and trapezius (the
A A periapical abscess may be drained by
drilling through the crown of the tooth
(cancerous tumours) of the lung and
other organs.
large, triangular muscle of the upper
back, shoulder, and neck). Damage to
into the pulp cavity in order to allow Pseudoacanthosis nigricans is a much the spinal fibres of the nerve paralyses
the pus to escape, followed by root-canal more common condition that is usually these muscles.
treatment (filling of the pulp cavity with seen in dark-complexioned people who
dental cement). In some cases, extrac- are overweight. In this form, the skin in accidental death
tion of the tooth (see extraction, dental) fold areas is both thicker and darker Death that occurs as a direct result
is necessary. Antibiotic drugs are pre- than the surrounding skin, and exces- of an accident. A high proportion of
scribed if the infection has spread. sive sweating usually occurs in affected deaths in young adults, particularly
A periodontal abscess can usually be areas. Pseudoacanthosis nigricans may among males, are accidental. Many of
treated by careful scraping away of the improve with weight loss. these deaths are as a result of road traf-
infected material by the dentist. fic accidents, drowning, or drug
acarbose overdose; and alcohol is a significant
absence A drug that is used in the treatment of contributory factor.
In medical usage, a temporary loss or type 2 diabetes mellitus. Acarbose acts on Falls in the home, and burning or
impairment of consciousness that enzymes in the intestines, inhibiting the asphyxiation as a result of fires, are
occurs in some forms of epilepsy, typi- digestion of starch and therefore slow- common causes of accidental death in
cally generalized absence (petit mal) ing the rise in blood glucose levels after a elderly people. Important causes of
seizures in childhood. carbohydrate meal. accidental death in infants are choking
on food or smothering by bedclothes or
absorption accessory nerve other materials such as plastic bags.
The process by which fluids or other The 11th cranial nerve. Unlike the other Fatal accidents at work have become less
substances are taken up by body tissues. cranial nerves, most of the accessory common with the introduction of
The term absorption is commonly nerve originates from the spinal cord. effective safety measures.
applied to the uptake of nutrients (from The small part of the nerve that origi-
digested food) into the blood and nates from the brain supplies many acclimatization
lymph from the digestive tract. muscles of the palate, pharynx (throat), Physical or psychological adjustment to
The major site of absorption is the and larynx (voice-box). Damage to this a different climate, environment, or
small intestine, which is lined with part of the nerve may lead to dysphonia situation. (See also heat disorders;
millions of microscopic fingerlike pro- (difficulty in speaking) and dysphagia mountain sickness.)
jections known as villi (see villus). The (difficulty in swallowing).
villi greatly increase the surface area of The spinal part of the accessory nerve accommodation
the intestine, thereby increasing the rate supplies large muscles in the neck and Adjustment, especially the process by
of absorption. back, most notably the sternomastoid which the eye adjusts itself to focus on
(which runs from the breastbone to the near objects. At rest, the eye is focused
abuse
Maltreatment of a person or misuse of a
substance. (See also child abuse; drug THE MECHANISM OF ACCOMMODATION
abuse; heroin abuse; sexual abuse; solvent
abuse; substance abuse.) In a normal, healthy eye, light reflected from a near object is brought into focus
on the retina by a process called accommodation. Focusing is achieved by an
acamprosate automatic change in lens shape.
A drug used in the treatment of alcohol Distant
dependence. object Ciliary muscle

acanthoma
A noncancerous tumour composed of
cells of the outer layer of skin. There are
various types of acanthoma. They are Lens

most likely to occur on the face, where

they develop in hair follicles, or on the Focusing on a distant object
Near Ciliary
legs. (See also keratoacanthoma.) object muscle The lens focused on a distant object is thin,
flat, and completely relaxed.
acanthosis nigricans
A rare, untreatable condition in which
thickened dark patches of skin appear in
the groin, armpits, neck, and other skin Focusing on a near object
folds. Acanthosis nigricans may occur in To bring a near object into sharp focus, the
young people as a genetic disorder or as ciliary muscles contract and the lens becomes
Lens more convex in shape.
the result of an endocrine disorder such
as Cushing’s syndrome. The condition

10
 ACHALASIA

for distant vision, when its lens is thin SIDE EFFECTS choline are called cholinergic actions,
and flat. To focus on a nearer object, the
ciliary muscle of the eye contracts,
Possible side effects include nausea, loss
of taste, headache, dizziness, and a dry
and these can be blocked by anticho-
linergic drugs.
A
which reduces the pull on the outer cough. The first dose may dramatically
rim of the lens, allowing it to become reduce blood pressure. acetylcholinesterase inhibitors
thicker and more convex. COMMON DRUGS
With age, the lens loses its elasticity. acellular • Donepezil • Rivastigmine
This makes accommodation increas- A term meaning “without cells” that is
ingly difficult and results in a form of generally used to describe pertussis A group of drugs that are used in the
longsightedness called presbyopia. (whooping cough) vaccines that contain treatment of mild to moderate dementia
only certain parts, rather than the caused by Alzheimer’s disease, in which
accouchement whole, of the pertussis bacteria cell. there is a deficiency of the neuro-
The French word for the delivery of an transmitter acetylcholine in the brain.
infant from the uterus (womb). (See acetabulum HOW THEY WORK
also childbirth.) A cuplike hollow in the pelvis into Acetylcholinesterase inhibitors work by
which the head of the femur (thigh blocking the action of acetylchol-
accretion bone) fits to form the hip joint. inesterase, the enzyme in the brain
A manner of growth involving the accu- responsible for the breakdown of
mulation of additional material of the acetaminophen acetylcholine. This raises acetylcholine
same type as that already present. The An analgesic drug that is more commonly levels, and, in up to half of all patients,
term accretion is used in dentistry to known as paracetamol. the drugs slow the rate of progression
refer to the collection of foreign mat- of dementia. However, they have no
erial, such as plaque (see plaque, acetazolamide effect on dementia due to other causes,
dental), on the surface of a tooth or A drug that is used in the treatment of such as stroke or head injury.
in a dental cavity. glaucoma (raised pressure in the eye- SIDE EFFECTS
ball) and, occasionally, to prevent or Common side effects include nausea,
acebutolol treat symptoms of mountain sickness dizziness, and headache. Rarely, difficul-
A beta-blocker drug used to treat hyper- (headache, weakness, and other symp- ty in passing urine may occur.
tension (high blood pressure), angina toms occurring at high altitudes).
pectoris (chest pain caused by impaired Possible side effects of acetazolamide acetylcysteine
blood supply to the heart muscle), and include lethargy, nausea, diarrhoea, and A drug that is used in the treatment of
certain types of arrhythmia (abnormal reduced libido. paracetamol overdose and also as a
heart rhythm) in which the heart beats mucolytic drug to loosen sputum in
too rapidly. acetic acid chronic bronchitis.
The colourless, pungent, organic acid To be effective as an antidote to
ACE inhibitor drugs that gives vinegar its sour taste. In med- paracetamol poisoning, acetylcysteine
COMMON DRUGS icine, acetic acid is an ingredient of must be given by injection within a few
• Captopril • Cilazapril • Enalapril • Fosinopril antiseptic gels that are used to treat cer- hours of the overdose having been
• Lisinopril • Moexipril • Perindopril tain vaginal infections. taken. The drug works by reducing the
• Quinapril • Ramipril • Trandolapril amount of toxic substances produced
acetone during the breakdown of paracetamol,
A group of drugs that are used to treat A chemical produced naturally when thereby reducing the risk of liver dam-
heart failure (reduced pumping effici- the body enters a state known as ketosis, age. When taken orally, acetylcysteine
ency of the heart), hypertension (high in which fats are broken down to pro- makes the mucus in sputum less sticky
blood pressure), and kidney problems duce energy. This can occur as the result and therefore easier to cough up.
associated with diabetes mellitus. ACE of metabolic changes caused by diabetes When acetylcysteine is taken in large
(angiotensin-converting enzyme) inhib- mellitus or, sometimes, as the result of doses, vomiting, rash, or breathing dif-
itors are often prescribed with other extreme dieting. ficulties may occur as rare side effects.
drugs such as diuretic drugs or beta- Pharmaceutical preparations contain-
blocker drugs. ing acetone are used as antiseptics and achalasia
HOW THEY WORK solvents. Acetone is also used in cosmet- A rare condition, of unknown cause, in
ACE inhibitors block the action of an ics such as nail varnish remover. (See which the muscles at the lower end of
enzyme that is responsible for converting also solvent abuse.) the oesophagus and the sphincter
angiotensin (a protein present in the (valve) between the oesophagus and the
blood) from inactive angiotensin I to acetylcholine stomach fail to relax to allow food into
angiotensin II. Angiotensin II encour- A type of neurotransmitter (a chemical the stomach after swallowing. As a
ages blood vessels to constrict; its that transmits messages between nerve result, the lowest part of the oesophagus
absence permits them to dilate, thus cells or between nerve and muscle is narrowed and becomes blocked with
reducing blood pressure. In diabetic cells). Acetylcholine is the neuro- food, while the part above widens.
nephropathy, ACE inhibitors slow the transmitter found at all nerve-muscle SYMPTOMS AND SIGNS
progress of the disorder and reduce the junctions and at many other sites in the Symptoms include difficulty and pain in
loss of albumin in the urine. nervous system. The actions of acetyl- swallowing, and pain in the lower chest

11
 ACHE

and upper abdomen. A foul taste in the Minor injuries to the Achilles tendon including herpes simplex (cold sores),
A mouth and bad breath may arise due to
the regurgitation of food. The ability to
are common. They are usually provoked
by too much exercise, faulty running
herpes zoster (shingles), and varicella
zoster (chickenpox) in adults.
swallow gradually deteriorates until the technique, or the wearing of unsuitable Aciclovir can be used as a life-saving
swallowing of liquids is also impeded. footwear. All of these injuries can result treatment for encephalitis (inflammation
DIAGNOSIS AND TREATMENT in inflammation of the tendon (tendin- of the brain). When it is used to treat
A barium swallow (a type of barium itis) and tearing of the tendon fibres. In cold sores or recurrent genital herpes,
X-ray examination) and gastroscopy (in most cases, these conditions clear up for which an ointment is available over
which a narrow viewing tube is passed with rest and physiotherapy. the counter, aciclovir does not provide a
down the oesophagus) may be perfor- Violent stretching of the Achilles ten- cure but does, however, reduce the
med in order to investigate achalasia. don can cause it to rupture, creating a severity of the attacks.
Drug treatment for achalasia is rarely snapping sensation in the injured area, Side effects of aciclovir are uncom-
successful. It is possible to widen the and pain, swelling, and impaired move- mon, but they can include nausea,
oesophagus for prolonged periods by ment of the affected part. In such cases, vomiting, and fatigue. Local reactions
oesophageal dilatation (passing a cylin- surgical repair may be needed, but commonly occur after topical use.
drical rod or a balloon catheter down the immobilization of the ankle in a plaster
oesophagus). Surgery to cut some of cast may be sufficient. acid
the muscles at the stomach entrance A substance that is defined as a donor
may be necessary to widen the passage- achlorhydria of hydrogen ions (hydrogen atoms
way for food. Absence of stomach acid secretions. with positive electrical charges). Acid
This may be due to chronic atrophic molecules, when mixed with or dis-
ache gastritis or to an absence or malfunction solved in water, split up to release their
A continuous, fixed, and often dull pain of acid-producing parietal cells in the constituent ions; all acids release hydro-
that is distinct from twinges. (See also stomach lining. gen as the positive ion (positive ions are
bone pain; earache; headache; stomach- Achlorhydria may not produce symp- known as cations; and negative ions are
ache; toothache.) toms and is not in itself a cause for called anions).
concern. However, it is sometimes asso- Examples of acids within the body
Achilles tendon ciated with stomach cancer and is also a include hydrochloric acid (a corrosive
The tendon that raises the heel. The feature of pernicious anaemia, a blood mineral acid that is produced by the
Achilles tendon is formed from the calf disorder caused by defective absorption stomach lining), and many organic
muscles (the gastrocnemius, soleus, and of vitamin B12 from the stomach (see acids, such as lactic acid, carbonic
plantaris muscles) and is attached to the anaemia, megaloblastic). acid, ascorbic acid (vitamin C), and
calcaneus (the heel-bone). The Achilles pyruvic acid. (See also acid–base
tendon is named after Achilles, the leg- achondroplasia balance; alkali.)
endary Greek hero who was vulnerable A rare genetic disorder of bone growth
only in his heel. that leads to short stature. Individuals acid–base balance
affected with achondroplasia have short A combination of mechanisms that ens-
limbs, a well-developed trunk, and a ures that the body’s fluids are neither
LOCATION OF THE head of normal size, except for a pro- too acid nor too alkaline (alkalis are also
ACHILLES TENDON truding forehead. called bases). The body functions nor-
The tendon runs from the base of
The condition is caused by a defect of mally only when its fluids are close to
the calf to the calcaneus. a dominant gene (see genetic disorders) chemical neutrality.
but often arises as a new mutation, Metabolic processes cause fluctua-
Femur rather than being inherited from a par- tions in the acidity and alkalinity of the
ent. The long bones of the arms and blood and other body fluids. The body
legs are affected mainly. The cartilage has three mechanisms for maintaining
that links each bone to its epiphysis of normal acid–base balance: buffers,
(the growing area at its tip) is converted breathing, and the activities of the kid-
Gastrocnemius to bone too early, preventing further neys. Buffers are substances in the blood
limb growth. that neutralize acid or alkaline wastes.
Achondroplasia is usually obvious at Rapid breathing increases the rate at
birth or during the first year of life and which carbon dioxide is eliminated
no treatment is available to alter the from the blood, resulting in the blood
Soleus outlook. Intelligence and sexual devel- becoming less acidic; slow breathing
opment are not affected, and lifespan is has the opposite effect; the kidneys help
close to normal. to maintain a constant acidity level in
Achilles tendon the blood by regulating the amounts of
aciclovir acid or alkaline wastes in the urine.
An antiviral drug that can be taken orally Disturbances of the body’s acid–base
Calcaneus in tablet or liquid form, applied to the balance result in either acidosis (exces-
skin as a cream, taken as eye-drops, or sive blood acidity) or alkalosis (excessive
given intravenously for viral infections blood alkalinity).

12
 ACOUSTIC NEUROMA

acid-fast TYPES help to keep it under control. Over-the-

A characteristic of particular bacteria
(especially those responsible for tuber-
The most common type of acne is
sometimes known as acne vulgaris,
counter topical drug treatments such as
benzoyl peroxide or azelaic acid are
A
culosis) that are resistant to the acids which almost always develops during often effective. Prescribed topical anti-
used to dye specimens for microscopic puberty. Chemical acne is caused by biotic drugs or retinoic acid (a derivative
examination (see staining). exposure of the skin to certain chemi- of vitamin A) are used to treat moderate
cals and oils. This results in the acne. Alternative treatment is with oral
acidosis development of acne in areas where antibiotics, often tetracycline drugs. In
A disturbance of the body’s acid–base the chemical has come into contact very severe cases, isotretinoin may be
balance in which there is an accumu- with the skin, such as on the thighs. given under hospital supervision. In
lation of acid or loss of alkali (base). Certain prescribed drugs, such as corti- all cases, exposure to ultraviolet light
There are two types of acidosis: meta- costeroid drugs, can also cause acne. (either natural or artificial) may also
bolic and respiratory. be beneficial. However, it is important
CAUSES not to burn the skin.
In metabolic acidosis, an increased Acne improves slowly over time, and
amount of acid is produced by meta- it often clears up by the end of the
bolic processes. One form of metabolic teenage years.
acidosis is ketoacidosis, which occurs in
uncontrolled diabetes mellitus and star- acoustic nerve
vation. Metabolic acidosis may also be The part of the vestibulocochlear nerve
caused by loss of bicarbonate (an alkali) (the eighth cranial nerve) concerned
as a result of severe diarrhoea. In kidney with hearing. The acoustic nerve is also
failure, there is insufficient excretion of called the auditory or cochlear nerve.
acid in the urine.
Respiratory acidosis occurs when acoustic neuroma
breathing fails to remove enough car- A rare, noncancerous tumour arising
bon dioxide from the lungs. This causes from supporting cells that surround the
increased acidity of the blood because vestibulocochlear nerve, usually within
the excess carbon dioxide remains in the internal auditory meatus (the canal
the bloodstream, where it dissolves to in the skull through which the nerve
form carbonic acid. Impaired breathing passes from the inner ear to the brain).
Acne
leading to respiratory acidosis may be The spots on this boy’s face are typical of acne; CAUSE AND INCIDENCE
caused by chronic obstructive pulm- the darker marks are healed spots, which fade Acoustic neuromas most commonly
onary disease (see pulmonary disease, gradually. Severe acne may leave pits in the skin. occur in people between the ages of 40
chronic obstructive), bronchial asthma, or and 60 and are slightly more common in
airway obstruction. CAUSE women than in men.
Acne spots are caused by the obstruc- Usually, the cause of an acoustic neu-
acid reflux tion of hair follicles by excess sebum roma is unknown. However, tumours
The regurgitation of acidic fluid from (the oily substance secreted by the seba- that affect the nerves on both sides of
the stomach into the oesophagus (the ceous glands). Bacteria multiply in the the head simultaneously may be part of
tube that connects the throat to the follicle, causing inflammation. Hor- a widespread neurofibromatosis (a dis-
stomach). Acid reflux is the result of monal changes at puberty, including ease characterized by changes in the
inefficiency of the muscular valve at the increased levels of androgen hormones nervous system, skin, and bones).
lower end of the oesophagus. (male sex hormones) in both males and SYMPTOMS
Also known as gastro-oesophageal females, stimulate the production of An acoustic neuroma can cause deafness,
reflux disease (GORD), acid reflux may sebum. There may also be a genetic pre- tinnitus (noises in the ear), loss of bal-
inflame the oesophagus, resulting in disposition to acne. ance, and pain in the face and the
heartburn (a burning pain in the chest) SYMPTOMS affected ear. As the tumour enlarges, it
due to oesophagitis (inflammation of Acne develops in areas in which there may lead to additional complications,
the oesophagus). is a high concentration of sebaceous such as ataxia (loss of coordination) due
Mild acid reflux is common but is glands, mainly the face, centre of the to the compression of the brainstem
not serious. It may occur during preg- chest, upper back, shoulders, and and cerebellum.
nancy and often affects overweight around the neck. Milia (whiteheads), DIAGNOSIS AND TREATMENT
people. Repeated episodes of discom- comedones (blackheads), nodules (firm Diagnosis is made by hearing tests fol-
fort may indicate a hiatus hernia (in swellings under the skin), and cysts lowed by X-rays or by CT scanning or MRI
which part of the stomach protrudes (larger, fluid-filled swellings) are the (techniques that produce cross-section-
into the chest). most common types of spot. Some, par- al or three-dimensional images of body
ticularly cystic spots, leave scars. structures).
acne TREATMENT AND OUTLOOK Surgery may be necessary to remove
A chronic skin disorder in which there There is no instant cure for acne, an acoustic neuroma, but treatment
is inflammation of the sebaceous glands although washing the affected areas at with radiotherapy to shrink it may
at the base of hair follicles in the skin. least twice a day with a mild soap may also be effective.

13
 ACQUIRED

acquired may take several years for the symptoms

LOCATION OF THE
A A term relating to a condition that
occurs after birth rather than being
and signs of the condition to appear.
SYMPTOMS AND SIGNS
ACROMIOCLAVICULAR JOINT
attributable to heredity. Acquired con- Symptoms and signs of acromegaly
trasts with congenital, which means include enlargement of the hands, feet, The joint lies at the junction of
the outer end of the clavicle and
present from birth. ears, and nose; a jutting lower jaw; and
the acromion.
a long face. There may also be deepen-
acquired immunity ing or huskiness of the voice. Symptoms Acromio- Clavicle
A form of immunity that develops after common to any brain tumour, such as clavicular
joint
birth through exposure to microorgan- headache and visual disturbances, are Acromion
isms or through immunization. also possible.
DIAGNOSIS AND TREATMENT
acrocyanosis Acromegaly is diagnosed by the meas-
A circulatory disorder in which the urement of blood levels of growth
hands and feet turn blue, may become hormone before and after a quantity of
cold, and sweat excessively. Acrocyan- glucose has been administered. Glucose
osis is caused by spasm of the small usually suppresses the secretion of
blood vessels and is often aggravated by growth hormone; if the glucose has no
cold weather. effect on the blood level of the hor-
Acrocyanosis is related to Raynaud’s mone, uncontrolled secretion of growth
disease, in which the skin of the fingers hormone by the pituitary gland can be
and toes may be damaged by reduced confirmed. CT scanning or MRI (tech-
blood flow. niques that produce cross-sectional or
three-dimensional images of body in subluxation (incomplete dislocation
acrodermatitis structures) may be carried out to with the bones still in contact) or,
Inflammation of the skin, principally on reveal a tumour or overgrowth of the rarely, to dislocation (complete displace-
the hands or feet. Acrodermatitis ent- pituitary gland. ment of the bones so that they are no
eropathica is a chronic (long-term), A tumour of the pituitary gland may longer in contact).
inherited variety of the condition. be removed surgically or treated by In subluxation, the synovium (joint
radiotherapy. The drug octreotide pre- lining) and the ligaments around it are
acrodermatitis enteropathica vents growth hormone production and stretched and bruised, the joint is
A rare, inherited disorder in which may be used to control symptoms by a swollen, and the bones feel slightly out
areas of the skin (most commonly of person awaiting surgery or until the of alignment. In dislocation, the liga-
the fingers, toes, scalp, and the areas effects of radiotherapy are felt. Bromo- ments are torn, the swelling is greater,
around the anus and mouth) are red- criptine sometimes causes the tumour to and the bone deformity is more pro-
dened, ulcerated, and covered with become smaller. nounced. In both cases, the joint is
pustules (pus-filled spots). painful and tender, and movement of
Acrodermatitis enteropathica is inher- the shoulder is restricted.
ited in an autosomal recessive manner TREATMENT
(see genetic disorders) and is due to the Treatment for subluxation is by resting
inability to absorb sufficient zinc from the arm and shoulder in a sling. If the
food. Zinc supplements usually bring pain and tenderness persist, injection of
about a rapid improvement. a corticosteroid drug and a local anaes-
thetic (see anaesthesia, local) into the
acromegaly joint may help.
A rare disease that is characterized by Dislocation of the acromioclavicular
abnormal enlargement of the skull, joint requires strapping around the clav-
the jaw, the hands and feet, and also of icle and elbow, for about three weeks,
the internal organs. Appearance of acromegaly to pull the outer end of the clavicle back
Enlargement of the hands is a typical feature of
CAUSE acromegaly. The condition is apparent when the
into position. Surgical correction may
Acromegaly is caused by excessive acromegalic hand, on the left, is compared to a occasionally be required.
secretion of growth hormone from the normal hand.
anterior pituitary gland at the base of the acromion
brain and is the result of a noncancer- acromioclavicular joint The bony prominence at the top of the
ous pituitary tumour. The joint that lies between the outer scapula (shoulderblade) that articulates
If such a tumour develops before end of the clavicle (collarbone) and the with the end of the clavicle (collarbone)
puberty, the result is gigantism (in acromion (the bony prominence at the to form the acromioclavicular joint.
which growth is accelerated) instead of top of the shoulderblade).
acromegaly. More commonly, however, INJURIES TO THE JOINT acroparaesthesia
the tumour develops after growth in the Injuries to the acromioclavicular joint A medical term for tingling sensations
long bones of the limbs has stopped. are rare. They are usually caused by a that occur in the fingers or toes (see
This leads to acromegaly, although it fall on to the shoulder and may result pins-and-needles).

14
 ADAM’S APPLE

ACTH acting out known as meridians. A blockage in one

The common abbreviation for adreno-
corticotrophic hormone (also called
Impulsive actions that may reflect an
individual’s unconscious wishes. The
or more of these meridians is thought
to cause ill health. Acupuncturists aim
A
corticotrophin). ACTH is produced by term is most often used by psycho- to restore health by inserting needles at
the anterior part of the pituitary gland (at therapists to describe behaviour during appropriate sites, known as acupuncture
the base of the brain) and stimulates the analysis when the patient “acts out”, points, along the affected meridians.
adrenal cortex (the outer layer of rather than reports, his or her fantasies, HOW IT WORKS AND WHY IT IS DONE
the adrenal glands, situated on the top of wishes, or beliefs. Acting out can also Research suggests that acupuncture
the kidneys) to release various cortico- occur as a reaction to frustrations provokes the release within the central
steroid hormones. ACTH is also necessary encountered in everyday life, often tak- nervous system of endorphins (sub-
for the growth and maintenance of the ing the form of antisocial, aggressive stances resembling morphine), which
cells of the adrenal cortex. behaviour that may be directed against act as natural analgesics (painkillers).
ACTIONS oneself or others. The disorder that is being treated and
The most important function of ACTH degree of anaesthesia required deter-
is to stimulate the adrenal cortex to actinic mine the needle temperature, place of
increase its production of hydrocortisone Relating to changes caused by the ultra- insertion, whether the needles are stim-
(cortisol). ACTH also causes the adrenal violet rays in sunlight, as in actinic ulated by rotation or electric current,
cortex to release aldosterone and andro- dermatitis (inflammation of the skin) and and the length of time the needles
gen hormones. actinic keratosis (roughness and thick- remain in position.
The production of ACTH is controlled ening of the skin). Both are caused by Acupuncture may be used as an
by a feedback mechanism that involves overexposure to solar radiation. anaesthetic for surgical procedures as
both the hypothalamus (an area in the well as to provide pain relief following
centre of the brain) and the level of actinomycosis operations and for chronic conditions.
hydrocortisone in the blood. When An infection caused by A CTINOMYCES acupuncture is also claimed to help in
ACTH levels are high, the production of or related actinomycete bacteria.
ISRAELII the treatment of addiction, depression,
hydrocortisone increases, which in turn These bacteria resemble fungi and and anxiety.
suppresses the release of ACTH from the cause diseases of the mouth, jaw, chest, SIDE EFFECTS
pituitary gland. If ACTH levels are low, and pelvis. After treatment with acupuncture, some
hydrocortisone production falls and the TYPES AND CAUSES people experience temporarily exacer-
hypothalamus releases factors that stim- The most common form of actinomy- bated symptoms. Other people may feel
ulate the pituitary gland to increase cosis affects the jaw area. A painful lightheaded, drowsy, or exhilarated for
production of ACTH. swelling appears and pus and char- a short while.
ACTH levels increase in response to acteristic yellow granules discharge It is important that acupuncture is
stress, emotion, injury, burns, infection, through small openings that develop in performed by a fully qualified acupunc-
surgery, and decreased blood pressure. the skin. Poor oral hygiene may con- turist because the use of inadequately
Cancerous tumours, particularly those tribute to this form of the infection. sterilized needles could result in the
of the lung, can sometimes produce a Another form of actinomycosis affects transmission of a variety of infections,
chemical that is similar to ACTH and the pelvis in women, causing lower including hepatitis B and HIV.
which causes symptoms. abdominal pain and bleeding between
DISORDERS OF ACTH PRODUCTION menstrual periods. This form was asso- acute
A tumour of the pituitary gland can ciated mainly with a type of IUD, no A term often used to describe a disorder
cause excessive production of ACTH, longer in use, that did not contain cop- or symptom that develops suddenly.
which, in turn, leads to overproduction per. Rarely, forms of the disorder affect Acute conditions may or may not be
of hydrocortisone by the adrenal cor- the appendix or lung. severe, and they are usually of short
tex, resulting in Cushing’s syndrome (a Actinomycosis is usually treated suc- duration. (See also chronic.)
hormonal disorder). Insufficient ACTH cessfully with antibiotic drugs.
production results in decreased pro- acute heart failure
duction of hydrocortisone, causing acuity, visual See heart failure, acute.
hypotension (low blood pressure). See visual acuity.
MEDICAL USES acyanotic
Synthetic ACTH was once given in the acupressure A diagnostic term meaning without cya-
treatment of arthritis or to treat allergy, A derivative of acupuncture in which nosis, a bluish coloration of the skin
but it is now rarely used. pressure is applied instead of needles. that is seen when blood oxygen levels are
abnormally low. The term is commonly
actin acupuncture used in relation to the classification of
A protein component of muscle fibres A branch of Chinese medicine in which congenital (present from birth) heart
that, together with myosin (another needles are inserted into a patient’s skin disease (see heart disease, congenital).
protein), provides the mechanism for as therapy for various disorders, to
muscles to contract. The microscopic relieve pain or to induce anaesthesia. Adam’s apple
filaments of actin and myosin slide in Traditional Chinese medicine main- The projection at the front of the
between each other to make the muscle tains that the chi (life-force) flows neck, just beneath the skin, that is
fibres shorter. through the body along channels formed by a prominence on the thyroid

15
 ADD

another hormone, melanocyte stimulat- Mesenteric lymphadenitis is inflammation

LOCATION OF THE
A ADAM’S APPLE
ing hormone (MSH), also increase,
which leads to increased synthesis of
of the lymph nodes inside the abdomen
and is usually caused by a viral infection.
melanin pigment in the skin. In many cases of adenitis, treatment
This projection at the front of the
neck, beneath the skin, is formed by CAUSES is not necessary. When it occurs as the
a prominence on the thyroid cartilage. Addison’s disease can be caused by any result of a bacterial infection, treatment
disease that destroys the adrenal cor- of the infection with antibiotic drugs will
tices. The most common cause is an generally also result in an improvement
autoimmune disorder in which the in the condition of the lymph nodes.
immune system produces antibodies
that attack the adrenal glands. adenocarcinoma
SYMPTOMS The technical name for a cancer of a
Symptoms of the disease generally dev- gland or glandular tissue, or for a can-
elop gradually over months or years and cer in which the cells form glandlike
include tiredness, weakness, abdominal structures. An adenocarcinoma arises
pain, and weight loss. Excess MSH may from epithelium (the layer of cells that
cause darkening of the skin in the crea- lines organs).
ses of the palms, pressure areas of the Cancers of the colon (the main part
body, and the mouth. of the large intestine), breast, pancreas,
Acute episodes, called Addisonian and kidney are usually adenocarcino-
crises, brought on by infection, injury, mas, as are some cancers of the cervix,
or other stresses, can also occur. The oesophagus, salivary glands, and various
Trachea Thyroid cartilage
symptoms of these are mainly due to other organs. (See also intestine, cancer
aldosterone deficiency and include of; kidney cancer; pancreas, cancer of.)
extreme muscle weakness, dehydration,
hypotension (low blood pressure), confu- adenoidectomy
sion, and coma. Hypoglycaemia (low Surgical removal of the adenoids. An
cartilage, which is part of the larynx blood glucose) also occurs due to a adenoidectomy is usually performed on
(voice-box). The Adam’s apple enlarges deficiency of hydrocortisone. a child with abnormally large adenoids
in males at puberty. DIAGNOSIS AND TREATMENT that are causing recurrent infections of
Diagnosis of Addison’s disease is gener- the middle ear or air sinuses. The oper-
ADD ally made if the patient fails to respond ation may be performed together with
The abbreviation for attention deficit to an injection of ACTH, which norm- tonsillectomy.
disorder, more commonly known as ally stimulates hydrocortisone secretion. There are few after-effects, and the
attention deficit hyperactivity disorder. Lifelong corticosteroid drug treatment patient can generally begin to eat nor-
is needed to replace the deficient hor- mally the following day.
addiction mones. Treatment of Addisonian crises
Dependence on, and craving for, a par- involves rapid infusion of saline and
ticular drug, such as alcohol, diazepam glucose and supplementary doses of LOCATION OF THE ADENOIDS
(a tranquillizer), or heroin. Reducing or corticosteroid hormones.
These swellings of glandular tissue
stopping intake of the drug may lead to
additives are found at the back of the nasal
characteristic physiological and/or psy- passage above the tonsils. Enlarged
chological symptoms (see withdrawal See food additives. adenoids are sometimes implicated
syndrome), such as tremor or anxiety. in sleep apnoea.
The term addiction may also be used in adduction
relation to compulsive behaviour, such Movement of a limb towards the central
as gambling. (See also alcohol depen- line of the body, or of a digit towards
dence; drug dependence.) the axis of a limb. Muscles that carry out
this movement are often called adduc-
Addison’s disease tors. (See also abduction.)
A rare chronic disorder in which there
is deficiency of the corticosteroid hor- adductor
mones hydrocortisone and aldosterone, Any one of the muscles that carry out
which are normally produced by the the movement of adduction.
adrenal cortex (the outer parts of the
adrenal glands, which are situated on the adenitis
top of the kidneys). In addition, exces- Inflammation of lymph nodes. Cervical
sive amounts of the hormone ACTH are adenitis (swelling and tenderness of the Nasal
cavity Tongue Adenoids
secreted by the pituitary gland (at the lymph nodes in the neck) occurs in cer-
base of the brain) in an attempt to tain bacterial infections, especially
Tonsil Larynx
increase output of the corticosteroid tonsillitis, and the viral infection gland-
hormones. The secretion and activity of ular fever (see mononucleosis, infectious).

16
 ADJUVANT THERAPY

adenoids ADH genital (present from birth), but they

A mass of glandular tissue at the back of
the nasal passage above the tonsils. The
The abbreviation for antidiuretic hor-
mone (also called vasopressin), which
most often develop as a result of scar-
ring after inflammation.
A
adenoids are made up of lymph nodes, is released from the posterior part of Adhesions are most common in the
which form part of the body’s defences the pituitary gland and acts on the kid- abdomen, where they often form after
against upper respiratory tract infec- neys to increase their reabsorption of peritonitis (inflammation of the abdom-
tions. They tend to enlarge during early water into the blood. inal lining) or surgery. Sometimes,
childhood, a time when such infections ACTIONS loops of intestine are bound together by
are common. Water is continually being taken into adhesions, causing intestinal obstruc-
DISORDERS the body in food and drink and is also tion (see intestine, obstruction of). In
In most children, the adenoids shrink produced by the chemical reactions in such cases, surgery is usually required
after the age of about five years, and cells. Conversely, water is also continu- to cut the bands of tissue.
disappear altogether by puberty. In ally being lost in urine, sweat, faeces,
some children, however, they enlarge, and in the breath as water vapour. ADH adipose tissue
obstructing the passage from the nose reduces the amount of water lost in the A layer of fat cells lying just beneath
to the throat and causing snoring, urine and helps to maintain the body’s the surface of the skin and around vari-
breathing through the mouth, and a overall water balance. ous internal organs.
characteristically nasal voice. The eusta- ADH production is controlled by the Adipose tissue is made up of fat
chian tubes, which connect the middle hypothalamus (an area in the centre of stored within adipocytes (fat cells). Fat
ear to the throat, may also become the brain), which detects changes in is deposited as a result of excess food
blocked, resulting in recurrent middle blood concentration and volume. If the intake, thus acting as an energy store;
ear infections and deafness. blood concentration increases (in other excessive amounts of fat stored within
Obstruction to the flow of secretions words, the blood contains less water), the adipose tissue is a feature of obesity.
behind the nose can result in rhinitis the hypothalamus stimulates the pitu- The tissue insulates against loss of
(inflammation of the nose), which may itary gland to release more ADH. If the body heat and helps to absorb shock in
spread to the middle ear (see otitis blood is too dilute, less ADH is pro- areas subject to sudden or frequent
media) and to the air sinuses behind the duced; as a result, more water is lost pressure, such as the buttocks, palms of
nose (see sinusitis). from the body in the urine. the hands or soles of the feet. Another
TREATMENT DISORDERS OF ADH PRODUCTION function of adipose tissue is to cushion
Infections usually become less frequent Various factors can affect ADH produc- organs such as the heart, kidneys,
as the child grows. If they do not, ade- tion and thus disturb the body’s water and eyeballs.
noidectomy (surgical removal of the balance. For example, alcohol reduces After puberty, the distribution of
adenoids) may be recommended. ADH production by direct action on the superficial adipose tissue differs in
brain, resulting in a temporary increase males and females. In men, superficial
adenoma in the production of urine. Urine pro- adipose tissue tends to accumulate
A noncancerous tumour or cyst that duction is also increased in the disorder around the shoulders, waist, and
resembles glandular tissue and arises diabetes insipidus, in which there is abdomen; in women, it occurs more
from the epithelium (the layer of cells either insufficient production of ADH commonly on the breasts, hips, and
that lines organs). by the pituitary gland or, more rarely, thighs. Adipose tissue tends to make up
Adenomas of endocrine glands (such as failure of the kidneys to respond to the a larger proportion of the total body
the pituitary gland, thyroid gland adre- ADH produced. weight of women than of men. In obe-
nal glands, and pancreas can result in The reverse effect, water retention, sity, central distribution of body fat
excessive hormone production, leading may result from temporarily increased around the waist is associated with a
to disease. For example, an adenoma of ADH production after a major opera- greater risk of cardiovascular disease and
the pituitary gland can result in tion. Water retention may also be caused diabetes. This may be because fat in this
acromegaly or Cushing’s syndrome. by the secretion of ADH by some area tends to result in raised blood lipid
tumours, especially of the lung. levels. (See also brown fat.)
adenomatosis MEDICAL USES
An abnormal condition of glands in Synthetic ADH is used in the treatment adjuvant
which they are affected either by hyper- of a variety of conditions, such as dia- A substance that enhances the action of
plasia (overgrowth) or by numerous betes insipidus. Side effects of the drug another substance in the body. The term
adenomas (noncancerous tumours). may include abdominal cramps, nausea, is used to describe an ingredient added
Adenomatosis may simultaneously headache, drowsiness, and confusion. to a vaccine to increase the production
affect two or more different endocrine of antibodies by the immune system,
glands, such as the adrenal glands, pitu- ADHD thus enhancing the vaccine’s effect. (See
itary gland, and pancreas. The abbreviation for attention deficit also adjuvant therapy.)
hyperactivity disorder.
adenosine diphosphate adjuvant therapy
See ADP. adhesion Treatment for cancer, usually with
The joining of normally unconnected anticancer drugs, that is given once
adenosine triphosphate parts of the body by bands of fibrous all the evidence of the original tumour
See ATP. tissue. Adhesions are sometimes con- has been removed. The aim of adjuvant

17
 ADLERIAN THEORY

therapy is to destroy any microscopic may not develop sufficiently to make adrenal glands
A deposits of malignant cells that may
exist, which reduces the risk of recur-
his or her own decisions or to form
new relationships outside the family.
A pair of small, triangular endocrine
glands (glands that secrete hormones
rence of the cancer and increases Most behavioural problems resolve directly into the bloodstream) that are
survival times. themselves over time. Maintaining open located on the top of the kidneys. Each
lines of communication between par- adrenal gland has two distinct parts: the
Adlerian theory ents and children is important in easing outer adrenal cortex and the smaller,
The psychoanalytical ideas set forth by this process. The most valuable support inner adrenal medulla.
the Austrian psychiatrist Alfred Adler parents can offer is to encourage self- ADRENAL CORTEX
(1870–1937). Also known as individual confidence and responsibility and thus The adrenal cortex secretes aldosterone,
psychology, Adler’s theories were based prepare their children for adult life. Par- which, by inhibiting the amount of
on the idea that everyone is born with ents should also ensure that their sodium excreted in the urine, helps
natural feelings of inferiority. Life is children are informed about issues such to maintain blood volume and blood
seen as a constant struggle to overcome as contraception and safer sex. pressure. The cortex also secretes hydro-
these feelings; and failure to do so leads to cortisone and corticosterone, as well as
neurosis. (See also psychoanalytic theory.) ADP small amounts of androgen hormones.
The abbreviation for adenosine diphos- Hydrocortisone controls the body’s use
adnexa phate, the chemical that takes up energy of fats, proteins, and carbohydrates and
An anatomical term meaning the struc- released during biochemical reactions is also important in helping the body to
tures that are adjacent to an organ. Most to form ATP (adenosine triphosphate), cope with stress. Hydrocortisone and
commonly, the word adnexa is used to the body’s main energy-carrying chem- corticosterone also suppress inflamma-
refer to the various appendages of the ical. When ATP releases its energy ADP is tory reactions and some activities of the
uterus: the ovaries, fallopian tubes, and reformed. (See also metabolism.) immune system.
ligaments. Hormone production by the adrenal
adrenal failure cortex is governed by other hormones,
adolescence Insufficient production of hormones by such as ACTH, that are produced in the
The period between childhood and the adrenal cortex (the outer part of the hypothalamus, in the centre of the brain,
adulthood, which broadly corresponds adrenal glands, situated on the top of the and the pituitary gland beneath it (see
to the teenage years. Adolescence is a kidneys). Adrenal failure can be acute feedback mechanism box).
complex stage of psychological develop- (of sudden onset) or chronic (of grad- ADRENAL MEDULLA
ment. It commences at and overlaps ual onset).The condition may be caused The adrenal medulla is part of the
with, but is not the same as, puberty. by a disorder of the adrenal glands, in sympathetic division of the autonomic
Common patterns of adolescent be- which case it is called Addison’s disease, nervous system, which is the body’s first
haviour include moodiness, a general or by reduced stimulation of the adren- line of defence against physical and
lack of interest, and fluctuating acad- al cortex by ACTH, a hormone produced emotional stress. The medulla secretes
emic performance. Adolescents often by the pituitary gland. (See also adrenal the hormones adrenaline (epinephrine)
worry about their changing body shape glands disorders box, overleaf.) and noradrenaline (norepinephrine) in
and physical appearance. They may lack
self-confidence, feel nervous and shy
and be unsure of their personal identity. ANATOMY OF THE ADRENAL GLANDS
Adolescents experiment with their
Also sometimes called the suprarenal glands, the adrenal glands
appearance, with views and opinions, are situated on top of the kidneys. Each gland is divided into two
with allegiances to peer groups, and regions: the adrenal cortex (which secretes hormones that affect
with political movements or other role the metabolism) and the adrenal medulla (which is part of the
models. Gender identity and sexuality sympathetic nervous system).
may be questioned. Adolescents may
also experiment with drugs and alcohol; Inferior vena cava Aorta
those who do so to relieve anxiety or Adrenal gland
depression are more likely to become
dependent than those who experiment
due to peer-group pressure. Sexual acti-
vity is common during adolescence and
may result in unwanted pregnancies
and sexually transmitted infections.
Some adolescents are assertive and Medulla
strive for independence. Rebellion
against parents is common but conflicts
with the emotional and financial sup- Cortex
port that adolescents still require. Kidney Kidney
Aggression and delinquency usually
Renal veins Renal arteries Cross section of adrenal gland
constitute a transient phase. However, a
teenager who remains too dependent

18
 ADRENOCORTICOTROPHIC HORMONE

and urine. Ultrasound scanning may be

FEEDBACK MECHANISM carried out to verify that there is no
tumour of the adrenal glands.
A
The rate at which many glands produce hormones is influenced by other hormones,
especially those secreted by the pituitary gland and the hypothalamus. If the
Treatment of congenital adrenal hyp-
amount of hormone produced is increased, negative feedback mechanisms act erplasia is with hormone replacement.
on the hypothalamus and pituitary so that they produce less of their stimulating If the treatment is started early, normal
hormones, thus reducing the target gland’s activity. If the amount of hormone sexual development and fertility gener-
produced is decreased, the feedback weakens, causing increased production of ally follow.
stimulating hormones.
adrenaline
Anterior pituitary gland
Stimulated by a releasing Also called epinephrine, a hormone re-
factor secreted by the
Hypothalamus
leased by the adrenal glands in response
hypothalamus, the anterior to signals from the sympathetic nervous
pituitary gland produces Influences the pituitary by
adrenocorticotrophic secreting hormones called system, part of the autonomic nervous
hormone (ACTH). releasing factors. The
hypothalamus itself is system. These signals are triggered by
influenced by information stress, exercise, or emotions such as fear.
coming from many parts
of the body. Adrenaline increases the speed and
force of the heartbeat. It widens the air-
ACTH ways to improve breathing and narrows
Released into the blood vessels in the skin and intestine
bloodstream by the
pituitary, ACTH acts so that an increased flow of blood
directly on the cortex reaches the muscles.
of the adrenal glands. Negative feedback Synthetic adrenaline is sometimes giv-
If the level of
hydrocortisone in the en by injection as emergency treatment
blood rises, it has a of anaphylactic shock (a severe allergic
negative feedback
effect inhibiting ACTH reaction) and cardiac arrest (a halt in the
Adrenal gland production by the heart’s pumping action). Eye-drops con-
Stimulated by the ACTH, pituitary. This has
the adrenal cortex the effect of slowing
taining dipivefrine (a drug that passes
produces hydrocortisone hydrocortisone quickly into the tissues and converts to
and other corticosteroid production by the adrenaline), may be used to treat acute
hormones. adrenal cortex.
(closed-angle) glaucoma. Regular use can
cause a burning pain and, occasionally,
blurred vision or pigment deposits on
response to stimulation by sympathetic affected fetus. In females, these andro- the eye surface. (See also noradrenaline.)
nerves. These nerves are most active gens cause enlargement of the clitoris
during times of stress. and some fusion of the outer lips of the adrenal tumours
The release of these hormones into vulva, resulting in genital ambiguity Rare cancerous or noncancerous tum-
the circulation produces effects similar (see sex determination). Some affected ours in the adrenal glands, usually
to sympathetic nerve stimulation. The males have an enlarged penis, which causing excess secretion of hormones.
heart rate and force of contraction of may either be evident at birth or may Tumours of the adrenal cortex may
the heart muscle increase so that more develop later. secrete aldosterone, causing primary
blood is pumped around the body and Other effects of the enzyme defect aldosteronism (also called Conn’s syn-
the airways are widened to ease breath- include hypotension (low blood pres- drome), or hydrocortisone, causing
ing. The hormones constrict blood sure), hypoglycaemia (low blood sugar Cushing’s syndrome.
vessels in the intestines, kidneys, and levels), weight loss, and dehydration. Tumours of the adrenal medulla may
liver, and widen blood vessels supplying Hyperplasia (enlargement) of the adre- cause excessive secretion of adrenaline
the skeletal muscles. Consequently, nal gland occurs due to excessive (epinephrine) and noradrenaline (norep-
more blood is supplied to the active secretion of the hormone ACTH, which inephrine). Two types of tumour affect
muscles and less to the internal organs. is a result of insufficient production of the medulla: phaeochromocytoma and
hydrocortisone. Excessive skin pigmen- neuroblastoma, which affects children.
adrenal hyperplasia, congenital tation may occur in skin creases and These tumours may cause intermittent
A rare genetic disorder, present from around the nipples. hypertension (high blood pressure) and
birth, in which an enzyme (a protein In severe cases, congenital adrenal sweating attacks.
that acts as a catalyst) defect blocks the hyperplasia is apparent soon after birth. Surgical removal of a tumour or an
production of corticosteroid hormones In milder cases, symptoms appear later, adrenal gland usually cures noncancer-
(hydrocortisone and aldosterone) from sometimes producing premature puber- ous tumours. Cancerous tumours may
the adrenal glands. ty in boys and delayed menstruation, require additional treatment with radio-
SYMPTOMS hirsutism (excessive hairiness), and po- therapy and/or chemotherapy. (See also
The enzyme block results in production tential infertility in girls. adrenal glands disorders box.)
of excessive amounts of androgens DIAGNOSIS AND TREATMENT
(male sex hormones), which can cause A diagnosis is confirmed by measuring adrenocorticotrophic hormone
abnormal genital development in an corticosteroid hormones in the blood See ACTH.

19
 ADRENOGENITAL SYNDROME

DISORDERS OF THE ADRENAL GLANDS

A
Adrenal gland disorders are a range of uncommon. The onset of an infection Hydrocortisone production by the
uncommon but sometimes serious or other acute illness in someone with adrenal cortex is controlled by the
conditions that result from deficient or Addison’s disease can precipitate acute secretion of ACTH (adrenocorticotrophic
excessive production of hormones by adrenal failure. hormone) by the pituitary gland.
one or both of the adrenal glands. A tumour or other pituitary gland
Impaired blood supply disorder, or tumours in the lung, breast,
Congenital defects Loss or obstruction of the blood supply to and elsewhere, can cause excess ACTH
A genetic defect causes congenital the adrenal glands, sometimes as a result of secretion, leading to excess production
adrenal hyperplasia, in which the arterial disease, is another possible cause of of hydrocortisone by the adrenals and,
adrenal cortex is unable to make Addison’s disease or acute adrenal failure. hence, to Cushing’s syndrome. Pituitary
sufficient hydrocortisone and disease is a cause of Cushing’s syndrome.
aldosterone. As a side effect of the Tumours
reduced hydrocortisone production, Cancerous or noncancerous growths in
the glands are stimulated into the adrenal glands are rare but generally INVESTIGATION
producing excess androgens (male lead to excess secretion of hormones. A
sex hormones); this can cause tumour of the adrenal cortex can secrete Blood and/or urine tests can detect the
masculinization of female babies. aldosterone, causing primary aldosteronism high levels of adrenal hormones that
occur with adrenal tumours. They can
(also called Conn’s syndrome), a
also detect the high levels of natural
Autoimmune disorders condition that is characterized by thirst corticosteroids that occur in Cushing’s
Deficient production of hormones by and high blood pressure. A tumour can syndrome, and the low levels that occur
the adrenal cortex is called adrenal also secrete hydrocortisone, causing in congenital adrenal hyperplasia. Blood
failure; if the deficiency is due to disease Cushing’s syndrome, which has various tests are used to measure salt and
of the adrenal glands themselves, it is features including muscle-wasting and potassium levels if Addison’s disease is
called Addison’s disease. The most obesity of the trunk. Androgens may suspected; further blood tests may be
common cause of Addison’s disease is also be produced in excess, causing carried out to measure corticosteroid
an autoimmune process (in which the masculinization in females. hormone levels. Diagnosis of Addison’s
body’s immune system attacks its own Two types of tumour affect the disease can be confirmed by the
tissues). Addison’s disease can take a adrenal medulla, phaeochromocytoma response to an injection of ACTH,
chronic course characterized by and neuroblastoma, which affects children. which, under normal circumstances,
will stimulate the adrenal glands. MRI or
weakness, weight loss, and skin These tumours may cause excess secretion
CT scanning can detect abnormalities
darkening, or an acute form of adrenaline (epinephrine) and of the adrenal glands and can confirm
(Addisonian crisis or acute adrenal noradrenaline (norepinephrine). the presence of an adrenal tumour.
failure), in which the patient may They can also distinguish between
become confused and comatose. Other disorders raised hormone levels due to an
In many cases, disturbed activity of the adrenal tumour, or those due to a
Infection adrenals is caused, not by disease of the pituitary tumour. Ultrasound scanning
Destruction of the adrenal glands by glands themselves, but by an increase or can rule out an adrenal tumour as the
tuberculosis was once a major cause of decrease in the blood level of hormones cause of congenital adrenal hyperplasia.
Addison’s disease but is now that influence the activity of the glands.

adrenogenital syndrome a vein) allows administration of drugs aerobic

See adrenal hyperplasia, congenital. such as adrenaline (epinephrine). In the A term that refers to anything that
event of ventricular fibrillation (rapid un- requires oxygen to live, function, and
advanced life support coordinated contractions of the heart), grow. Humans and many other forms
Treatment of cardiac arrest (a halt in the defibrillation (a brief electric shock to of life are dependent on oxygen for
heart’s pumping action) by medical or the heart using two paddles placed on “burning” foods in order to produce
paramedical professionals when basic life the chest) may be used. energy (see metabolism). Because of
support, (which may be performed by a this dependence, they are described as
first-aider) has failed to restore a normal adverse reaction obligate aerobes.
heartbeat and spontaneous breathing. See side effect. In contrast, many bacteria have fund-
Advanced life support involves the use amentally different metabolisms and
of drugs and medical equipment. Aedes thrive without oxygen (some are even
An ECG monitor is used to record the A genus of disease-transmitting mos- killed by exposure to oxygen); such
electrical activity of the heart muscle. quitoes. Many species of AEDES are microorganisms are described as anaero-
Ventilation delivers oxygen by way of an responsible for spreading important bic. There are also certain bacteria and
endotracheal tube inserted, via the viral infections; AEDES AEGYPTI is the yeasts, known as facultative aerobes,
mouth, into the trachea (windpipe). A main vector of dengue and yellow fever. that flourish in oxygen but can also live
cannula (a thin plastic tube inserted into (See also mosquito bites.) without it. (See also aerobics.)

20
 AGE

aerobics mist. Some drugs are prescribed in this aflatoxin

Exercises, such as swimming, jogging,
and cycling, that allow muscles to work
form for use in an inhaler or in a vapor-
izer. (See also solvent abuse.)
A poisonous substance produced by
ASPERGILLUS FLAVUS moulds, which con-
A
at a steady rate with a constant, ade- taminate stored foods, especially pea-
quate supply of oxygen-carrying blood aetiology nuts, grains, and cassava. Aflatoxin is
that allows them to be sustained for The cause of, or the study of the various believed to be one of the factors respon-
long periods. Oxygen is needed to factors involved in causing, a disease. sible for the high incidence of liver
release energy from the body’s stores. To For some cases of a particular dis- cancer in tropical Africa.
fuel aerobic exercise, the muscles use order, a specific aetiology can be
fatty acid, burning it completely to pro- identified. For example, laboratory afterbirth
duce energy, carbon dioxide, and water. studies may show that an attack of diar- The common name for the tissues that
Anaerobic exercise relies on a different rhoea is the result of a particular type of are expelled from the uterus following
series of biochemical reactions to virus or bacterium. Other disorders the delivery of a baby (see childbirth).
obtain energy from the muscles’ stores have a multifactorial aetiology: the The afterbirth consists of the placenta
of fat and sugar. The waste products of causative factors of degenerative arthri- and the membranes that surrounded
anaerobic exercise are acidic and, as tis, for example, include genetic the fetus.
they accumulate in muscles, cause mus- susceptibility, repeated joint injuries,
cle fatigue; high-intensity exercises, and excess weight. On the other hand, aftercare
which are anaerobic, can be performed many disorders, such as schizophrenia, The medical care of a patient following
only for relatively short periods. are of unknown aetiology. treatment, particularly after surgery.
BENEFITS OF AEROBIC EXERCISE
When performed regularly, aerobic exer- afebrile afterpains
cise improves stamina and endurance. It A medical term meaning without fever. Contractions of the uterus that continue
encourages the growth of capillaries (See also febrile.) after childbirth. Afterpains are normal,
(small blood vessels), thereby improving indicating that the uterus is shrinking as
blood supply to the cells. It improves the affect it should, and are experienced by many
body cells’ capacity to use oxygen and A term used to describe a person’s women, especially during breast-feed-
increases the amount of oxygen that the mood. The two extremes of affect are ing. Afterpains usually disappear a few
body can use in a given time. elation and depression. A person who days after the birth, but analgesic drugs
As the body becomes fitter, the con- experiences extreme moods or changes (painkillers) may be needed.
dition of the heart also improves: the in moods may have an affective disorder.
heart rate becomes slower, both at rest Shallow or reduced affect (in which agammaglobulinaemia
and during exercise; the heart muscle responses to events seem flat) may be a A type of immunodeficiency disorder in
becomes thicker and stronger; and the sign of schizophrenia or of an organic which there is an almost complete
amount of blood pumped with each brain syndrome. absence of B-lymphocytes and immuno-
beat (the stroke volume) increases. The globulins in the blood.
overall result is that the heart needs to affective disorders
do less work to achieve the same level Mental illnesses that are characterized agar
of efficiency in pumping blood around predominantly by marked changes in An extract of certain seaweeds that has
the body. (See also exercise; fitness.) affect (mood). Mood may vary over a similar properties to gelatine. Agar can
period of time between mania (extreme be taken for constipation to soften and
aerodontalgia elation) and severe depression. (See also give bulk to faeces, and to relieve indi-
Sudden pain in a tooth brought on by a manic–depressive illness.) gestion and heartburn. It is also used as
change in surrounding air pressure. a gelling agent in media for growing
Flying at high altitudes in lowered afferent bacterial cultures.
atmospheric pressure can cause a pocket A term meaning carrying towards.
of air in the dental pulp to expand and Afferent is used mainly to describe age
irritate the nerve in the root. Aerodon- blood vessels that supply organs, or A person’s age is usually measured
talgia is more likely with improperly nerves that carry impulses from peri- chronologically but can also be meas-
fitted fillings or poorly filled root canals. pheral sense receptors to the brain and ured in terms of physical, mental, or
spinal cord. developmental maturity. Age may be of
aerophagy medical significance in diagnosis and in
Excessive swallowing of air, which may affinity determining treatment.
occur during rapid eating or drinking A term used to describe the attraction PHYSICAL AGE
or may be caused by anxiety. After laryn- between chemicals that causes them The age of a fetus is known as gesta-
gectomy (surgical removal of the to bind together, as, for example, tional age, which can be calculated
larynx), voluntary aerophagy is used to between an antigen and an antibody from the date of the mother’s last men-
produce oesophageal speech. (see immune response). In microbiology, strual period. Alternatively, it can be
affinity describes the physical similarity assessed by ultrasound scanning, which
aerosol between organisms (viruses, for exam- is more accurate. The estimation of ges-
A suspension of minute liquid or solid ple). In psychology, the term refers to tational age is important in neonatal
particles in the air, producing a fine attraction between two people. paediatrics for identification of babies

21
 AGENESIS

who are too small and who may sub- age spots mon in elderly people are freckles, solar
A sequently have problems as a result of
their low birthweight.
Blemishes that appear on the skin with
increasing age. The most common type
keratoses (small scaly patches, often
appearing on the backs of the hands,
In children, bone age (the degree of are brown or yellow slightly raised that are a result of overexposure to the
bone maturity as seen on an X-ray) can spots called seborrhoeic keratoses, sun), and De Morgan’s spots, which are
be a useful measure of physical devel- which can occur at any site. Also com- red, pinpoint blemishes on the trunk.
opment because all healthy individuals
reach the same adult level of skeletal
THE PRACTICAL EFFECTS OF AGING
maturity and each bone passes through
the same sequence of growth. Assess- In the body, aging is associated with loss of elasticity in the skin, blood vessels,
ment of bone age is useful in the and tendons. There is also progressive decline in the functioning of organs such
investigation of delayed puberty or short as the lungs, kidneys, and liver. Mechanical wear and tear causes cumulative
stature in children. A prediction of the damage to certain organ systems. Brain cells, specialized kidney units, and many
final adult height can be made if the other body structures are never replaced after they have reached maturity.
chronological age, bone age, and cur-
rent height are known. Hip joint in a Hip joint in an
young person elderly person
Dental age, which is another measure The X-ray shows This X-ray of an
of physical maturity, can be assessed the rounded head osteoarthritic
by the number of teeth that have erup- of the thigh-bone hip shows
ted (see eruption of teeth) or by the (femur) separated almost complete
amount of dental calcification (see calci- by cartilage from degeneration and
the surrounding disappearance
fication, dental), as seen on an X-ray, hip socket. of the cartilage
compared with standard values. in the joint.
In adults, physical age is difficult to
assess other than by physical appear-
ance. It can be estimated after death by
the state of certain organs, particularly EFFECTS OF AGING
by the amount of atheroma (fatty Organ or tissue Natural effects Accelerated by
deposits) lining the arteries.
MENTAL AND DEVELOPMENTAL AGE
Skin Loss of elastic tissue causes skin to sag Exposure to sun;
Mental age can be assessed by the com- and wrinkle. Weakened blood capillaries smoking.
parison of scores achieved in intelligence cause skin to bruise more easily.
tests with standard scores for different
chronological ages. A young child’s age Brain and Loss of nerve cells leads to reduction in Excessive consumption
can be expressed in terms of his or her nervous ability to memorize or to learn new of alcohol and other
level of developmental skills, manual system skills. Reaction time of nerves increases, drugs; repeated head
dexterity, social skills, and language making responses slower. trauma (for example
from boxing).
when compared to those of other chil-
dren. Patterns of development in these
Senses Some loss of acuity in all senses, mainly Loud noise (hearing);
fields have been described for children due to loss of nerve cells. smoking (smell/taste).
up to the age of five. (See also child
development.)
Lungs Loss of elasticity with age, so that Air pollution; smoking;
breathing is less efficient. lack of exercise.
agenesis
The complete absence, at birth, of an Heart Becomes less efficient at pumping, Excessive use of
organ or a component of the body. Age- causing reduced tolerance to exercise. alcohol and cigarettes;
nesis is caused by developmental failure a fatty diet.
in the embryo.
Circulation Arteries harden, causing poor blood Lack of exercise;
agent circulation and higher blood pressure. smoking; poor diet.
Any substance or force capable of bring-
ing about a biological, chemical, or Joints Pressure on intervertebral discs causes Athletic injuries; being
height loss; wear on hip and knee joints overweight.
physical change. (See also reagent.) reduces mobility.
Agent Orange
Muscles Loss of muscle bulk and strength Lack of exercise;
A herbicide and defoliant of which the starvation.
major constituent (50 per cent by vol-
ume) is the phenoxy acid herbicide Liver Becomes less efficient in processing Damage from alcohol
2,4,5 T. The highly toxic contaminant toxic substances in the blood consumption and virus
TCDD, commonly known as dioxin, infections
may be added to this substance during
manufacture (see defoliant poisoning).

22
 AGRAPHIA

Treatment is usually unnecessary for Wear and tear causes cumulative dam- Some people, after suffering a stroke
any of these age spots, apart from solar
keratoses, which may eventually pro-
age to the joints, and the muscles lose
bulk and strength. Wound healing and
that damages the right cerebral hemi-
sphere, seem unaware of any disability
A
gress to skin cancer. Freezing the resistance to infection also decline. in the affected left limbs. This is called
keratoses with liquid nitrogen or apply- Gradual loss of nerve cells can lead to anosognosia or sensory inattention.
ing a cream containing a cytotoxic drug is reduced sensory acuity and difficulties OUTLOOK
the usual treatment. They may also be with learning and memory. However, There is no specific treatment for
removed surgically under a local anaes- dementia occurs in only a minority of agnosia, but some of the lost interpreta-
thetic (see anaesthesia, local). elderly people. tive ability may eventually return.
Heredity is an important determinant
ageusia of life expectancy, but physical degener- agonist
The lack of, or an impairment of, the ation may be accelerated by factors such A term that means to have a stimulating
sense of taste (see taste, loss of). as smoking, excessive alcohol intake, effect. In pharmacology, an agonist
poor diet, and insufficient exercise. drug, which is sometimes known as an
agglutination With advances in medical science, life activator, is a drug that binds to a spe-
See clumping. expectancy in the developed world has cific area on the surface of a cell (a
risen dramatically over the last century. receptor) and triggers or increases a par-
aggregation, platelet ticular activity in that cell.
The clumping together of platelets agitation
(small, sticky blood particles). Aggrega- Restlessness and the inability to keep agoraphobia
tion takes place when a blood vessel is still, usually as a result of anxiety or Fear of going into open spaces or public
damaged. It is the first stage of blood tension. People who are agitated engage places. Agoraphobia may sometimes
clotting, helping to plug injured vessels. in aimless, repetitive behaviour, such as overlap with claustrophobia (a fear of
Inappropriate aggregation can have pacing up and down or wringing their enclosed spaces). Agoraphobic individ-
adverse effects; if it occurs in an artery, hands, and they often start tasks and fail uals who do venture out may have a
for example, thrombosis (a blood clot to complete them. panic attack, further restricting their
forming in an undamaged blood vessel) Persistent agitation is seen in anxiety activities, and may eventually be house-
may result. Many drugs, including aspi- disorders, especially if there is an under- bound. Treatment with behaviour therapy
rin and clopidogrel, help to reduce lying physical cause such as alcohol is often successful; antidepressant drugs
platelet aggregation. withdrawal. Depression may also be may also help.
accompanied by agitation.
aggression agranulocytosis
A general term for a wide variety of agnathia A potentially life-threatening disorder,
acts of hostility. A number of factors, A developmental defect in the fetus in in which there is a severe acute lack of
including human evolutionary survival which the lower jaw is only partially neutrophils (white blood cells that seek
strategies, are thought to be involved. formed or may be entirely absent. (See and destroy infective microorganisms).
CAUSES also birth defects.) This deficiency seriously weakens the
Androgen hormones (male sex hormones) body’s defences against infection.
seem to promote aggression, whereas agnosia In agranulocytosis, the bone marrow
oestrogen hormones (the female sex hor- The inability to recognize objects, fails to produce adequate neutrophils.
mones) may suppress it. Age is another despite adequate sensory information This may be an adverse effect of a
factor; aggression is more common in about them reaching the brain via the drug such as carbimazole (used to treat
teenagers and young adults, and some eyes or ears or through touch. In order thyroid diseases) or an effect of some
people believe that it can result from for an object to be recognized, the sen- drug treatments for cancer (see chemo-
frustration or lack of affection as a sory information it provides must be therapy). Fever and mouth ulcers
child. Sometimes a brain tumour or interpreted, which involves the recall of commonly occur.
head injury may lead to aggression. memorized information about similar Treatment is with antibiotic drugs,
Psychiatric conditions associated with objects. Agnosia is caused by damage to which should be started immediately to
aggressive outbursts are schizophrenia, areas of the brain involved in interpre- prevent the development of severe, and
antisocial personality disorder, mania, and tative and recall functions. The most potentially fatal, infections.
abuse of alcohol or amphetamine drugs. common causes of this kind of damage
Temporal lobe epilepsy, hypoglycaemia, are stroke or head injury. agraphia
and confusion due to physical illnesses TYPES Loss of or impaired ability to write, des-
are other, less common, medical causes. Agnosia is usually associated with just pite normal functioning of the hand
one of the senses of vision, hearing, or and arm muscles. Agraphia can result
aging touch and is described as visual, audit- from damage to the parts of the cere-
Aging is the physical and mental ory, or tactile respectively. For example, brum (the main mass of the brain)
changes that occur with the passing of an object may be completely recogniz- concerned with writing.
time and is associated with degenerative able by hearing and touch, but it cannot CAUSES
changes in various organs and tissues, be recognized by sight, despite the The ability to write depends on a com-
such as loss of elasticity in the skin and sense of vision being perfectly normal plex sequence of mental processes,
a progressive decline in organ function. (an example of visual agnosia). including the selection of words and

23
 AGUE

recall from memory of these words are face. These cells include a type of white the development of full-blown AIDS.
A spelled, formulation and execution of
the required hand movements, and vis-
blood cell called a CD4 lymphocyte (a
T lymphocyte with a CD4 receptor), that
The main types of antiviral drug used
are protease inhibitors, such as indinavir,
ual checking that written words match is responsible for fighting infection, and and reverse transcriptase inhibitors such as
their representation in the brain. These cells in other tissues such as the brain. zidovudine. Several drugs are usually
processes may take place in a number of The virus reproduces within the infected used together to prevent resistance from
connected regions of the brain. Agraph- cells, which then die, releasing more developing. AIDS-defining illnesses are
ia may be caused by damage to any of virus particles into the blood. If the in- treated as they develop.
these regions (most commonly as a fection is left untreated, the number of Since the introduction of antiviral
result of a head injury, a stroke, or a brain CD4 lymphocytes falls, resulting in drug combination therapies, deaths
tumour) and can therefore be of differ- greater susceptibility to certain infec- from AIDS in the developed world have
ent types and degrees of severity. tions and some types of cancer. been reduced dramatically. HIV infec-
Agraphia is often accompanied by SYMPTOMS AND SIGNS tion remains life-threatening, however,
alexia (loss of reading ability) or may be Some people experience a short-lived and the most effective strategy for
part of an expressive aphasia (a general illness similar to infectious mononuc- defeating it is prevention of infection.
disturbance in expression of language). leosis when they are first infected with PREVENTION OF INFECTION
OUTLOOK HIV. Many individuals have no obvious The risk of infection can be reduced by
There is no specific treatment for agra- symptoms. After the initial illness, many practising safer sex. and by intravenous
phia, but some of the lost writing skills people remain well. Some may suffer drug users not sharing needles. There is
may return in time. from enlarged lymph nodes, muscle a small risk to health workers handling
pain, and excessive sweating. Severe infected needles or blood products, but
ague bacterial infections, such as pneumonia, this can be minimized by the adoption
An outdated term for the fever in mala- are common. Later, vague complaints, of safe practices in the workplace.
ria and similar diseases, in which the such as weight loss, fevers, sweats, or
sufferer alternately feels excessively hot unexplained diarrhoea (described as AIDS-related complex
and shiveringly cold. AIDS-related complex) may herald the A combination of symptoms including
development of AIDS. weight loss, fever, neurological prob-
AIDS Other features of infection with HIV lems, and recurrent infections in an
The abbreviation for acquired immune include skin disorders and a variety of individual who has been infected with
deficiency syndrome, a deficiency of viral, fungal and bacterial infections. HIV (the virus that causes AIDS) but has
the immune system due to infection with HIV may also affect the brain, causing not yet developed AIDS. Many people
the human immunodeficiency virus neurological disorders such as dementia. with AIDS-related complex will eventu-
(see HIV). The interval between infec- Certain conditions, known as AIDS- ally develop the features of AIDS.
tion and the development of AIDS is defining illnesses, mark the develop-
highly variable. Without treatment, ment of full-blown AIDS. These include air
around half of those individuals in- cancers (lymphoma of the brain, Kap- The colourless, odourless mixture of
fected will develop AIDS within eight to osi’s sarcoma, and cancer of the cervix) gases that forms the Earth’s atmosphere.
nine years. In about one in ten cases, and various infections (pneumocystis Air consists of 78 per cent nitrogen, 21
however, progression to AIDS is very pneumonia, cytomegalovirus infection, per cent oxygen, small quantities of car-
slow, taking up to 20 years or longer. toxoplasmosis, diarrhoea as a result of bon dioxide and other gases, and some
Illness and death from AIDS is a grow- CRYPTOSPORIDIUM or ISOSPORA, candidiasis, water vapour.
ing health problem worldwide, and disseminated strongyloidiasis, and crypto- The balance of atmospheric gases is
there is, as yet, no cure or vaccine. coccosis), many of which are described maintained largely by the mutual needs
METHODS OF TRANSMISSION as opportunistic infections. of plants and animals. Plants use carbon
HIV is transmitted in body fluids such DIAGNOSIS dioxide and release oxygen in a process
as semen, blood, vaginal secretions, and Confirmation of HIV infection involves called photosynthesis; animals use oxy-
breast milk. Major methods of transmis- testing a blood sample for the presence gen during respiration, and produce
sion are sexual contact (vaginal, anal, or of antibodies to HIV (see HIV test), carbon dioxide as a waste product;
oral), blood to blood (via transfusions, which may not develop for three However, the level of carbon dioxide in
or needle-sharing in drug users), and months after initial infection. The con- the atmosphere is gradually increasing
mother-to-fetus. HIV has also been dition is monitored using blood tests as a result of large-scale deforestation
transmitted through blood products that measure the number of CD4 lym- and the burning of fossil fuels, which
given to treat haemophilia, kidney trans- phocytes in the blood or by measuring may lead to significant global warming,
plants, and artificial insemination by viral load (the amount of virus also known as the greenhouse effect.
donated semen; but improved screening detectable in the blood). Diagnosis of (See also pollution.)
has greatly reduced these risks. HIV is full-blown AIDS is based on a positive
not spread by everyday contact, such as HIV test along with the presence of an air conditioning
hugging or sharing crockery. AIDS-defining illness. A system that controls the temperature,
EFFECTS OF THE VIRUS TREATMENT AND OUTLOOK humidity, and purity, of the air in a
The virus enters the bloodstream and Treatment of HIV infection with a com- building. Contaminated air-condition-
infects cells with a particular receptor, bination of antiviral drugs can slow the ing systems may cause legionnaires’
called the CD4 receptor, on their sur- progress of the disease, and may prevent disease (a type of pneumonia) and

24
 AIR CONDITIONING

CAUSES AND PREVENTION OF AIDS

A
AIDS is caused by the human
immunodeficiency virus (HIV) (right), Surface proteins
which consists of some nucleic acid
(genetic material) inside two protective
shells and an outer envelope. Full- Outer envelope
blown AIDS develops in only some
people infected with HIV.
Outer shell

Inner protein layer

Ribonucleic
acid (RNA)

HIV (the AIDS virus)

The electron micrograph
at left shows a human
immunodeficiency virus Reverse
transcriptase
(HIV) particle erupting from
an infected human
lymphocyte (cell of the
immune system).

HOW HIV AFFECTS THE IMMUNE SYSTEM RECOMMENDATIONS FOR

PREVENTING THE SPREAD
CD4 lymphocyte OF AIDS
HIV
• Do not have sexual intercourse with
many partners, and especially not
HIV with people known to have HIV,
without using a condom.
Unaffected CD4
lymphocyte • Do not use intravenous (IV) drugs.
If you use IV drugs, do not share
Viral RNA needles or syringes.
HIV enters the bloodstream and infects The virus attaches to and enters the
1 cells that have CD4 receptors on their
surface, particularly CD4-lymphocytes,
2 CD4-lymphocytes. It then loses its
protective shell, releasing its RNA and
• Do not have sex with people who use
IV drugs.
which are responsible for fighting infection. reverse transcriptase (an enzyme).
• People with AIDS or who have had
HIV reproduces CD4 lymphocyte positive HIV antibody test results
may pass the disease on to others
and should not donate blood,
HIV
plasma, body organs, other tissues,
or sperm. They should not exchange
body fluids during sexual activity.

• There is a risk of infecting (or being

infected by) others through sexual
intercourse, sharing needles, and,
possibly, exposure of others to
Invading saliva through oral-genital contact
organism
or “wet” kissing. Condoms
New virus
particle Dead CD4 substantially reduce the risk
released lymphocyte of infection.
Reverse transcriptase enables the viral When disease organisms invade,
3genetic
RNA to use the host CD4-lymphocyte’s
material to reproduce itself. The new
4shortage
immune responses may fail, due to a
of CD4-lymphocytes. The disease
• Toothbrushes, razors, or other
implements that could become
virus particles are released into the blood, organism may then overwhelm the immune contaminated with blood should
killing the infected CD4-lymphocyte. system and lead to the features of AIDS. not be shared.

25
 AIR EMBOLISM

humidifier fever (a lung disease causing asthma and bronchitis), results in breath-
A coughing and breathing difficulties).
Air conditioning is also thought to be
ing difficulty. (See also rescue breathing;
lung disorders box.)
a factor in some cases of sick building
syndrome, which produces headache, akathisia
irritability, and loss of energy. The inability to sit still, which occas-
ionally occurs as a side effect of an
air embolism antipsychotic drug or, less commonly, as a
The blockage of a small artery by an complication of Parkinson’s disease.
air bubble carried in the blood. Air
embolism is rare. In most cases, it is akinesia
caused by air entering the circulation Complete or almost complete loss of
through a vein, either as a result of movement. Akinesia may result from
injury or following surgery. Air embol- damage to part of the brain due, for ex-
ism can also occur during scuba-diving ample, to a stroke or Parkinson’s disease. Appearance of albinism
or air-travel accidents, in which lung Albinism is characterized by the lack of melanin
tissue ruptures, releasing air into the albinism pigment in the skin, hair, and eyes.
bloodstream. A rare, inherited disorder that is char-
acterized by a lack of the pigment
air pollution melanin, which gives colour to the skin,
See pollution. hair, and eyes.
Oculocutaneous albinism (the most
air swallowing common type of albinism) is transmit-
See aerophagy. ted as an autosomal recessive trait (see
genetic disorders). The genetic defect
air travel results in deficiency of a specific enzyme
See aviation medicine; barotrauma. (a protein that acts as a catalyst); this
deficiency interferes with the produc-
airway tion of melanin in the affected tissues.
A collective term for the passages In oculocutaneous albinism, the hair,
through which air enters and leaves skin, and eyes are all affected. The skin
the lungs (see respiratory system). The cannot tan and ages prematurely. In Albinism in an African boy
airway is made up of the nasal passages, addition, skin cancers may develop on The condition occurs only rarely, but it is found in
the oral cavity, the upper part of the areas of skin exposed to the sun. Less people of all ethnic groups.
pharynx (throat), the larynx (voice- often, only the eyes are affected. Visual
box), the trachea (windpipe), the problems affecting people with albin- albuminuria
bronchi (the main air passages to ism include photophobia (an intolerance The presence of the protein albumin in
the lungs), and the bronchioles (the to bright light), nystagmus (abnormal the urine; a type of proteinuria. Norm-
smaller air passages in the lungs that flickering movements), myopia (short- ally, the glomeruli (the filtering units of
branch off from the bronchi). sightedness), and squint. the kidneys) do not allow albumin to
The term airway is also applied to a Glasses are usually needed from an pass into the urine. Albuminuria there-
tube that is inserted into the mouth of early age, and tinted glasses help to fore usually indicates that there is
an unconscious person to prevent the reduce photophobia. If the skin is damage to the kidneys’ filtering mech-
tongue from obstructing breathing. affected, it should be carefully protected anisms. Such damage may be due to a
Preservation of the airway can also be from the sun. kidney disorder, such as glomerulo-
achieved by inserting an endotracheal nephritis or nephrotic syndrome, or it may
tube into the trachea, either through the albumin be a sign that the kidneys have been
mouth or nose or via an incision in the The most abundant protein in the blood affected by hypertension. In diabetes mel-
neck, as in a tracheostomy operation. plasma. Albumin is made in the liver litus, the presence of even small
(See also respiratory system.) from amino acids that have been amounts of albumin in the urine (a
absorbed from digested protein. condition known as microalbuminuria)
airway obstruction Albumin helps to retain substances is an early indicator of kidney damage.
Narrowing or blockage of the respira- (such as calcium, some hormones, and Albuminuria can be detected by a sim-
tory passages. The obstruction may be certain drugs) in the circulation by ple urine test.
due to a foreign body, such as a piece of binding to them to prevent them from
food, that becomes lodged in part of being filtered out by the kidneys and alcohol
the upper airway and may result in excreted in the urine. Albumin also reg- A colourless liquid produced from the
choking. Certain diseases and disorders, ulates the movement of water between fermentation of carbohydrates by yeast.
such as diphtheria and lung cancer, can tissues and the bloodstream by osmosis Also known as ethanol or ethyl alcohol,
cause obstruction. Additionally, spasm (the movement of water to an area with alcohol is the active constituent of alco-
of the muscular walls of the airway, as a higher concentration of salts or pro- holic drinks such as beer, wine, and
occurs in bronchospasm (a feature of teins). (See also albuminuria.) spirits. In medicine, alcohol is used as

26
 ALCOHOL INTOXICATION

an antiseptic and a solvent. Methanol, hol. Genetic factors may play a part in Alcohol-dependent persons are more
also known as methyl alcohol, is a rela-
ted, highly toxic, substance.
causing alcohol dependence in some
cases, but it is now widely believed that
susceptible than others to a variety of
physical and mental disorders (see alco-
A
MENTAL EFFECTS anyone, irrespective of personality, envi- hol-related disorders).
Alcohol is a drug and produces a wide ronment, or genetic background, is TREATMENT
range of mental and physical effects. capable of becoming dependent. Stress Many problem drinkers require medical
The effect of alcohol on the central is often a major factor in precipitating help in overcoming their physical
nervous system (the brain and spinal heavy drinking. withdrawal symptoms (detoxification)
cord) is as a depressant, decreasing its DEVELOPMENT OF DEPENDENCE when they stop drinking alcohol, fol-
activity and thereby reducing anxiety, Alcohol dependence usually develops in lowed by long-term treatment. There
tension, and inhibitions. In moderate four main stages that occur over a num- are different methods of treatment,
amounts, alcohol produces a feeling of ber of years and merge imperceptibly. which may be combined.
relaxation, confidence, and sociability. In the first phase, tolerance (being able Psychological treatments for alcohol
However, alcohol slows reactions, and to drink more alcohol before experienc- dependence involve psychotherapy and
the more that is drunk, the greater ing its effects) develops in the heavy are commonly carried out as group
the impairment of concentration and social drinker. In the second phase, the therapy. Social treatments may offer
judgment. Excessive consumption of drinker experiences memory lapses practical help, such as with problems at
alcohol results in poisoning or acute relating to events during the drinking work, and tend to involve family mem-
alcohol intoxication, with effects ranging episodes. In the third phase, there is loss bers in the process. Physical treatment
from euphoria to unconsciousness. of control over alcohol consumption. includes the use of disulfiram, a drug
PHYSICAL EFFECTS The final phase is characterized by pro- that sensitizes the drinker to alcohol so
Short-term physical effects include peri- longed binges of intoxication, and that he or she experiences unpleasant
pheral vasodilation (widening of small mental or physical complications. side effects when drinking, or acam-
blood vessels), causing flushing and SYMPTOMS AND EFFECTS prosate, which helps to reduce craving.
increased flow of gastric juices, which Behavioural symptoms of alcohol Alcoholics Anonymous and other self-
stimulates the appetite. Alcohol increa- dependence are varied, and they can help organizations can provide support
ses sexual confidence, but high levels include grandiose, aggressive, or furtive and advice.
can cause impotence. Alcohol also acts as behaviour; personality changes (such as
a diuretic, increasing urine output. irritability, jealousy, or uncontrolled Alcoholics Anonymous
In the long term, regular excessive anger); neglect of food intake and per- A worldwide, independent, self-help
consumption of alcohol can cause gas- sonal appearance; and lengthy periods organization that is operated locally by
tritis (inflammation and ulceration of of intoxication. people working on a voluntary basis to
the stomach lining) and can lead to Physical symptoms of the condition overcome alcohol dependence. Regular
alcohol-related disorders. Heavy drinking may include nausea, vomiting, or shak- group meetings are held in which
in the long term may also lead to alcohol ing in the morning; abdominal pain; members are encouraged to help one
dependence. However, individuals who cramps; numbness or tingling; weak- another to stay sober by sharing their
drink regular, small amounts of alcohol, ness in the legs and hands; enlarged experiences openly and by offering
(1–2 units (see alcohol, unit of) per day) blood vessels in the face; irregular support and advice.
seem to have lower rates of coronary pulse; unsteadiness; confusion; memory
artery disease and stroke than those who lapses; and incontinence. Sudden with- alcohol intoxication
abstain totally. drawal from alcohol may lead to The condition that results from consum-
The consumption of alcohol during delirium tremens (severe shakes, halluci- ing an excessive amount of alcohol,
pregnancy may result in fetal alcohol syn- nations, and convulsions). often over a relatively short period.
drome, miscarriage, or a disruption in
normal fetal development.
ALCOHOL AND PREGNANCY
alcohol dependence
The damage to a fetus by alcohol intake
An illness characterized by habitual,
during pregnancy has been recognized only
compulsive, long-term, heavy alcohol recently. Intake of more that two units (see
consumption and the development of alcohol, unit of) per day increases the risk of
withdrawal symptoms when drinking is fetal alcohol syndrome (consisting of facial
stopped suddenly. abnormalities such as cleft lip and palate,
CAUSES heart defects, abnormal limb development,
Causative factors that interact in the and lower-than-average intelligence). The
development of alcohol dependence risk of miscarriage is also increased. Binge
include: personality, environment, and drinking can have the same effect, even if
the addictive nature of alcohol. People the mother drinks little otherwise. Because
Fetal alcohol syndrome
of an inadequate, insecure, or immature a proportion of the alcohol reaches the An affected baby is abnormally small, with small
personality are at greater risk. Environ- baby, there is a risk that even small eyes and a small jaw. He or she may also suffer
amounts can disrupt normal development from heart defects or a cleft lip and palate, may
mental factors are important, especially
(causing, for example, low birth weight). suckle poorly, sleep badly, and be irritable.
the ready availability, affordability, and
widespread social acceptance of alco-

27
 ALCOHOL INTOXICATION

ALCOHOL AND THE BODY

A
Alcohol is a drug and, even in small
amounts, its effects on the body are Alcohol 100
noticeable. Problems arise when in blood Person
people fail to take into account the (mg per 80 has first
effects of alcohol on tasks requiring 100 ml) drinks
coordination (such as driving) when 60
they become intoxicated or when they Person has
become dependent on the drug. 40 second
drink/s
Alcohol dependence can cause early
death and is a major factor in crime, Time 12p.m. 2p.m. 4p.m. 6p.m. 8p.m. 10p.m.
marital breakdown, child abuse,
accidents, and absenteeism. Cumulative effects of alcohol
The body takes some time to eliminate even small amounts of alcohol. If a person has
Prolonged heavy drinking that two drinks at lunchtime, and then has one or two early in the evening, the cumulative
stops just short of dependence still blood alcohol level could be over the legal limit for driving, even after several hours.
may cause a wide variety of diseases,
such as cardiomyopathy and cirrhosis Alcohol levels
of the liver. in different drinks
The table below highlights the A unit is the measure used
effects of alcohol on the occasional to define the amount of
social drinker. These effects occur with alcohol in an alcoholic drink.
higher concentrations as alcohol One unit constitutes 10 ml of
pure alcohol. The number of
tolerance increases.
units per drink is calculated by
the volume of the drink and
the percentage of alcohol by Beer Wine Sherry Whisky
EFFECTS OF INCREASING BLOOD volume. The drinks shown here (250 ml) (100 ml) (50ml) (25ml)
ALCOHOL LEVELS each contain approximately (4 per cent (10 per cent (20 per cent (40 per cent
one unit of pure alcohol. by volume) by volume) by volume) by volume)
Concentration Observable effects
(milligrams per LONG TERM EFFECTS ON THE BODY
100 millilitres)
Persistent heavy drinking eventually Brain and nervous system
30-50 Flushed face, euphoria, Alcohol depresses the central
talkativeness, increased damages body tissues; the main nervous system. Prolonged
social confidence effects are shown below. alcohol abuse permanently
impairs brain function and
damages peripheral nerves.
50-150 Disturbed thinking and Liver
coordination, irritability, The liver is the main organ responsi-
reduced self-control, ble for metabolizing alcohol from the
irresponsible talk and blood; it manifests many of the long- Skin
term effects of heavy drinking. These Alcohol causes facial flushing,
behaviour effects include fatty liver, hepatitis, which becomes constant in
cirrhosis, and liver cancer. heavy drinkers.
150-250 Marked confusion,
unsteady gait, slurred
speech, unpredictable Digestive system Heart and circulation
shows of emotion and Irritation from large Prolonged heavy drinking
aggression amounts of alcohol can cause heart failure,
can cause gastritis hypertension, and stroke.
and pancreatitis.
250-400 Extreme confusion and
disorientation, difficulty Urinary system
remaining upright, Reproductive system Alcohol acts as a diuretic,
drowsiness, delayed or Alcohol increases increasing urine output.
incoherent reaction to sexual confidence, but
questions progressing in the long term can
to coma (a state of cause shrinkage of
testes and breast
deep unconsciousness development in men.
from which the person
cannot be aroused) Cirrhosis of the liver
This condition is commonly
400-500 Risk of death due to caused by heavy drinking.
arrest of breathing When compared to a normal
(although habitual liver (far left), the cirrhotic liver
drinkers may survive clearly shows the formation of
even such high levels) bands of scar tissue, which
and choking on vomit impair its function.

28
 ALEXANDER TECHNIQUE

EFFECTS gait, and eventual coma (see Wernicke– aldosteronism

The effects of high intake alcohol dep-
end on many factors, including mental
Korsakoff syndrome). Severe deficiency
can also cause heart failure (reduced
A disorder that results from excessive
production of the hormone aldosterone
A
and physical state, body size, social situ- pumping efficiency of the heart). from one or both of the adrenal glands.
ation, and acquired tolerance; but the A prolonged high level of alcohol in Aldosteronism caused by an adrenal
important factor is the blood alcohol the blood and tissues can disturb the tumour is known as Conn’s syndrome.
level. Mild intoxication promotes relax- body chemistry, resulting in hypoglycae- Aldosteronism may also be due to dis-
ation and increases social confidence. mia (low blood glucose levels) and orders, such as heart failure (reduced
However, alcohol causes acute poi- hyperlipidaemia (high blood fat levels). pumping efficiency of the heart) or
soning if it is consumed in sufficiently These may damage the heart, liver, liver damage, that reduce blood flow
large amounts. It depresses the activity blood vessels, and brain; irreversible through the kidneys. This reduction in
of the central nervous system, (the brain damage may cause premature death. the flow of blood flow leads to over-
and spinal cord), leading to loss of nor- production of renin and angiotensin,
mal mental and physical control. In aldosterone which, in turn, leads to excessive aldos-
extreme cases, consumption of a large A hormone secreted by the adrenal cor- terone production.
amount of alcohol over a short period tex (the outer part of the adrenal SYMPTOMS AND SIGNS
of time may lead to loss of conscious- glands). Aldosterone plays an important Symptoms of the condition are directly
ness and even death. role in the control of blood pressure and related to the actions of aldosterone.
TREATMENT regulation of sodium and potassium Excess sodium is retained in the body,
In most cases, recovery from alcohol concentrations in the blood and tissues. leading to a rise in blood pressure, and
intoxication occurs naturally as the Aldosterone acts on the kidneys to excess potassium is lost in the urine.
alcohol is gradually broken down in the decrease the amount of sodium lost in Low levels of potassium cause tiredness
liver. Medical attention is required if the the urine; the sodium is reabsorbed into and muscle weakness and impair kidney
intoxication has resulted in coma. the blood from urine before it leaves function, leading to thirst and over-
For a description of the effects of the kidneys and is replaced in the urine production of urine.
long-term heavy drinking, see alcohol by potassium. The sodium draws water TREATMENT
dependence and alcohol-related disorders. back into the blood with it, thereby Treatment in all cases of aldosteronism
increasing the blood volume and raising includes restriction of salt in the diet
alcoholism the blood pressure. and use of the diuretic drug spirono-
See alcohol dependence. Aldosterone production is stimulated lactone. This drug blocks the action of
mainly by the action of angiotensin II, a aldosterone on the kidneys, leading to
alcohol-related disorders chemical produced by a series of reac- increased loss of sodium from the body,
A wide variety of physical and mental tions involving the enzymes renin and lowered blood pressure, and reduced
disorders associated with heavy, pro- angiotensin-converting enzyme. Produc- potassium loss. If the cause of aldos-
longed consumption of alcohol. tion of aldosterone is also stimulated by teronism is an adrenal tumour, this may
High alcohol consumption increases the action of ACTH, which is produced be surgically removed.
the risk of cancer of the mouth, tongue, by the pituitary gland.
pharynx (throat), larynx (voice-box), alendronate sodium
and oesophagus (gullet), especially if alcohol, unit of See alendronic acid.
combined with smoking. Incidence of A measure that is commonly used to
liver diseases, such as liver cancer, alco- define the amount of alcohol that is alendronic acid
holic hepatitis and cirrhosis, is higher in present in a single alcoholic drink. A A bisphosphonate drug that is used in the
alcohol-dependent persons. High con- unit is defined as 10 millilitres of pure treatment of osteoporosis and Paget’s dis-
sumption of alcohol increases the risk alcohol. The number of units in one ease of bone. The most common side
of cardiomyopathy (disease of heart mus- drink is calculated by multiplying the effect of alendronic acid is inflamma-
cle), hypertension (high blood pressure), alcohol content of that drink with its tion of the oesophagus, which causes
and stroke. Alcohol irritates the digestive volume, then dividing by 1000. As a heartburn or difficulty in swallowing.
tract and may cause gastritis. Heavy rough guide, half a pint (or a bottle) Other side effects can include headache,
drinking during pregnancy increases of beer, lager, or cider has one unit; a abdominal pain and distension, and
the risk of miscarriage and fetal alcohol single measure (25 ml) of spirits has diarrhoea or constipation.
syndrome. Problem drinkers are more one unit; and a small glass of wine
likely to suffer from anxiety and depres- has one unit. Alexander technique
sion and to develop dementia. Various countries have official guide- A therapy that aims to improve health
Many problem drinkers have a poor lines on the maximum number of units by teaching people to stand and move
diet and are prone to diseases caused that can be consumed per day without more efficiently.
by nutritional deficiency, particularly of endangering health. In the UK, the Developed in the 1920s by F. Mathias
thiamine (see vitamin B complex). Severe Department of Health has defined safe Alexander, the technique is based on
thiamine deficiency (see beriberi) dis- limits for men as three to four units per the belief that bad patterns of body
turbs nerve function, causing cramps, day (or less) and for women as two to movement interfere with the proper
numbness, and weakness in the legs and three units per day (or less). In addi- functioning of the body and therefore
hands. Its effects on the brain can cause tion, one or two alcohol-free days per contribute to the development of dis-
confusion, disturbances of speech and week are usually recommended. ease. By releasing unnecessary muscle

29
 ALEXIA

culture, or a peer group. Alienation is

ALCOHOL-RELATED DISORDERS
A common in adolescents, and it also
occurs in individuals who are isolated
Cancer
High alcohol consumption increases the risk alcohol intake, along with smoking, produces by cultural or language differences. In
of breast cancer in women and cancers of the a much higher total risk of cancer than the some people, alienation may be an early
mouth, tongue, pharynx (back of the throat), sum of their separate risks. The risk of liver symptom of schizophrenia or a persona-
larynx (voicebox), and oesophagus, probably cancer, along with most types of liver disease, lity disorder.
due to irritant action. In each of these cancers, is also higher among problem drinkers.
alignment, dental
Liver damage and disease
Liver diseases caused by a high alcohol although nutritional deficiency may also play
The movement of teeth by the use of
consumption include fatty liver, alcoholic some part. The risk of alcoholic hepatitis and either fixed or removable orthodontic
hepatitis, cirrhosis, and liver cancer. They cirrhosis developing increases in proportion to appliances (braces) to correct maloc-
develop in sequence over a period of years. It the amount of alcohol consumed and the clusion (an incorrect bite).
is thought that a breakdown product of alcohol number of years of high consumption; liver
(acetaldehyde) has a toxic effect on liver cells cancer develops in about one in five sufferers alimemazine
and is the main cause of these diseases, of cirrhosis.
An antihistamine drug that is used mainly
Nervous system disorders
to relieve the itching that occurs in
Thiamine (vitamin B1) deficiency, also known Wernicke–Korsakoff syndrome). The effect allergic conditions such as urticaria and
as beriberi (which disturbs nerve functioning), on the peripheral nervous system (nerve atopic eczema. Alimemazine frequently
may develop in problem drinkers. The effect pathways outside the brain and spinal cord) causes drowsiness.
of severe deficiency on the brain produces produces polyneuropathy, with symptoms
Wernicke's encephalopathy, with symptoms
such as confusion, disturbances of speech
such as pain, cramps, numbness, tingling, alimentary tract
and weakness in the legs and hand. Excess
and gait, and eventual coma. Korsakoff’s consumption of alcohol can also cause Also known as the alimentary canal, the
psychosis may also occur (see dementia. tubelike structure that extends from the
mouth to the anus (see digestive system).
Psychiatric illness
Problem drinkers are more likely than others to develop dementia (irreversible mental alkali
suffer from anxiety and depression (frequently deterioration). The incidence of suicide Also called a base, an alkali is chemi-
related financial, work , or family problems) attempts and actual suicide is also higher cally defined as a donor of hydroxyl
and from paranoia. They are also more likely to among problem drinkers.
ions (each of which comprises an atom
of hydrogen linked to an atom of oxygen
Heart and circulatory disorders
Severe deficiency of thiamine in problem increases the risk of hypertension (high
and has an overall negative electrical
drinkers can result in heart failure (reduced blood pressure), cerebral haemorrhage, and charge). Antacid drugs, such as sodium
pumping efficiency ), which is usually cardiomyopathy. One type of stroke is also bicarbonate (bicarbonate of soda), are
combined with oedema (the collection of fluid associated with excessive consumption examples of alkalis. Some alkalis, such
in tissues). A high consumption of alcohol also of alcohol. as sodium hydroxide (caustic soda), are
corrosive and cause burns. (See also
Genito-urinary system disorders acid; acid–base balance.)
High consumption of alcohol can lead to carries the risk of spontaneous abortion and
fertility problems in women and to impotence
in men. Heavy drinking during pregnancy
of the baby being born with fetal alcohol
syndrome.
alkaloids
A group of nitrogen-containing subs-
Other medical disorders
tances that are obtained from plants.
Other physical diseases and disorders that linked to an irritant action of alcohol), Morphine, codeine, nicotine, and strych-
are associated with high intake of alcohol osteoporosis (thinning of the bones), and nine (see strychnine poisoning) are
include gastritis and acute and chronic damage to the skeletal muscles and those of examples of alkaloids.
pancreatitis, (all of which are probably the genito-urinary tract.
alkalosis
A disturbance of the body’s acid–base
tensions, the Alexander technique aims alfacalcidol balance in which there is an accumula-
to eliminate or reduce the severity of A synthetic form of vitamin D. tion of alkali (base) or a loss of acid.
many disorders, including back pain, There are two types of alkalosis: meta-
asthma, and stammering. alginates bolic and respiratory.
Substances used in certain types of In metabolic alkalosis, the increase in
alexia antacid drugs. Alginates float on top of alkalinity may be caused by taking too
Word blindness; the inability to recog- the stomach contents, forming a raft, much of an antacid drug or by losing a
nize and name written words. Alexia which reduces acid reflux. and protects large amount of stomach acid as a result
results from damage to part of the cere- the oesophagus. of severe vomiting.
brum (the main mass of the brain) by, In respiratory alkalosis, there is a
for example, a stroke. The condition alienation reduction in the blood level of carbonic
severely disrupts the reading ability of Feeling like a stranger, even when acid (derived from carbon dioxide).
an individual who was previously liter- among familiar people or places, and This reduction is a consequence of
ate. (See also dyslexia.) being unable to identify with family, a hyperventilation (overbreathing), which

30
 ALLERGY

may occur during a panic attack or at

ALLERGY AND THE BODY
high altitudes due to lack of oxygen.
(See also acidosis.)
A
An allergy is an inappropriate immune drugs, and some foods, most commonly
system response (causing symptoms) dairy products, seafood, strawberries,
Alka-Seltzer to substances that, in most people, and cereals, can also cause allergies. In
A brand-named analgesic and antacid cause no response. The response is diagnosing an allergy, the individual’s
containing aspirin, sodium bicarbonate, mainly to harmless substances that medical history is important. The doctor
and citric acid. Alka-Seltzer is used to come in contact with the respiratory needs to know if the symptoms vary
treat headaches and stomach upset. airways, skin, or eye surface. Common according to the time of the day or the
allergens are pollen, spores, house- season, and if there are pets or other
alkylating agents dust mites, and animal dander. Certain likely sources of allergens in the home.
A class of anticancer drugs.
THE ORIGIN OF AN ALLERGY
allele
One of two or more different forms of a The immune system is sensitized once it has been exposed to an allergen
gene that occupies a specific position on (steps 1 to 3). Symptoms occur when the allergen is met again (step 4).
a chromosome. (See also inheritance.)
Lymphocyte Antibody
Lymphocyte formed by
allergen lymphocytes
A normally harmless substance that
causes an allergic reaction (see allergy)
in people who have become sensitized
to it. Allergens can include foods (for
example, nuts, eggs, and shellfish); Newly
inhaled substances (such as pollen, recognized
allergen Antibody
house dust, and fur); and some drugs.
An allergen enters the body and is A few days to weeks later, the
1 recognized by lymphocytes (blood cells
that form part of the body’s immune system).
2 lymphocytes produce antibodies that
are specific to the allergens.

Mast cell Nucleus Histamine granule Allergen

Mast cell

Electron micrograph of various pollen grains Histamine

Pollen is a common example of an allergen. The Antibodies on surface released
airborne pollen grains from plants (such as grasses The antibodies attach to cells in the Binding of allergens to antibodies on the
and trees) can trigger an allergic reaction, the most
common of which is allergic rhinitis (hay fever).
3granules
tissues called mast cells, which contain
of histamine.
4 surface of mast cells leads to the release
of histamine and to the symptoms of allergy.

allergic alveolitis, extrinsic

See extrinsic allergic alveolitis. DIAGNOSING SKIN ALLERGY
allergic rhinitis One type of skin allergy, also known as allergic contact dermatitis, develop
See rhinitis, allergic. slowly. Tests are performed to identify specific reactions to allergens. Small
amounts of various substances are applied to the skin to see whether or not
allergy a reaction occurs.
Various conditions caused by inappro- Tiny samples A reddened
priate or exaggerated reactions of the
immune system to a wide variety of sub-
1 of allergens
are placed on
2 area of skin
where a disc had
stances known as allergens. Many small discs and been in contact
stuck to the skin denotes a
common illnesses, such as asthma and positive reaction.
with inert tape.
hay fever (see rhinitis, allergic), are The discs are Some reactions
caused by allergic reactions to sub- removed after may take longer
stances that, in the majority of people, two days. to appear.
cause no symptoms.
Allergic reactions occur only on sec-
ond or subsequent exposure to the
allergen, after first contact has sensitized
the body. It is unclear why only certain

31
 ALLOGRAFT

people develop allergies, but about one reacts to prolonged contact with sub- aloe
A person in eight seems to have an inher-
ited predisposition to them (see atopy).
stances such as nickel, is the result of a
Type IV hypersensitivity reaction.
The juice of leaves from various plants
of the ALOE genus. Aloe may be added to
TYPES AND CAUSES TREATMENT compound benzoin tincture, an aromat-
The function of the immune system is Whenever possible, the most effective ic inhalation for relieving sinusitis and
to recognize antigens (foreign proteins) treatment for allergy of any kind is nasal congestion.
on the surfaces of microorganisms and avoidance of the relevant allergen.
to form antibodies (also called immuno- Drug treatment for allergic reactions alopecia
globulins) and sensitized lymphocytes includes the use of antihistamine drugs, Loss or absence of hair, which may
(white blood cells). When the immune which relieve the symptoms. Some anti- occur at any hair-bearing site on the
system next encounters these antigens, histamines have a sedative effect, which body but which is usually noticeable
the antibodies and sensitized lympho- is useful, for example, in treating itch- only on the scalp.
cytes interact with them, leading to the ing at night due to eczema; many do TYPES
destruction of the microorganisms. not cause drowsiness, making them Male-pattern baldness, the most com-
A similar immune response occurs in more suitable for daytime use. mon form of alopecia, is hereditary and
allergies, except that the immune system Drugs such as sodium cromoglicate and most commonly affects men. Normal
forms antibodies or sensitized lymph- corticosteroids can be used regularly to hair is lost, initially from the temples
ocytes against harmless substances prevent symptoms from developing. and crown, and is replaced by fine,
because these allergens are misidenti- Hyposensitization can of valuable for a downy hair; the affected area gradually
fied as potentially harmful antigens. minority of people who suffer allergic widens. Other hereditary forms of alo-
The inappropriate or exaggerated reactions to specific allergens such as pecia are rare and may be due to
reactions that are seen in allergies are bee stings. Treatment involves gradually absence of hair roots or abnormalities
known as hypersensitivity reactions and increasing doses of the allergen to pro- of the hair shaft.
can have any of four different mecha- mote formation of antibodies that will
nisms (which are termed Types I to IV block future reactions. Hyposensitiza-
hypersensitivity reactions). tion must be carried out under close
TYPE I HYPERSENSITIVITY REACTIONS supervision because a severe allergic reac-
Most well known allergies are caused by tion can result. (See also delayed allergy.)
Type I (also known as anaphylactic or
immediate) hypersensitivity, in which allograft
allergens cause immediate symptoms Sometimes referred to as a homograft,
Stages in male pattern baldness
by provoking the immune system into tissue or an organ transplanted from one In this common form of alopecia, the man first
producing specific antibodies, belong- person to another. (See also grafting.) loses hair from the temples and the crown, then the
ing to a type called immunoglobulin E bald area gradually widens.
(IgE), which coat cells (known as allopathy
mast cells or basophils) that are present The practice of conventional medicine. In generalized alopecia, the hair falls
in the skin and the lining of the stom- (See also homeopathy.) out in large amounts. Such hair loss
ach, lungs, and upper respiratory occurs when all the hairs simultaneous-
airways. When the allergen is encoun- allopurinol ly enter the resting phase; they then fall
tered for the second time, it binds to A drug used in the long-term preven- out about three months later. Causes
the IgE antibodies and causes the gran- tion of gout attacks. Allopurinol works include surgery, prolonged illness, or
ules in mast cells to release various by decreasing production of uric acid in childbirth. In such cases, the hair will
chemicals, which are responsible for the body, thereby preventing the forma- regrow without treatment. Many anti-
the symptoms of the allergy. tion of uric acid crystals in the joints. cancer drugs cause temporary alopecia.
Among the chemicals released is hist- Possible adverse effects of allopurinol The hair usually regrows when the
amine, which causes widening of blood include itching, rashes, and nausea. The treatment is completed.
vessels, leakage of fluid into tissues, and drug cannot relieve the pain of an acute Localized alopecia may be the result
contraction of muscles, especially in the gout attack and may even precipitate one of permanent skin damage (for exam-
airways of the lung. Symptoms can at the start of treatment. Such attacks can ple, following burns or radiotherapy) or
include itching, swelling, sneezing, and be prevented by taking a combination of trauma to the hair roots by styling
wheezing. Particular conditions asso- of allopurinol and a nonsteroidal anti- or, rarely, trichotillomania (a disorder in
ciated with Type I reactions include inflammatory drug (NSAID) or colchicine. which sufferers pull out their hair). The
asthma, hay fever, urticaria (nettle rash), most common type of localized hair
angioedema, anaphylactic shock (a severe, almond oil loss is alopecia areata, an autoimmune
generalized allergic reaction), possibly An oil prepared from the seeds of the disorder (in which the immune system
atopic eczema, and some food allergies. bitter almond tree (PRUNUS AMYGDALUS). attacks the body’s own tissues). There is
TYPES II TO IV HYPERSENSITIVITY REACTIONS Almond oil is a common ingredient of no specific treatment for alopecia area-
Because Types II to IV hypersensitivity emollient skin preparations. ta, but the hair usually regrows within a
reactions have different mechanisms to few months. Alopecia universalis is a
Type I reactions, they are less often almotriptan rare, permanent form of alopecia areata
implicated in allergies. However, contact A serotonin agonist drug that is used in that causes loss of all hair on the scalp
allergic dermatitis, in which the skin the treatment of acute migraine attacks. and body, including the eyelashes and

32
 ALVEOLITIS

eyebrows. Skin diseases such as scalp maternal blood from the latter part of Most of the aluminium taken into the
ringworm (see tinea), lichen planus,
lupus erythematosus, and skin tumours
the first trimester of pregnancy, and its
concentration rises between the 15th
body is excreted. Excessive amounts are
toxic and are stored in the lungs, brain,
A
may also cause localized hair loss. and 20th weeks. liver, and thyroid gland, where they
TREATMENT Raised levels of AFP are associated may result in organ damage.
Treatments for male-pattern baldness with fetal neural tube defects, such as Certain industrial processes give off
include hair transplants or drug treat- spina bifida or anencephaly, and certain fumes containing aluminium into the
ments with minoxidil or finasteride. kidney abnormalities. High levels of AFP air. Inhalation of these fumes can cause
Generalized alopecia often resolves also occur in multiple pregnancies (see fibrosis of lung tissue. Drugs that contain
without treatment. Treatment of local- pregnancy, multiple) and threatened or aluminium interfere with the absorp-
ized alopecia depends on the cause. actual miscarriage. tion and excretion of a number of other
AFP levels may be unusually low if drugs and should not, therefore, be
alpha1-antitrypsin deficiency the fetus has Down’s syndrome. For this taken simultaneously.
A rare genetic disorder in which a person reason, measurement of blood AFP is
is missing the enzyme alpha1-antitryp- included in blood tests that are used to alveolectomy
sin, which protects the body from screen pregnant women for increased See alveoloplasty.
damage by other enzymes. The disease risk of Down’s syndrome.
mainly affects tissues in the lungs, ALPHA-FETOPROTEIN IN ADULTS alveolitis
resulting in emphysema, and the liver, AFP levels are commonly raised in Inflammation and thickening of the
causing cirrhosis. The effects of alpha1- adults with hepatoma (see liver cancer), walls of the alveoli (the tiny air sacs in
antitrypsin deficiency may not become cancerous teratoma of the testes or the lungs). Alveolitis reduces the elastic-
apparent until after the age of 30. There ovaries, or cancer of the pancreas, stom- ity of the lungs during breathing and
is no cure, but symptoms can be relieved ach, or lung. For this reason, AFP is reduces the efficiency of the transfer of
by drug treatment. In severe cases, a known as a “tumour marker”. gas between the lungs and the sur-
liver transplant may be a possibility. AFP levels can be used to monitor rounding blood vessels.
results of treatment of such cancers; CAUSES
alpha-blocker drugs increasing levels after chemotherapy or Alveolitis is commonly caused by an
COMMON DRUGS surgery may indicate recurrence. How- allergic reaction to inhaled dust of ani-
• Alfuzosin • Doxazosin • Indoramin • Prazosin ever, AFP levels are also raised in some mal or plant origin, as in farmer’s lung
• Tamsulosin • Terazosin noncancerous conditions such as viral (caused by spores from mouldy hay),
and alcoholic hepatitis and cirrhosis. bagassosis (caused by spores from
A group of drugs used to treat hyperten- mouldy sugar-cane residue), and pigeon
sion (high blood pressure) and urinary alprazolam fancier’s lung (caused by particles from
symptoms resulting from an enlarged A benzodiazepine drug that is used in bird droppings). This type of alveolitis
prostate gland (see prostate, enlarged). the treatment of anxiety, panic attacks, is known as extrinsic allergic alveolitis.
Alpha-blocker drugs interfere with and phobias.
the nerve signals that govern the con-
traction of blood vessels This causes the alprostadil
vessels to widen (vasodilation), thereby A prostaglandin drug used to minimize
Trachea
reducing the blood pressure. In the the effects of congenital (present from
treatment of an enlarged prostate gland, birth) heart defects in newborn babies Bronchus
alpha-blockers relax the ring of muscles prior to corrective surgery; it is usually
at the bladder outlet, which improves administered in hospital. Alprostadil is Bronchiole
the outflow of urine. also used as treatment for impotence. To
Side effects may include dizziness and produce an erection, it is self-adminis- Lung
fatigue (caused by a drop in blood pres- tered, either by injection into the penis
sure on standing up), drowsiness, or as a gel introduced into the urethra.
headache, nausea, and a dry mouth. Bronchiole
alternative medicine
alpha-fetoprotein Also called complementary medicine, any
A protein that is produced in the liver medical system based on a theory of
and gastrointestinal tract of the fetus disease or method of treatment other
and by some abnormal tissues in adults. than orthodox Western medicine.
ALPHA-FETOPROTEIN IN PREGNANCY
Alpha-fetoprotein (AFP) is excreted in altitude sickness
the fetal urine into the amniotic fluid; See mountain sickness.
the fluid is swallowed by the fetus,
which introduces AFP into the fetal aluminium Normal
alveoli
Inflamed
alveoli
digestive system. Most of the AFP is A light, metallic element that is found
Effects of alveolitis
broken down in the fetal intestine, but in bauxite and various other minerals. The alveoli become inflamed and their walls
some of it passes into the mother’s cir- Aluminium compounds are used in thicken, causing the lungs to become less elastic
culation. AFP can be measured in the antacid drugs and in antiperspirants. and less able to transfer oxygen.

33
 ALVEOLOPLASTY

Fibrosing alveolitis is an autoimmune dis- gum is drawn back over the bone and factors also result in the abnormal
A order (in which the immune system
attacks the body’s own tissues). In some
stitched together. Some bruising and
swelling of the mouth may occur, but
deposition of a protein in the brain
called beta amyloid. Other chemical
cases, it occurs with other autoimmune the gum usually heals within two weeks. abnormalities include deficiency of the
disorders, such as rheumatoid arthritis or neurotransmitter acetylcholine.
systemic lupus erythematosus. alveolus, dental SYMPTOMS AND SIGNS
Radiation alveolitis is caused by irra- The bony cavity or socket supporting The features of Alzheimer’s disease vary,
diation of the lungs and may occur as a each tooth in the jaw. but there are three broad stages. At
rare complication of radiotherapy for first, the affected individual becomes
lung or breast cancer. alveolus, pulmonary increasingly forgetful; and problems
SYMPTOMS AND DIAGNOSIS One of millions of tiny, balloonlike sacs with memory may cause anxiety and
Alveolitis usually causes a dry cough at the end of a bronchiole (one of the depression. Some deterioration in mem-
and breathing difficulty on exertion. many small air passages in the lungs) ory is a feature of normal aging, and
A chest X-ray of a person suffering where gases are exchanged during res- this alone is not evidence of dementia.
from alveolitis usually shows mottled piration. In each lung, there are In the second stage of the disease,
shadowing across the lungs. Blood tests approximately 300 million alveoli that loss of memory, particularly for recent
may be performed to look for specific are arranged in groups resembling events, gradually becomes more severe,
antibodies (proteins manufactured by bunches of grapes. and there may be disorientation as to
the immune system: see antibody) to an time or place. The person’s concentra-
allergen. They may also be performed to tion and numerical ability decline, and
look for evidence of an autoimmune ANATOMY OF THE ALVEOLI there is noticeable dysphasia (inability
disorder (in which the immune system These tiny sacs contain
to find the right word). Anxiety increas-
attacks the body’s own tissues). Pul- capillaries in their thin es, mood changes are unpredictable,
monary function tests show reduced lung walls that allow oxygen and personality changes may occur. If
capacity without obstruction to air flow to be absorbed into the patient is left unsupervised, he or
through the bronchi (air passages to the the blood. she may repeatedly wander off.
lungs). A lung biopsy (removal of a Finally, confusion becomes profound.
sample of tissue for microscopic analy- Bronchiole There may be symptoms of psychosis,
sis) may be the only way to make a Capillaries such as hallucinations and delusions.
conclusive diagnosis of alveolitis. Signs of nervous system disease, such as
TREATMENT AND OUTLOOK abnormal reflexes (involuntary actions)
For most types of alveolitis, a short and faecal or urinary incontinence, begin
course of corticosteroid drugs relieves to develop.
symptoms, but for fibrosing alveolitis DIAGNOSIS
the drugs may need to be taken indefi- Alzheimer’s disease is usually diagnosed
nitely. If the cause of allergic alveolitis is from the symptoms, but tests including
recognized and avoided before lung blood tests and CT scanning or MRI (tech-
damage occurs, the effects are not niques that produce cross-sectional or
permanent. In fibrosing alveolitis, the three-dimensional images) of the brain
damage progresses despite treatment, may be needed to exclude other causes
causing increasing breathing difficulty Alveoli of dementia.
and, sometimes, respiratory failure.
Deep folds Enlarged
alveoloplasty of tissue ventricles

Dental surgery that is carried out to Alzheimer’s disease

remove protuberances and to smooth A progressive condition in which nerve
out other uneven areas from tooth- cells in the brain degenerate and the
bearing bone in the jaw. Alveoplasty is brain shrinks. Alzheimer’s disease is the
performed either under a general anaes- most common cause of dementia (a
thetic (see anaesthesia, dental) or, more general decline in all areas of mental
usually, under local anaesthetic. The ability). Its onset is uncommon before
procedure is usually carried out to facil- the age of 60, but incidence increases
itate the fitting of dentures on people steadily with age thereafter.
whose alveolar ridge, underlying the CAUSES
gums, would not otherwise be smooth Early onset Alzheimer's disease, in which
and even enough for dentures to be fit- symptoms develop before the age of 60,
ted easily or worn comfortably. is often inherited as a dominant trait
An incision is made in the gum, (see genetic disorders).
which is then peeled back to expose the Late onset Alzheimer's disease is asso-
MRI of the brain in Alzheimer’s disease
uneven bone. The bone is then either ciated with one of the genes that is The volume of the brain substance has shrunk
reshaped with large forceps or filed responsible for the production of the markedly, resulting in deep folding of the tissue
down to the required shape. Finally, the blood protein apolipoprotein E. Genetic and enlargement of the fluid-filled brain ventricles.

34
 AMENORRHOEA

TREATMENT times applied to toxic or nutritional toms. In some cases, the patient can
The most important aspect of treatment
for Alzheimer’s disease is the provision
causes of decreased visual acuity, as in
tobacco–alcohol amblyopia.
send the recording over the telephone
by means of telecardiography (transmis-
A
of suitable nursing and social care for If normal vision is to develop during sion of an impulse to a site that is
sufferers and support for their relatives. infancy and childhood, it is essential remote from the patient).
Tranquillizer drugs can often improve that clear, corresponding visual images
difficult behaviour and to help with are formed on both retinas so that com- amelioration
sleep. Treatment with acetylcholinesterase patible nerve impulses pass from the In medical usage, improvement in the
inhibitors, such as rivastigmine and don- eyes to the brain. If no images are medical condition of a patient.
epezil, may slow the progress of the received, normal vision cannot develop.
disease for a time, but will not improve If the images from each eye differ amelogenesis imperfecta
mental ability. Side effects such as nau- markedly, one will be suppressed to An inherited condition of the teeth in
sea and dizziness may occur. avoid double vision. which the enamel is either abnormally
CAUSES thin or is deficient in calcium. The teeth
amalgam, dental The most common cause of amblyopia of affected individuals may be pitted and
A material, consisting of an alloy of mer- is squint (a deviation of one eye relative discoloured (see discoloured teeth) and
cury with other metals, that is used as to the other) in young children. Failure more susceptible to dental caries (tooth
fillings for teeth. Amalgam is soft to form normal retinal images may also decay) and wear.
enough to be easily workable by the result from congenital (present from
dentist but sets rapidly into a hard, birth) cataract (opacity of the lens of the amenorrhoea
strong solid (see filling, dental). eye), and severe, or unequal, focusing The absence of menstrual periods. Pri-
errors, such as when one eye is normal mary amenorrhoea is defined as failure
amantadine and there is an uncorrected large degree to start menstruating by the age of 16.
An antiviral drug that is used in the pre- of astigmatism in the other. Toxic and Secondary amenorrhoea is the tempo-
vention and treatment of influenza A. nutritional amblyopia may be the result rary or permanent cessation of periods
Amantadine is also used to help relieve of damage to the retina and/or the in a woman who has menstruated regu-
symptoms of Parkinson’s disease. optic nerve. larly in the past.
TREATMENT AND OUTLOOK PRIMARY AMENORRHOEA
amaurosis fugax The usual treatment for amblyopia due The main cause of primary amenor-
Brief loss of vision, lasting for seconds to squint is patching (covering up the rhoea is the delayed onset of puberty.
or minutes, usually affecting one eye good eye to force the deviating eye to The delay may not indicate a disorder
only and caused by the temporary function properly). Surgery to place the but, rarely, may result from a disorder of
blockage of a small blood vessel in the deviating eye in the correct position the endocrine system, such as a pituitary
eye by an embolus (a particle of solid may be necessary. Glasses may be need- tumour, hypothyroidism (underactivity of
matter such as cholesterol or clotted ed to correct severe focusing errors. the thyroid gland), an adrenal tumour, or
blood). These emboli are carried in the Cataracts may be removed surgically. adrenal hyperplasia. Another rare cause
bloodstream from diseased arteries in After the age of eight, amblyopia cannot of delayed puberty is Turner’s syndrome,
the neck or, rarely, the heart. Sufferers usually be remedied. in which one female sex chromosome
typically experience a loss or dimming is missing. In some cases, menstruation
of vision, in one eye only, rather like a ambulance fails to take place because the vagina or
shade being pulled down or up. A vehicle for transporting sick, injured, uterus has been absent from birth. It
Attacks may be infrequent, or they or disabled people, usually to hospital, may also fail to occur because there is
may occur many times a day, which that is staffed by trained personnel who no perforation in the hymen (the mem-
indicates an increased risk of stroke and can provide emergency treatment dur- brane across the opening of the vagina)
requires medical investigation. ing the journey. to allow blood to escape.
SECONDARY AMENORRHOEA
ambidexterity ambulatory ECG The most common cause of temporary
The ability to perform manual skills, In ambulatory ECG (electrocardiography), secondary amenorrhoea is pregnancy.
such as writing or using cutlery, equally a wearable device called a Holter monitor Secondary amenorrhoea may also be
well with either hand because there is is used to record the electrical activity caused by hormonal changes that occur
no definite handedness (preference for of the heart by means of electrodes as a result of stress, depression, anorexia
the use of one hand in particular). attached to the chest. The monitor is nervosa, certain drugs, or a pituitary or
Ambidexterity is an uncommon and usually worn for at least 24 hours and thyroid disorder. Another possible cause
often familial trait. detects intermittent arrhythmias (abnor- is a disorder of the ovary, such as poly-
mal heart rates and rhythms). It is also cystic ovary (see ovary, polycystic) or an
amblyopia used to assess the programming of a ovarian tumour. Amenorrhoea occurs
A permanent defect of visual acuity in cardiac pacemaker. The wearer presses a permanently after the menopause or
which there is usually no structural button on the monitor to mark the following a hysterectomy (a surgical
abnormality in the eye. In many cases, recording whenever symptoms occur. operation to remove the uterus).
there is a disturbance of the visual The recording can be analysed later to INVESTIGATION AND TREATMENT
pathway between the retina and the determine whether the periods of Investigation of amenorrhoea usually
brain. The term amblyopia is also some- arrhythmia coincide with the symp- involves a physical examination and

35
 AMFEBUTAMONE

blood tests to measure hormone levels. The 20 amino acids that make up pro- ammonia
A CT scanning or MRI (techniques that
produce three-dimensional or cross-
teins also occur free within cells and in
body fluids. In addition, there are more
A colourless, pungent gas that dissolves
in water to form ammonium hydrox-
sectional images) of the skull may be than 200 other amino acids that are not ide, an alkaline solution (see alkali).
carried out to exclude the possibility of found in proteins but play an important Ammonia consists of one nitrogen atom
a pituitary tumour and ultrasound scan- role in chemical reactions within cells. linked to three hydrogen atoms. Ammo-
ning of the abdomen and pelvis to nia is produced in the body and helps
exclude a tumour of the adrenal glands aminoglutethimide to maintain the acid–base balance.
or ovaries. In some cases, laparoscopy An anticancer drug used to treat certain In severe liver damage, the capacity of
(examination of the inside of the types of breast cancer, prostate cancer, the liver to convert ammonia to urea is
abdomen using a rigid or flexible view- and some endocrine gland tumours. diminished. This leads to a high con-
ing tube) may be required to inspect centration of ammonia in the blood,
the ovaries. aminoglycoside drugs which is thought to be a major cause of
Treatment of amenorrhoea, if found Aminoglycosides, a type of antibiotic drug, the impaired consciousness that occurs
to be necessary, is of the underlying are given by injection and, because their in liver failure.
cause. (See also dietary amenorrhoea.) use can damage the inner ear or kidneys,
are generally reserved for the treatment amnesia
amfebutamone of serious infections. Important exam- Loss of the ability to memorize infor-
A drug used, along with self-help mea- ples of these drugs are gentamicin and mation and/or recall information stored
sures, as an aid to stopping smoking. streptomycin, which are also used topi- in memory. Amnesic conditions affect
Side effects include a dry mouth and cally for eye and ear infections. mainly long-term memory (where infor-
gastrointestinal disturbances. mation is retained indefinitely) rather
aminophylline than short-term memory (where it is
amfetamine A bronchodilator drug that is used to treat only retained for seconds or minutes).
An alternative spelling for amphetamine chronic bronchitis, asthma, and, occa- Many people with amnesia have a
(see amphetamine drugs). (See also con- sionally, heart failure (reduced pumping memory gap that extends back for some
trolled drugs.) efficiency of the heart). time before the onset of the disorder.
Aminophylline relieves breathing dif- This condition, known as retrograde
amiloride ficulty by widening the bronchi (the amnesia, is principally a deficit of recall.
A potassium-sparing diuretic drug, amil- main air passages to the lungs). It also In the majority of cases, the memory
oride is used in combination with loop dilates (widens) blood vessels, thereby gap gradually shrinks over time.
or thiazide diuretics in the treatment of improving blood flow from the heart, Some people with amnesia are unable
hypertension (high blood pressure) and and increases the production of urine. to store new information in the period
the oedema (fluid retention) that results Possible side effects of aminophylline following the onset of the illness. The
from heart failure (reduced pumping include nausea, vomiting, headache, resultant gap in memory, known as
efficiency of the heart) or liver cirrhosis. dizziness, and palpitations. anterograde amnesia, extends from the
moment of onset of the amnesia to the
amino acids amiodarone time when the long-term memory
A group of chemical compounds that An antiarrhythmic drug used in the treat- resumes (if at all). This memory gap is
form the basic structural units of all pro- ment of various types of arrhythmia usually permanent.
teins. Each amino acid molecule consists (irregular heart rate or rhythm). Long- CAUSES
of amino and carboxyl groups of atoms term use of amiodarone may result in Amnesia is the result of damage to, or
that are linked to a variable chain or inflammation of the liver, thyroid prob- disease of, regions in the brain that are
ring of carbon atoms. lems, and damage to the eyes and lungs. concerned with memory function. Pos-
Individual amino acid molecules are For this reason, amiodarone is usually sible causes of such damage are head
linked together by chemical bonds given only when other drugs have injury; degenerative disorders such as
(called peptide bonds) to form short failed to be effective. Alzheimer’s disease and other forms of
chains of molecules called polypeptides. dementia; infections such as encephalitis;
Hundreds of polypeptides are, in turn, amitriptyline thiamine deficiency in problem drink-
linked together (also by peptide bonds) A tricyclic antidepressant drug with a ers, which leads to Wernicke–Korsakoff
to form a protein molecule. What dif- sedative effect. Amitriptyline is useful in syndrome; brain tumours; strokes; and sub-
ferentiates one protein from another is the treatment of depression accompa- arachnoid haemorrhage. Amnesia can also
the sequence of the amino acids. nied by anxiety or insomnia. Possible occur in some forms of psychiatric ill-
There are 20 different amino acids adverse effects include blurred vision, ness (in which there is no apparent
that make up all the proteins in the body. dizziness, and drowsiness. physical damage to the brain). Some
Of these, 12 can be made by the body; deterioration of memory is a common
they are known as nonessential amino amlodipine feature of aging.
acids because they do not need to be A calcium channel blocker drug that is
obtained from the diet. The other eight, used to prevent angina and to treat amniocentesis
the essential amino acids, cannot be hypertension (high blood pressure). Pos- A diagnostic procedure in which a small
made by the body and must be sible side effects of amlodipine include amount of amniotic fluid is withdrawn,
obtained in the diet. headaches and dizziness. using a syringe guided by ultrasound

36
 AMOXAPINE

scanning, from the amniotic sac (the amnion celled parasite that lives in the human
membrane that surrounds the fetus in
the uterus).
One of the membranes that surrounds
the fetus in the uterus.The outside of the
large intestine. Amoebiasis is spread
through eating food or drinking water
A
WHY IT IS DONE amnion is covered by another mem- contaminated by human excreta con-
The amniotic fluid contains fetal cells, brane called the chorion. taining cysts of the amoeba.
which can be subjected to chromosome Once the cysts are swallowed, the
analysis in order to identify or exclude amniotic fluid cyst walls break down, and the amoe-
chromosomal defects, such as Down’s The clear, watery fluid (popularly called bae hatch out to parasitize the large
syndrome, or genetic analysis to look for the “waters”) that surrounds the fetus intestine. In the intestine, the amoebae
genetic disorders such as haemophilia, in the uterus and is contained within the multiply and develop protective cap-
cystic fibrosis, and Tay–Sachs disease. The amniotic sac (a thin, membranous bag). sules, forming new cysts. These cysts
amniotic fluid also contains chemicals; Amniotic fluid cushions the fetus are passed out of the body in the faeces
and analysis of the fluid can help to against pressure from the mother’s and can survive for long periods before
diagnose or exclude developmental internal organs, allowing movement. the next person acquires them.
abnormalities such as spina bifida. The Amniotic fluid is produced by cells SYMPTOMS
severity of rhesus incompatibility and that line the amniotic sac and is con- Some individuals carry the ENTAMOEBA
the maturity of the fetal lungs can also stantly circulated. The fetus swallows HISTOLYTICA parasite in their intestines
be checked by amniocentesis. the fluid, which is absorbed into the and excrete cysts without having symp-
HOW IT IS DONE fetal bloodstream and then excreted by toms. However, some strains of the
Amniocentesis is usually performed in the kidneys as urine. The fluid is 99 per amoebae invade and ulcerate the intes-
the 14th to 18th week of pregnancy. It cent water. The remainder consists of tinal wall, causing diarrhoea and
may be performed earlier, but this is dilute concentrations of the substances abdominal pain, which may develop
technically more difficult a this early found in blood plasma, along with cells into full-blown dysentery.
stage. The skin of the abdomen is and lipids (fats) from the fetus. The amoebae may spread through
cleaned and a needle is inserted into the Amniotic fluid appears during the the bloodstream to the liver or, rarely, to
amniotic sac; (in all cases, ultrasound first week following conception, and it the brain or lung, where they cause
scanning is used to avoid contact with gradually increases in volume until the abscesses. Symptoms of an amoebic
the fetus and placenta). An attached tenth week, when it increases very liver abscess include weight loss, chills,
syringe removes some fluid for analysis. rapidly. After approximately 35 weeks’ fever, and painful liver enlargement.
COMPLICATIONS gestation, the volume of fluid slowly Liver abscesses may also sometimes
Amniocentesis slightly increases the risk starts to decline. occur in the absence of symptoms.
of miscarriage or early rupture of the In a small number of pregnancies, PREVENTION AND TREATMENT
membranes, and the procedure is there- polyhydramnios (the formation of exces- Travellers to countries where sanitary
fore recommended only when the fetus sive amounts of amniotic fluid) occurs; standards are low can reduce their risk
is thought to be at increased risk of an less frequently, oligohydramnios (the for- of acquiring amoebiasis by drinking
abnormality. (See also antenatal care, mation of insufficient fluid) occurs. only bottled or thoroughly boiled water
chorionic villus sampling.) and by not eating uncooked vegetables
amniotic sac or unpeeled fruit.
Ultrasound transducer The membranous bag that surrounds Treatment of all forms of amoebiasis
the fetus and is filled with amniotic fluid is with drugs such as metronidazole or
Placenta
as pregnancy advances. The sac is made diloxanide. These drugs kill the parasite
Amniotic up of two membranes, the inner amnion within a few weeks, leading to com-
sac
and the outer chorion. plete recovery.
Needle amniotomy amoebic dysentery
Artificial rupture of the amniotic mem- See amoebiasis.
branes. Amniotomy, which is popularly
known as “breaking of the waters”, is amoebicides
performed for induction of labour. A group of drugs that are used to treat
amoebiasis. Examples of amoebicides
amoeba are diloxanide and metronidazole. The
A type of protozoon (see protozoa). An drugs work by killing amoebae (see
amoeba is a microscopic single-celled amoeba) in the intestine and in other
organism with an irregular, changeable body tissues.
shape. Amoebae live in moist environ-
ments such as fresh water and soil. amoxapine
Uterus Some types are parasites of humans, A tricyclic antidepressant drug. Possible
Fetus Amniotic fluid causing diseases such as amoebiasis. adverse effects of amoxapine include a
dry mouth, blurred vision, dizziness,
Procedure for amniocentesis amoebiasis drowsiness, abnormal muscular move-
A needle, guided by ultrasound, is introduced
through the uterine wall into the amniotic sac; An infection caused by the amoeba ments, menstrual irregularities, and
a sample of amniotic fluid is then withdrawn. ENTAMOEBA HISTOLYTICA, a tiny single- enlargement of the breasts.

37
 AMOXICILLIN

amoxicillin ampoule time after amputation, there may also be

A A penicillin drug commonly used to treat
a variety of infections, including cystitis,
A small glass or plastic vessel that can be
hermetically sealed to hold liquid sub-
an unpleasant sensation that the limb is
still present. This phenomenon is
bronchitis, and ear and skin infections. stances, in a sterile condition, for known as “phantom limb”. A prosthesis
Allergy to it causes a blotchy rash and, injection. Each ampoule usually contains will usually be fitted, if necessary, once
rarely, fever, swollen mouth and tongue, a single dose of a drug. the stump has healed and the swelling
itching, and breathing difficulty. has gone down.
ampulla
Amoxil An enlarged, flask-shaped area at the amputation, congenital
A brand name for the antibiotic drug end of a tubular structure or canal. The separation of a body part (usually a
amoxicillin. There are several ampullae in the body, limb, finger, or toe) from the rest of the
including those at the end of each body, as a result of the blood supply to
amoxycillin fallopian tube, on each of the three the part being blocked, in the uterus, by
See amoxicillin. semicircular canals of the inner ear, and a band of amnion (fetal membrane). At
at the opening of the bile duct leading birth, the affected part may be either
amphetamine drugs into the intestine. completely separated, or it may show
COMMON DRUGS the marks of the “amniotic band”. (See
• Dexamfetamine amputation also limb defects.)
The surgical removal of part or all of a
A group of stimulant drugs used mainly limb. Amputation may be needed if the amputation, traumatic
in the treatment of narcolepsy (a rare blood supply to the limb has been per- Loss of a finger, toe, or limb through
disorder that is characterized by exces- manently lost. It may also be necessary injury. (See also microsurgery.)
sive sleepiness). in some instances of cancer. The oper-
HOW THEY WORK ation is now quite rarely performed. amylase
Amphetamine drugs stimulate secretion WHY IT IS DONE An enzyme that is found in saliva and
of neurotransmitters (chemicals released Amputation is necessary if peripheral pancreatic secretions (see pancreas).
by nerve endings), such as noradrenaline vascular disease, as a result of atheroscler- Amylase helps the body to digest
(norepinephrine), which increase nerve osis or diabetes mellitus, has destroyed the dietary starch, breaking it down into
activity in the brain and make a person blood supply to a limb. If the blood smaller components, such as the sugars
wakeful and alert. supply cannot be restored, amputation glucose and maltose.
SIDE EFFECTS is carried out to prevent the develop-
In high doses, amphetamines can cause ment of gangrene (tissue death). Amsler chart
tremor, sweating, anxiety, and sleeping Amputation may also occasionally be A diagnostic tool used by ophthalm-
problems. Delusions, hallucinations, high performed to prevent the spread of a ologists to detect changes in the retina,
blood pressure), and seizures may also bone cancer or malignant melanoma particularly those changes that indicate
occur. Prolonged use may produce toler- (see melanoma, malignant), a type of macular degeneration. A typical Amsler
ance and drug dependence. skin cancer. If a limb has been irrepara- chart consists of a grid of black lines on
ABUSE bly damaged in an accident, a decision a white background. In an individual
Amphetamines are often abused for may also be taken to amputate. with retinal changes, the lines may
their stimulant effect and, for this rea- HOW IT IS DONE appear distorted.
son, they are controlled drugs. During the operation, skin and muscle
are cut below the level at which the amyl nitrite
amphotericin bone is to be severed to create flaps that A nitrate drug that was once prescribed
An antifungal drug used to treat can- will later provide a fleshy stump. The to relieve angina pectoris (chest pain as a
didiasis of the mouth or intestine. The blood vessels are tied off, the bone is result of impaired blood supply to the
drug is taken as tablets but is also given sawn through, the area is washed with heart muscle). Because it frequently
by intravenous infusion to treat life- saline (salt solution), and the flaps of causes adverse effects, the drug has now
threatening systemic (generalized) fungal skin and muscle are stitched over the been superseded by other drugs such as
infections such as cryptococcosis and sawn end of bone to form a smooth and glyceryl trinitrate and isosorbide. Amyl
histoplasmosis. rounded stump. nitrite is sometimes abused for its effect
Side effects, which include vomiting, If a prosthesis (see limb, artificial) is to of intensifying pleasure during orgasm.
fever, headache, and, rarely, seizures, be fitted, the surgeon tries to ensure
may occur with intravenous infusion. that nerves are severed well above the amyloidosis
stump in order to reduce the risk of An uncommon disease in which a sub-
ampicillin pressure pain. In an amputation at the stance called amyloid, composed of
A penicillin drug commonly used to treat ankle (Syme’s amputation), the tough fibrous protein, accumulates in tissues
cystitis, bronchitis, and ear infections. skin of the heel pad is retained to cover and organs, including the liver, kidneys,
Diarrhoea is a common adverse effect. the stump, reducing the need for a tongue, spleen, and heart.
Some people are allergic to ampicillin prosthetic foot. CAUSES
and suffer from rash, fever, swelling of RECOVERY AND OUTLOOK Amyloidosis may occur for no known
the mouth and tongue, itching, and The stump is usually swollen for about reason, in which case it is known as
breathing difficulty. six weeks after the operation. For some primary amyloidosis; more commonly,

38
 ANAEMIA

it is a complication of some other dis- anaemia classified into those due to decreased or
ease, and in such cases it is called
secondary. Conditions that may lead to
A condition in which the concentration
of the oxygen-carrying pigment haemo-
defective red blood cell production by
bone marrow (see anaemia, aplastic;
A
amyloidosis include multiple myeloma (a globin in the blood is below normal. anaemia, megaloblastic; anaemia, iron-
cancer of bone marrow), rheumatoid Haemoglobin molecules are carried deficiency) and those due to decreased
arthritis, familial Mediterranean fever, inside red blood cells and transport survival of the red cells in the blood
tuberculosis, and other longstanding oxygen from the lungs to the tissues. (see anaemia, haemolytic). The illustrated
infections such as chronic osteomyelitis Normally, stable haemoglobin concen- box shows the main types of anaemia.
(bone infection). Amyloid is also trations in the blood are maintained by SYMPTOMS
deposited in the brain in Alzheimer’s dis- a balance between red-cell production The symptoms common to all forms of
ease. Small deposits of amyloid are a in the bone marrow and red-cell des- anaemia result from the reduced oxy-
normal feature of aging. truction in the spleen. Anaemia may gen-carrying capacity of the blood, and
SYMPTOMS AND SIGNS result if this balance is upset. the severity of symptoms depends on
The symptoms of amyloidosis vary, TYPES AND CAUSES how low the haemoglobin concentra-
depending on the organs affected and Anaemia is not a disease in itself but a tion has become. Slightly reduced levels
the duration of the condition. Affected feature of many different disorders. can cause tiredness, and lethargy. Sev-
organs typically become enlarged. An There are various types, which can be erely reduced levels can cause breathing
accumulation of amyloid in the heart
may result in arrhythmias (disturbances
of the heart rate or rhythm) and heart TYPES AND CAUSES OF ANAEMIA
failure (reduced pumping efficiency of
Anaemia results either from reduced or defective production or an excessively
the heart). If the stomach and intestines high rate of destruction of oxygen-carrying red blood cells. Four of the main
are affected, symptoms such as diar- types are shown below, but anaemia can have many other causes (such as
rhoea may develop, and the lining of various forms of leukaemia).
these organs may become ulcerated.
Primary amyloidosis is often charac- Stem
terized by deposits of amyloid in the cell Red-cell production
skin, which appear as slightly raised, Red cells are produced in bone
marrow from stem cells, which
waxy spots. Deposits of amyloid in divide to form erythroblasts. The
the kidneys may cause kidney failure, latter divide to form red blood cells.
which can be fatal.
TREATMENT
There is no treatment for the removal of Bone Erythroblasts
amyloid deposits. However, it is possible
to halt the progression of secondary Bone marrow
amyloidosis by treatment of the under-
lying disorder. Healthy
blood cell
amyotrophic lateral sclerosis
See motor neuron disease. Aplastic anaemia
Failed formation and division
amyotrophy of stem cells in the marrow
causes a drop in the number of
Shrinkage or wasting away of a muscle, red and other blood cells.
caused by a reduction in the size of its
fibres, leading to weakness. Amyotrophy
is usually the result of poor nutrition,
reduced use of the muscle (as occurs
when a limb is immobilized for a long
period), or disruption of the blood or
nerve supply to the muscle (as can
occur in poliomyelitis or diabetes mel-
litus). (See also atrophy.)

anabolic steroids
See steroids, anabolic. Iron-deficiency anaemia Haemolytic anaemia Megaloblastic anaemia
Lack of iron prevents the This type includes all A deficient supply of
anabolism bone marrow from making
sufficient haemoglobin for
anaemias in which the rate
of red-cell production is
certain vitamins causes
the bone marrow to produce
The manufacture of complex molecules the red cells. The cells normal or high but in red cells that are larger
such as fats and proteins from simpler produced are small and pale which the cells are than normal; they also
molecules by metabolic (chemical and and have a reduced oxygen- destroyed at a much faster have a reduced oxygen-
carrying capacity. rate than normal. carrying capacity.
physical) processes in living cells. (See
also catabolism; metabolism.)

39
 ANAEMIA, APLASTIC

difficulty on exercise, dizziness as a DIAGNOSIS AND TREATMENT haemoglobin in the cell (as in sickle-cell
A result of reduced oxygen reaching the
brain, angina pectoris (chest pain due to
Aplastic anaemia is usually suspected
from the results of a blood test, particu-
anaemia), or a defect of one of the cell’s
enzymes. An inherited deficiency of the
impaired oxygen supply to the heart larly a blood count, and is confirmed by glucose-6-phosphate dehydrogenase en-
muscle), and palpitations as the heart a bone marrow biopsy (the removal of a zyme (see G6PD deficiency) may result in
works harder to compensate. General small sample of bone marrow for episodes of haemolytic anaemia since
symptoms include pallor, particularly of microscopic analysis). the red cells are prone to damage by
the skin creases, the lining of the Blood and platelet transfusions can infectious illness or certain drugs or
mouth, and the inside of the eyelids. control symptoms. Immunosuppression foods. One variety of G6PD deficiency
Other features may occur with partic- (therapy to suppress the immune sys- is most common in Mediterranean
ular forms of anaemia. For example, tem) is used to treat aplastic anaemia countries (see favism).
some degree of jaundice occurs in most due to an autoimmune process. Severe Haemolytic anaemias due to defects
types of haemolytic anaemia because persistent aplastic anaemia may be fatal outside the red cells fall into three main
the high rate of destruction of red without a bone marrow transplant . groups. First are disorders in which red
blood cells leads to an increased level of cells are destroyed by buffeting (by arti-
the yellow pigment bilirubin (produced anaemia, deficiency ficial surfaces such as replacement heart
by the breakdown of the haemoglobin Forms of anaemia (a reduced level of valves, abnormal blood-vessel linings,
in red cells) in the blood. the oxygen-carrying pigment haemoglo- or a blood clot in a vessel, for example).
DIAGNOSIS bin in the blood) caused by lack of one In the second group, the red cells are
Anaemia is diagnosed from the patient’s or more substance that are essential for destroyed by the immune system. Im-
symptoms and by blood tests (see blood normal haemoglobin synthesis and mune haemolytic anaemias may occur
count). A bone marrow biopsy (removal of maintenance. Deficiency anaemia may if foreign blood cells enter the blood-
a small sample of bone marrow for arise by various means, such as by mal- stream, as occurs in an incompatible
analysis) may be required to determine absorption or insufficient dietary intake blood transfusion, or they may be due
whether or not red blood cell produc- of a particular nutrient. Iron-deficiency to an autoimmune disorder (in which the
tion is defective. anaemia and megaloblastic anaemia are immune system attacks the body’s own
examples of deficiency anaemias. tissues). In haemolytic disease of the new-
anaemia, aplastic born, the baby’s red cells are destroyed
A rare but serious type of anaemia (a anaemia, haemolytic by antibodies, produced by the mother,
reduced level of the oxygen-carrying A form of anaemia (a reduced level of crossing the placenta. Thirdly, the red
pigment haemoglobin in the blood). In the oxygen-carrying pigment haemoglo- cells may be destroyed by microorgan-
aplastic anaemia, the red cells, white bin in the blood) caused by premature isms in the blood; the most common
cells, and platelets in the blood are all destruction of red blood cells in the cause is malaria.
reduced in number. The condition is bloodstream (see haemolysis). The bone SYMPTOMS
caused by a failure of the bone marrow to marrow has the capacity to increase its People with haemolytic anaemia may
produce stem cells, the initial form of red cell production approximately six- have symptoms common to all types of
all blood cells. fold over normal rates. Haemolytic anaemia, such as fatigue and breathless-
CAUSES anaemia will result only if the shorten- ness, or symptoms that are specifically
Treatment of cancer with radiotherapy or ing of the lifespan of red blood cells is due to haemolysis, such as jaundice
anticancer drugs can temporarily inter- sufficiently severe to overcome the (caused by an excessive concentration
fere with the cell-producing ability of reserve capacity of the bone marrow. in the blood of bile pigments formed
bone marrow, as can certain viral infec- TYPES AND CAUSES from the destruction of red blood cells).
tions and other drugs. Long-term Haemolytic anaemias can be classified DIAGNOSIS AND TREATMENT
exposure to insecticides or benzene in two ways: if the cause of the haem- Diagnosis is confirmed by microscopic
fumes may cause more persistent aplas- olysis is an abnormality of the red cells examination of the blood (see blood
tic anaemia; and another recognized themselves, the condition is usually film). Treatment depends on the cause.
cause is a moderate to high dose of inherited; if the cause of the haemolysis Some inherited anaemias can be con-
nuclear radiation. An autoimmune disorder is outside the cells, the condition is usu- trolled by removing the spleen (see
(in which the immune system attacks ally acquired later in life. splenectomy). Others, such as G6PD
the body’ own tissues) is responsible in When haemolysis is due to a defect deficiency and favism, can be prevented
some cases. Aplastic anaemia sometimes within the red cells, the underlying by avoiding the drugs or foods that pre-
develops for no known reason. problem may be abnormal rigidity of cipitate haemolysis. Anaemias due to
SYMPTOMS the cell membrane (the thin layer of tis- immune processes can often be con-
A low level of red blood cells may cause sue surrounding each cell). This causes trolled by immunosuppressant drugs.
symptoms, such as fatigue and breath- the cells to become trapped, at an early Transfusions of red cells are sometimes
lessness, that are common to all types of stage of their life-span, in the small needed for emergency treatment of life-
anaemia. Deficiency of white cells blood vessels of the spleen, where they threatening anaemia.
increases susceptibility to infection, are destroyed by macrophages (cells
resulting in frequent or severe infec- that ingest foreign particles). Abnormal anaemia, iron-deficiency
tions; platelet deficiency may lead to a rigidity may result from an inherited The most common form of anaemia (a
tendency to bruise easily, bleeding defect of the cell membrane (as in reduced level of the oxygen-carrying
gums, and nosebleeds. hereditary spherocytosis), a defect of the pigment haemoglobin in the blood).

40
 ANAESTHESIA

Iron-deficiency anaemia is caused by a experience tiredness, a sore mouth and

deficiency of iron, an essential cons-
tituent of haemoglobin.
tongue, weight loss, and mild jaundice.
If B12 deficiency continues for a long
A
CAUSES time, additional symptoms as a result of
The commonest cause of iron-defici- nerve damage, including numbness and
ency anaemia is iron loss due to heavy tingling in the feet, may develop.
or persistent bleeding; the most com- DIAGNOSIS AND TREATMENT
mon cause in women of childbearing Megaloblastic anaemia is diagnosed by
age is particularly heavy periods (see blood tests and confirmed if a bone
menorrhagia). Pregnancy stops menstru- marrow biopsy (removal of a small sam-
al losses, but the baby is an even greater ple of marrow for microscopic analysis)
drain on maternal iron stores. Other reveals the presence of large numbers of
causes include blood loss from the megaloblasts.
digestive tract due to disorders such as Megaloblastic anaemia caused by
erosive gastritis, peptic ulcer, stomach Bone marrow in megaloblastic anaemia
poor diet can be remedied with a short
cancer, inflammatory bowel disease, haem- In this microscopic view, some of the large cells are course of vitamin B12 injections or folic
orrhoids, and bowel tumours (see colon, abnormal red-cell precursors (megaloblasts). acid tablets and the introduction of a
cancer of). Prolonged use of aspirin and normal diet. A lifelong course of vita-
other nonsteroidal anti-inflammatory drugs excess of cells known as megaloblasts min B12 injections or folic acid tablets is
(NSAIDs) can cause gastrointestinal (abnormal immature red cells) appears required if the underlying cause of mal-
bleeding. In some countries, hookworm in the marrow. Megaloblasts give rise to absorption is incurable.
infestation of the digestive tract is an enlarged and deformed red blood cells
important cause of anaemia. Rarely, known as macrocytes. anaemia, pernicious
bleeding may also occur as a result of CAUSES See pernicious anaemia.
disorders of the urinary tract (such as Vitamin B12 deficiency Vitamin B12 is
kidney tumours or bladder tumours). found only in foods of animal origin, anaemia, sickle cell
Iron deficiency may also be caused or such as meat and dairy products. It is See sickle cell anaemia.
worsened by lack of iron in, or its poor absorbed from the small intestine by
absorption from, the diet. Malabsorption first combining with intrinsic factor, a anaerobic
of iron may have various causes, includ- chemical produced by the stomach Capable of living, functioning, and
ing the removal of part or all of the lining. The most common cause of vita- growing without oxygen. Many bacteria
stomach (see gastrectomy) or coeliac dis- min B12 deficiency is pernicious anaemia are anaerobes and thrive in the intesti-
ease (a disorder that impairs digestion). in which the stomach lining fails to pro- nal canal or in tissue that has a poor
SYMPTOMS duce intrinsic factor, usually as a result supply of oxygenated blood.
The symptoms of iron-deficiency anae- of an autoimmune disorder (in which the Some human body cells are capable
mia are those of the underlying cause, immune system attacks the body’s own of limited anaerobic activity. When
along with a sore mouth or tongue; and tissues). Total gastrectomy (removal of muscular exertion is so strenuous that
those that are common to all forms of the stomach) also prevents the produc- oxygen is used faster than the blood
anaemia, such as fatigue, headaches, tion of intrinsic factor, and removal of circulation can supply it (during sprint-
and breathlessness. part of the small intestine prevents B12 ing, for example), the muscle cells can
DIAGNOSIS AND TREATMENT absorption, as does the intestinal dis- temporarily work anaerobically. When
Diagnosis is made from a blood count order Crohn’s disease. In a minority of this happens, lactic acid is produced as a
that reveals the red blood cells to be cases, vitamin B12 deficiency is due to a waste product (instead of the carbon
microcytic (abnormally small). Meas- vegan diet (which excludes all foods of dioxide that is produced from aerobic
urement of the iron levels in the blood animal origin). activity). This acid buildup can cause
confirms the diagnosis but further Folic acid deficiency Folic acid is found muscle fatigue and pain, thereby limit-
investigation will be needed to establish mainly in green vegetables and liver.The ing the time for which anaerobic
the underlying cause. Treatment is given usual cause of deficiency is a poor diet. activity can be carried out. Compensa-
for the underlying cause, along with a It can also be caused by anything that tion for this anaerobic activity requires
course of iron tablets or, very rarely, interferes with absorption of folic acid oxygen to convert the lactic acid to
iron injections in order to build up the from the small intestine (Crohn’s glucose or to carbon dioxide, which
depleted iron stores. disease or coeliac disease, for example). explains the need to continue to breathe
Folic acid is required by rapidly dividing rapidly following vigorous exertion. The
anaemia, megaloblastic cells, as in the fetus. Women are advised deficit of oxygen that builds up in the
A major type of anaemia (a reduced to take folic acid supplements before muscles during exercise is known as the
level of the oxygen-carrying pigment conception and in early pregnancy, oxygen debt.
haemoglobin in the blood). Megalo- although this is to reduce the risk of the
blastic anaemia is caused by deficiency fetus having a neural tube defect rather anaesthesia
of vitamin B12 or another vitamin, folic than to prevent anaemia. The absence of all sensation; insensib-
acid. Either of these deficiencies seri- SYMPTOMS ility. The term most commonly refers to
ously interferes with the production of Many people with mild megaloblastic anaesthesia that is induced artificially
red blood cells in the bone marrow. An anaemia have no symptoms. Others may for medical purposes.

41
 ANAESTHESIA, DENTAL

Two types of anaesthesia may be used: tube passed into the trachea through the are often used for children. The throat,
A local (see anaesthesia, local) and general
(see anaesthesia, general). A patient given
nose or mouth). During the anaesthetic,
blood pressure, pulse, oxygen saturation
larynx (voice-box), and respiratory pas-
sages can be sprayed with an anaesthetic
a local anaesthetic remains conscious, (see oximeter), and other vital signs are before bronchoscopy (examination of the
and sensation is abolished in only a spe- monitored continuously. The principal bronchi, the main airways of the lungs,
cific part of the body. A patient under stages in administering, maintaining, using a rigid or flexible viewing tube)
general anaesthesia is rendered uncon- and reversing general anaesthesia are and the urethra can be numbed with a
scious and maintained in this state with shown in the illustrated box. gel before cystoscopy (examination of the
a combination of drugs that are either POSSIBLE COMPLICATIONS urethra and bladder using a rigid or flex-
injected into a vein or inhaled. General anaesthetics have become much ible viewing tube).
Damage to nerve tissues by injury or safer and serious complications are now For minor surgical procedures, such
disease can produce anaesthesia in a rare. However, the presence of severe as stitching of small wounds, local
localized area. pre-existing diseases, such as lung or anaesthesia is usually produced by dir-
heart disorders, increase the risks of the ect injection into the area to be treated.
anaesthesia, dental procedure. Minor after-effects, such as To anaesthetize a large area, or when a
Loss of sensation induced in a patient to nausea and vomiting, are usually con- local injection would not penetrate
prevent pain during dental treatment. trolled effectively with antiemetic drugs. deeply enough into body tissues, a nerve
Topical anaesthetics (usually using the block (in which the local anaesthetic is
drug lidocaine (lignocaine) as a cream anaesthesia, local injected around nerves at a point remote
or spray) are often used on the surface Loss of sensation induced in a limited from the area to be treated) may be used.
of the gums before injection of a local region of the body to prevent pain dur- Nerve impulses can also be blocked
anaesthetic (see anaesthesia, local). ing diagnostic or treatment procedures, where they branch off from the spinal
For minor procedures, a local anaes- examinations, and surgery. Local anaes- cord, as in epidural anaesthesia, which is
thetic is injected either into the gum at thesia is produced by administration of used in childbirth or caudal block, and
the site being treated or around the drugs that temporarily interrupt the spinal anaesthesia, which is used for sur-
nerve a short distance away (a procedure action of pain-carrying nerve fibres. gery on the lower limbs and abdomen.
known as a peripheral nerve block). For HOW IT IS DONE POSSIBLE COMPLICATIONS
more complicated procedures, such as Local anaesthetics may be applied topi- Serious reactions are uncommon, but
periodontal (gum) surgery and multiple cally, before injections or blood tests, as repeated use of topical preparations
tooth extractions, general anaesthesia sprays, skin creams, and ointments.These may cause local allergic rashes.
(see anaesthesia, general) is carried out.
anaesthesia, epidural LOCAL ANAESTHETICS
See epidural anaesthesia. Drug Common uses How taken
anaesthesia, general tetracaine (amethocaine) Prior to taking a blood sample Gel
Loss of sensation and consciousness that or inserting a cannula
is induced to prevent the perception of
pain throughout the body during sur- To treat painful conditions of
benzocaine Lozenges,
gery. General anaesthesia is also used to the mouth and throat, painful suppositories, spray,
abolish muscle tone and cardiovascular anal conditions (e.g. cream, ointment
reflexes in the patient. haemorrhoids), skin wounds
The state of general anaesthesia is
produced and maintained by an anaes- bupivacaine As nerve block (e.g.epidural Injection
thetist, who gives combinations of anaesthesia and caudal block)
drugs by injection, inhalation, or both.
The anaesthetist is also responsible for cocaine For surgery on the nose, Spray, liquid
the pre-anaesthetic assessment and throat and larynx
medication of patients, their safety dur-
ing surgery, and their recovery during lidocaine (lignocaine) For relief of pain during Injection, gel, spray,
the post-anaesthetic period. dental treatment; for spinal cream, ointment,
anaesthesia, nerve blocks liquid, eye-drops,
HOW IT IS DONE
(e.g. epidural anaesthesia), suppositories
General anaesthesia is usually induced eye surgery, and before
by intravenous injection of a barbiturate taking blood samples in
drug, usually via a cannula (a blunt- children; for urethra prior to
ended tube), which is left in place in catheterization and larynx
prior to laryngoscopy
case further drugs need to be given.
Anaesthesia is maintained by the inhala-
tion of anaesthetic gases such as prilocaine As nerve block (e.g. Injection
epidural anaesthesia
enflurane or halothane, which may be and caudal block)
introduced into the lungs via a face
mask or an endotracheal tube (a flexible

42
 ANAESTHESIA, LOCAL

TECHNIQUES FOR GENERAL ANAESTHESIA

A
The main phases in the administration
DRUGS USED IN GENERAL ANAESTHESIA
of a general anaesthetic are induction
(bringing about unconsciousness), Type Action Examples
maintenance (of unconsciousness),
and emergence (returning the patient
Drugs given as Relax patient, relieve Atropine, diazepam, hyoscine,
to consciousness). Some of the main premedication anxiety; some reduce saliva lorazepam, temazepam
stages are shown below. Often, to and mucus formation
allow surgical manipulation, a muscle
relaxant must be given in addition to
anaesthetic gases or injections. Induction agents Induce unconsciousness Etomidate, ketamine, propofol,
thiopental sodium
Because the relaxant temporarily
paralyses the breathing muscles, the
patient’s lungs must be ventilated Anaesthetic gases Induce and/or maintain Enflurane, halothane,
artificially. Modern general and volatile agents unconsciousness isoflurane, nitrous oxide
anaesthetics have few side effects,
and recovery is usually prompt. Analgesics Abolish pain Fentanyl, ketoprofen, morphine

Muscle relaxants Relax (paralyse) muscles Pancuronium, vecuronium

Before the
1anaesthetist
operation, the
talks Reversal agents Reverse muscle relaxation Neostigmine
to and examines
the patient to
assess his or In other cases, an endotracheal tube is inserted
her fitness for
anaesthesia and
4relaxant
for delivery of the anaesthetic gases. If a muscle
is used, artificial ventilation is necessary.
surgery. He or she
also answers any
questions the Laryngoscope
patient may have.
Tongue

Trachea

Cuff on
endotracheal tube

Anaesthetic
Monitor machine

Endotracheal tube Anaesthetist

ECG leads connected

to monitor
The induction agent is usually given
2cannula
via a cannula inserted into a vein. The
is left in position so that other
drugs can be given rapidly if needed.

breathing, blood pressure, temperature, blood

3If noSometimes, anaesthesia is induced or
maintained with gases delivered by mask.
muscle relaxant is used, the patient may
5 During surgery, the patient is kept at a level of
anaesthesia deep enough for him or her to be
unaware of the operation. The composition of the
oxygenation, and exhaled carbon dioxide are
monitored. After surgery, anaesthesia is stopped,
be able to continue breathing naturally. gas mixture, and the patient’s heart rate, and reversal agents are given if necessary.

43
 ANAESTHESIA, SPINAL

anaesthesia, spinal The tear often heals naturally over a few weak opioid (such as codeine) with a
A See spinal anaesthesia. days, although spasm of the anal mus-
cles may delay healing. Treatment of
nonopioid analgesic (such as aspirin)
relieve more severe pain. Potent opioids
anaesthetics recurrent or persistent fissures is usually such as morphine can produce tolerance
A term for the group of drugs that pro- by anal dilatation (a procedure to and drug dependence and are used only
duce anaesthesia and for the medical enlarge the anus) and a high-fibre diet, when other preparations are ineffective.
discipline that is concerned with their including whole-grain products, fruit HOW THEY WORK
administration. and vegetables, and plenty of fluids, to When body tissues are damaged, they
An anaesthetist is a specialist who help soften the faeces. Surgery to remove produce prostaglandins (chemicals that
administers anaesthetics. Before a patient the fissure is occasionally necessary. trigger the transmission of pain signals
goes to the operating theatre, the anaes- to the brain). Except for paracetamol,
thetist assesses the condition of the anal fistula nonopioid analgesics work by preven-
patient’s heart, lungs, and circulation. An abnormal channel connecting the ting the production of prostaglandin;
He or she decides the type and amount inside of the anal canal with the skin paracetamol works by blocking the
of drugs needed to induce and maintain surrounding the anus. pain impulses within the brain itself,
anaesthesia, determines the patient’s An anal fistula may be an indication preventing the perception of pain. Opi-
position on the operating table, watches of Crohn’s disease, colitis, or cancer of oid analgesics act in a similar way to
for problems, and decides on the action the colon or rectum (see colon, cancer of; endorphins (pain-relieving substances
to be taken if an emergency develops. rectum, cancer of). In most cases, it is the formed by the body) by blocking pain
The anaesthetist is also responsible for result of an abscess that develops for impulses at specific sites in the brain
monitoring the progress of the waking unknown reasons in the anal wall. The and spinal cord.
patient, and watching for and treating abscess discharges pus into the anus and SIDE EFFECTS
any post-anaesthetic complications. out on to the surrounding skin. Side effects are uncommon with para-
An anal fistula is treated surgically cetamol; aspirin and most NSAIDs may
anal dilatation by opening the abnormal channel and irritate the stomach lining and cause
A procedure in which the anus is removing the lining. The operation is nausea, abdominal pain, and, rarely, a
stretched. Anal dilatation is used to performed under a general anaesthetic peptic ulcer. Nausea, drowsiness, consti-
treat conditions in which the anus be- (see anaesthesia, general). The wound is pation, and breathing difficulties may
comes too tight, such as anal stenosis then left to heal naturally. occur with opioid analgesics. The
and anal fissure. It is also used to treat euphoric effect produced by some opi-
haemorrhoids. Anal dilatation is usually analgesia oid analgesics have led to their abuse.
performed under general anaesthesia The loss of or reduction in pain sensa- WARNING
(see anaesthesia, general). tion. Analgesia differs from anaesthesia Over-the-counter (nonopioid) analgesic
Reflex anal dilatation, in which the (loss of all sensation) in that sensitivity drugs should not be taken for longer
anus dilates in response to local contact, to touch is still preserved. Analgesia can than 48 hours, after which time medi-
may occur in certain anal disorders or be induced by the use of analgesic drugs. cal advice should be sought. If pain
after repeated anal penetration. persists, becomes more severe, recurs,
analgesic drugs or differs from pain previously experi-
anal discharge COMMON DRUGS enced, a doctor should be consulted.
The loss of mucus, pus, or blood from OPIOIDS • Co-codamol • Co-codaprin • Codeine For precautions on specific drugs, see
the anus. Haemorrhoids, anal fissures • Co-dydramol • Co-proxamol • Diamorphine the individual drug entries.
(tears), and proctitis (inflammation of • Dipipanone • Fentanyl • Meptazinol
the rectum) can all cause anal discharge. • Methadone • Morphine • Pentazocine anal phase
• Pethidine • Phenazocine • Tramadol A term used in psychoanalytic theory to
analeptic drugs NSAIDS • Aspirin • Celecoxib • Diclofenac refer to a stage of a person’s psycho-
Drugs that stimulate breathing. Replaced • Diflunisal • Etodolac • Fenbufen sexual development. The anal phase
by ventilation, analeptic drugs are now • Fenoprofen • Flurbiprofen • Ibuprofen begins at around 18 months of age and
seldom used. • Indomethacin • Ketoprofen • Ketorolac lasts for up to two years. (See also geni-
• Mefenamic acid • Naproxen • Piroxicam tal phase; oral phase.)
anal fissure • Rofecoxib
A common disorder of the anus that is OTHER NONOPIOIDS • Nefopam • Paracetamol anal stenosis
caused by an elongated ulcer or tear Tightness of the anus, sometimes known
that extends upwards into the anal canal Drugs used to relieve pain. The two as anal stricture. Anal stenosis prevents
from the anal sphincter (the ring of main types are nonopioid and opioid normal passage of faeces, causing consti-
muscle that surrounds the anal orifice). analgesics. Nonopioid analgesics are use- pation and pain during defaecation.
An anal fissure may be caused by the ful for treating mild to moderate pain. Anal stenosis may be present from
passage of hard, dry faeces. They include paracetamol for headache; birth or may be caused by a number of
There is usually pain during defae- or toothache and nonsteroidal anti- conditions in which scarring has occur-
cation, and the muscles of the anus may inflammatory drugs (NSAIDs) such as red, such as anal fissure, colitis, or cancer
go into spasm. There may also be a aspirin and ibuprofen, which can help to of the anus. The condition sometimes
small amount of bright red blood on relieve mild pain and stiffness in occurs after surgery on the anus (for
faeces or toilet paper. arthritic conditions. Combinations of a example, to treat haemorrhoids).

44
 ANATOMY

Anal stenosis is treated by anal dilatation anaphylactic shock antihistamine drugs and corticosteroid
(a procedure that expands or enlarges
the anus).
A rare, life-threatening allergic reaction.
Anaphylactic shock is a Type I hypersen-
drugs may also be
hyposensitization.)
given. (See also A
sitivity reaction (see allergy) that occurs
anal stricture in people with extreme sensitivity to a anastomosis
See anal stenosis. particular substance (an allergen), most A natural or artificial communication
commonly insect venom or certain between two blood vessels or between
anal tag foods or drugs. tubular cavities that may or may not
A type of skin tag. When the allergen enters the blood- normally be joined.
stream, massive amounts of histamine Natural anastomoses usually occur
analysis, chemical and other chemicals are released, caus- when small arteries are attached directly
Determination of the identity of a sub- ing sudden, severe lowering of blood to veins without passing through capil-
stance or of the individual chemical pressure and constriction of the air- laries. Anastomoses occur in the skin
constituents of a mixture. Analysis may ways. Other symptoms of anaphylactic where they are used to help control
be qualitative (as in determining shock may include abdominal pain, temperature regulation.
whether or not a particular substance is diarrhoea, swelling of the tongue and A surgical anastomosis is used to cre-
present), or it may be quantitative (that throat, and an itchy rash. ate a bypass around a blockage in an
is, measuring the amount or concen- Anaphylactic shock requires emer- artery or in the intestine. They are also
tration of one or more constituents). gency medical treatment. An injection used to rejoin cut ends of the bowel or
(See also assay.) of adrenaline (epinephrine) may be life- blood vessels. (See also bypass surgery.)
saving. If the person’s breathing or
analysis, psychological heartbeat has stopped, cardiopulmonary anastrozole
See psychoanalysis. resuscitation should be performed, and An anticancer drug that is used to treat
advanced breast cancer in postmeno-
pausal women.
HOW ANALGESICS WORK
anatomical snuffbox
When tissue is damaged (for example, Pain signal
A depression on the back of the wrist
by injury, inflammation, or infection) to brain
that is formed between the tendons of
the body produces prostaglandins. Nerve ending
These substances combine with the thumb when the thumb is stretched
receptors (specific sites on the surface outwards. The anatomical snuffbox is of
Prostaglandin significance because tenderness in this
of cells in the brain and spinal cord). molecule
As a result, a signal is passed along area is a feature of a fracture of the
a series of nerve cells to the brain, Damaged cell scaphoid bone.
where the signal is interpreted as
pain by brain cells. Analgesics Action of opioids
anatomy
(except for paracetamol) work either When tissue damage occurs, the body produces The structure of the body of any living
by preventing the production of prostaglandins, chemicals that trigger the thing, and its scientific study. Human
prostaglandins at the site of damage transmission of pain signals (above). Normally, anatomy, together with physiology (the
or by blocking pain impulses in the the pain signal is transmitted between brain
cells, but opioid drugs (below) combine with study of the functioning of the body),
brain and spinal cord. Paracetamol
opiate receptors to prevent the signals from dates back to ancient Egyptian times
works by blocking prostaglandin
production in the brain, which
being transmitted. and forms the foundation of all medical
prevents pain impulses from science. The dissection of human
being transmitted in the brain. corpses has provided the primary
Brain cell
source of information for anatomists.
Receptor Anatomy as a scientific study today is
Opioid drug
subdivided into many branches. These
Nerve ending
include comparative anatomy (the study
Pain signal
blocked
of the differences between human and
Nonopioid animal bodies), surgical anatomy (the
drug practical knowledge required by sur-
Prostaglandin
geons), embryology (the study of
molecule structural changes that occur during the
development of the embryo and fetus),
Damaged cell
systematic anatomy (the study of the
Action of NSAIDs structure of particular body systems),
Nonopioid drugs block the production
of prostaglandins (chemicals released in
and cytology and histology (the micro-
response to tissue damage). This action scopic study of cells and tissues
prevents stimulation of the nerve endings, respectively).
so that no pain signal passes on to the brain. Pain signals in Every anatomical structure is scientif-
As a result, these drugs provide pain relief. brain blocked ically named in Latin, but today
anatomists prefer to use simpler terms,

45
 ANCYLOSTOMIASIS

DESCRIPTIVE TERMS IN ANATOMY

A
The relative positions and Lateral rotation Sample coronal plane
movements of body parts are Medial
conventionally described with rotation
Examples of
reference to the “anatomical transverse, or
position” (that is, an upright horizontal,
posture with the eyes and palms planes
facing forwards). In this position,
the parts of the body can be
described in relation to various Adduction
geometrical planes.
In radiology, body imaging Abduction Pronation
pictures (such as CT scans and
MRI) are often taken in a series of Supination
transverse planes through part of
Median, or
the body. sagittal, plane

Flexion
Planes through the body
Extension Medial rotation The median plane divides the body into right
Joint movements and left halves. Coronal planes are vertical
Lateral rotation planes at right angles to the median plane;
Extension is straightening, and flexion is
bending; abduction is moving away from, Adduction the coronal plane most often referred to
Eversion
adduction is moving towards, the midline Abduction divides the body into front and back halves.
of the body. Other movements are forms of Inversion Transverse planes are horizontal slices
rotation around an axis. through the body.

where they exist, as alternatives. For When taken by women, the drugs can tion of sebum, which, if excessive,
example, the main blood vessel in the lead to the development of male charac- causes acne. In early adult life, andro-
femur (thigh) is usually referred to as teristics, such as facial hair. gens promote male-pattern baldness.
the femoral artery rather than the arte- DEFICIENCY
ria femoralis. For further information androgen hormones Androgen deficiency may occur if the
on the descriptive terms used in ana- A group of hormones (the male sex testes are diseased or the pituitary gland
tomy, see the illustrated box. hormones) that stimulate virilization fails to secrete gonadotrophins. Typical
(the development of male secondary effects include high-pitched voice,
ancylostomiasis sexual characteristics such as growth of decreased body and facial hair, under-
Infestation of the small intestine by the facial hair, deepening of the voice, and developed genitalia, reduced sexual
ANCYLOSTOMA hookworm species. (See increased muscle bulk). drive, and poor muscle development.
also hookworm infestation.) FORMATION EXCESS
Androgens are produced by specialized Overproduction of androgens may be
androblastoma cells in the testes in males and the adre- the result of adrenal disorders such as
See arrhenoblastoma. nal glands in both sexes. The ovaries adrenal tumours, congenital adrenal
secrete very small quantities of androgens hyperplasia (see adrenal hyperplasia, con-
androgen drugs until the menopause. The most active genital), testicular tumours (see testis,
Natural or synthetic androgen hormones androgen is testosterone (produced in cancer of), or, rarely, androgen-secreting
(male sex hormones) that are used as the testes). Androgen production by the ovarian tumours (see ovary, cancer of).
drugs, of which one of the most impor- testes is controlled by certain pituitary In men, excess androgens accentuate
tant is testosterone. Androgen drugs are hormones called gonadotrophins. Adrenal male physical characteristics; in boys,
used in the treatment of male hypo- androgens are controlled by ACTH, they cause premature sexual develop-
gonadism (underactivity of the testes) another pituitary hormone. ment. In women, excess androgens
to stimulate the development of male EFFECTS cause virilization, features of which
sexual characteristics. Androgens stimulate the appearance, at include increased body hair, deepening
Androgen drugs are occasionally puberty, of male secondary sexual char- of the voice, enlarged clitoris, and amen-
used to treat certain types of breast acteristics such as deepening of the orrhoea (the absence of menstruation).
cancer. They have also been widely used voice and the growth of facial hair. They
by athletes and bodybuilders wishing to have an anabolic effect (they raise the anencephaly
increase their muscle bulk and strength, rate of protein synthesis and lower the Absence of the brain and cranial vault
which can be dangerous to health (see rate at which it is broken down), which (top of the skull) at birth. Most infants
steroids, anabolic). increases muscle bulk and accelerates with anencephaly are stillborn or survive
Possible side effects include fluid growth. At the end of puberty, andro- for only a few hours. Anencephaly is
retention, weight gain, increased blood gens cause the long bones to stop detectable early in pregnancy by meas-
cholesterol, and, rarely, liver damage. growing. They also stimulate the secre- urement of the maternal alpha-fetoprotein,

46
 ANGINA PECTORIS

arterial wall can also be weakened by

TYPES OF ANEURYSM inflammation, as occurs in polyarteritis
nodosa. A dissecting aneurysm is one in
A
An aneurysm forms when pressure from the blood flow causes a weakened artery
which the inner layer of the artery wall
wall to distend or forces blood through a fissure. Aneurysms can form anywhere in
the body, although the most common sites are the aorta and the arteries
ruptures, allowing blood to track along
supplying the brain. the length of the artery and block any
branching arteries. Ventricular aneu-
Outer coat Fissure rysms are aneurysms that sometimes
Aneurysm develop in the heart wall due to weaken-
Aneurysm Blood ing of an area of heart muscle as a result
clot of a heart attack (see myocardial infarction).
Some of the common types, sites, and
shapes of aneurysm are shown in the
illustrated box.
SYMPTOMS AND SIGNS
Most aneurysms are symptomless and
Tunica media Blood flow remain undetected. However, if the
aneurysm expands rapidly and causes
Common aneurysm Dissecting aneurysm
This type forms when the tunica media, the In this type, blood is forced through a fissure in
pain, or is very large, the symptoms are
artery’s middle wall, is weakened; the strong force the internal wall of the artery. The internal lining due to pressure on nearby structures.
of the blood flow distends the wall of the artery. is stripped away, forming a false channel. Aneurysms may eventually rupture,
cause fatal blood loss, or, in the case of a
Cerebral (or berry) cerebral aneurysm, loss of conscious-
aneurysm ness (see subarachnoid haemorrhage). A
A swelling where
arteries branch, often dissecting aneurysm usually causes severe
at the base of the pain, and there is a high risk of the ves-
brain, usually caused sel rupturing. Ventricular aneurysms
by congenital seldom rupture, but they interfere with
weakness.
the pumping action of the heart.
DIAGNOSIS AND TREATMENT
Saccular aneurysm Aneurysms of the aorta may be detected
A balloon-shaped
distension of part of by ultrasound scanning, and cerebral
the wall of an artery, aneurysms by CT scanning or MRI. Angi-
often seen in aortic ography can provide more detailed
aneurysms just above information on all types of aneurysm. A
the heart.
ruptured or enlarged aneurysm requires
immediate arterial reconstructive surgery.
Fusiform aneurysm (See also microaneurysm.)
A spindle-shaped
distension around
the circumference angina
of an artery, often A strangling or constrictive pain. The
seen in lower aortic term angina has become synonymous
aneurysms.
with the heart disorder angina pectoris.
Other types of angina include abdo-
minal angina (abdominal pain after
by ultrasound scanning, by amniocentesis, Aneurysms most commonly affect the eating caused by poor blood supply to
or by fetoscopy; if anencephaly is detect- aorta and arteries supplying the brain. the intestines) and Vincent’s angina,
ed, termination of the pregnancy may TYPES AND CAUSES which is pain caused by inflammation
be considered (see abortion, induced). The most common cause of an aneu- of the mouth (see Vincent’s disease).
Anencephaly is caused by a failure in rysm is atherosclerosis, a condition in
the development of the neural tube, which fatty deposits weaken the artery angina pectoris
which is the nerve tissue in the embryo wall. The aorta is the usual site of Pain in the chest that is the result of
that normally develops into the spinal atherosclerotic aneurysms. insufficient oxygen being carried to
cord and brain (see neural tube defects). Less commonly, aneurysms may be the heart muscle in the blood. The pain
due to a congenital (present from birth) of angina pectoris usually occurs when
aneurysm weakness of the artery walls. Most cere- the heart is working harder and
Abnormal dilation (ballooning) of an bral aneurysms, known as berry aneurysms requires more oxygen, such as during
artery caused by the pressure of blood because of their appearance, are con- exercise or at times of stress.
flowing through a weakened area. The genital. Marfan syndrome, an inherited CAUSES
weakening may be due to disease, disorder in which the wall of the aorta Inadequate blood supply to the heart
injury, or a congenital (present from is defective, is often associated with is usually due to coronary artery disease,
birth) defect of the arterial wall. aneurysms just above the heart. The in which the coronary arteries are

47
 ANGINA, PRINZMETAL’S

narrowed by atherosclerosis (fat deposits angina, unstable of a hole in the windpipe) to prevent
A on the artery walls). Other causes inc-
lude coronary artery spasm, in which
A type of angina pectoris (chest pain due
to impaired blood supply to the heart
suffocation. Corticosteroid drugs may also
be given. In less severe cases, antihista-
the blood vessels narrow suddenly for a muscle) that occurs during sleep or mine drugs may relieve symptoms.
short time, aortic stenosis, in which the without provocation (such as exertion).
heart’s aortic valve is narrowed, and angiogenesis
arrhythmias (abnormal heart rhythms). angioedema The growth of new blood vessels.
The pain of angina pectoris is brought A type of reaction caused by allergy. Angiogenesis is the process that enables
on by exertion and is relieved by rest. Angioedema is similar to urticaria tumours to grow: cancerous cells pro-
If the pain continues, it may be due to a (hives) and is characterized by large, duce chemicals (called growth factors)
heart attack (see myocardial infarction). well-defined swellings, of sudden on- that stimulate new blood vessels to
Rarer causes of the pain include severe set, in the skin, larynx (voice-box), and form near the tumour, supplying it with
anaemia, which reduces the blood’s other areas. If they are left untreated, nutrients and oxygen.
oxygen-carrying efficiency, and poly- the swellings may last a number of days.
cythaemia, which thickens the blood and CAUSES angiography
causes its flow through the heart muscle The most common cause of angio- An imaging procedure that enables
to slow down. edema is a sudden allergic reaction to blood vessels to be seen clearly on
SYMPTOMS a food. Less commonly, the condition X-ray film following the injection of a
The chest pain of angina varies from may be due to a drug allergy (such as contrast medium (a substance that is
mild to severe and is often described as to penicillin), a reaction to an insect bite opaque to X-rays). Digital subtraction
a sensation of pressure on the chest. The or sting, or it may occur as a result of angiography uses computer techniques
pain usually starts in the centre of the infection, emotional stress, or exposure to process images and remove unwanted
chest but can spread to the throat, to animals, moulds, pollens, or cold background information. Magnetic res-
upper jaw, back, and arms (usually the conditions. There is also a hereditary onance angiography (MRA) can produce
left), or between the shoulderblades. If form of angioedema. images of blood vessels without the use
it develops during sleep or without SYMPTOMS of a contrast medium.
provocation, it is called unstable angina. Angioedema may cause sudden diffi- WHY IT IS DONE
Other possible symptoms of angina culty in breathing, swallowing, and Angiography is used to detect condi-
pectoris include nausea, sweating, dizzi- speaking, accompanied by swelling of tions that alter the appearance of blood
ness, and breathing difficulty. the lips, face, and neck, depending on vessels, such as an aneurysm (ballooning
DIAGNOSIS AND TREATMENT the area of the body affected. of an artery) and narrowing or blockage
Diagnostic tests usually include an ECG Angioedema that affects the throat of blood vessels by atherosclerosis (fatty
(measurement of the electrical activity and the larynx is potentially life-threat- deposits lining artery walls), a thrombus
of the heart), which may register nor- ening because the swelling can block the (abnormal clot), or an embolus (frag-
mal between attacks, and a cardiac stress airway, causing asphyxia (suffocation). ment of a clot that is carried in the
test (an ECG undertaken while the TREATMENT blood). Angiography is also used to
patient is exercising enough to cause Severe cases are treated with injections detect changes in the pattern of blood
chest pain). Blood tests and coronary of adrenaline (epinephrine) and may vessels that supply organs injured or
angiography (X-ray examination of the require intubation (a breathing tube affected by a tumour.
blood vessels) may also be performed to inserted via the mouth into the wind- Carotid angiography (angiography of
look for an underlying cause. pipe) or tracheostomy (surgical creation the arteries in the neck) may be used to
To help to control the symptoms of
angina pectoris, it is important for the Internal Cerebral blood
carotid artery vessels Aorta Iliac arteries
person to stop smoking and to lose
weight if necessary. Attacks may be
prevented and treated by nitrate drugs,
which increase blood flow through the
heart muscle. Beta-blocker drugs, calcium
channel blockers, lipid-lowering drugs, and
antiplatelet drugs may also be prescribed.
Drug treatment can control the symp-
toms for many years but cannot cure
the disorder. If attacks become more
severe or more frequent, despite treat-
ment, coronary artery bypass surgery or
angioplasty may be necessary.

angina, Prinzmetal’s
A type of unstable angina pectoris (see
Angiogram of brain Magnetic resonance angiogram of groin
angina, unstable) in which the attacks of Contrast medium is passed through a catheter into This MRA provides a clear image of the arteries
chest pain occur while the body is at the arteries at the back of the brain, and a series of of the groin area without the need for X-rays or
rest and are not brought on by exertion. X-rays is taken. the injection of radio-opaque dye.

48
 ANHEDONIA

investigate transient ischaemic attacks angioplasty, balloon of stents (metal mesh structures),
(symptoms of stroke lasting for less than
24 hours). Cerebral angiography can be
A technique for widening a narrowed
or blocked section of blood vessel by
which are inserted into an artery fol-
lowing balloon dilation to help keep the
A
used to detect an aneurysm in the brain the introduction of a balloon-tipped blood vessel open.
or to pinpoint the position of a brain catheter (flexible tube) into the con-
tumour. Coronary angiography, often stricted area of the vessel. angiotensin
combined with cardiac catheterization, The balloon is inflated to widen the The name of two related proteins
can identify sites of narrowing or narrowed area, deflated, then removed. involved in regulating blood pressure.
blockage in coronary artery disease. Balloon angioplasty is used to increase The first, angiotensin I, is inactive and is
During angiography, some types of or restore blood flow in a significantly formed when renin, which is produced
treatment, such as balloon angioplasty narrowed artery in peripheral vascular by the kidneys, acts on the substance
(see angioplasty, balloon) and embol- disease and coronary artery disease. angiotensinogen. Angiotensin I is then
ization, that sometimes eliminate a Coronary balloon angioplasty is usu- converted to the second, active, form,
previous need for surgery may be car- ally successful in the short term, but angiotensin II, by angiotensin-convert-
ried out. (See also aortography.) narrowing of the affected vessel may ing enzyme.
recur, requiring repeat treatment. Angio- Angiotensin II causes narrowing of
angioma plasty of peripheral vessels is most the small blood vessels in tissues, result-
A noncancerous tumour made up of successful in treating the iliac and ing in increased blood pressure. It also
blood vessels (see haemangioma) or femoral arteries in the legs. Results have stimulates release (from the adrenal
lymph vessels (see lymphangioma). improved further with the introduction cortex, the outer part of each adrenal
gland) of the hormone aldosterone,
which also increases blood pressure.
PROCEDURE FOR BALLOON ANGIOPLASTY Certain kidney disorders can increase
BALLOON CATHETER
the production of angiotensin II, re-
A blockage or narrowing of a blood vessel
may be treated by introducing a balloon
sulting in hypertension (high blood
catheter into the area and then inflating pressure). Hypertension can be treated
the balloon to stretch the constricted with ACE inhibitor drugs, which reduce
part. The balloon is then deflated and the formation of angiotensin II, or with
the catheter withdrawn. The procedure angiotensin II antagonists.
is carried out using a local anaesthetic.
angiotensin-converting enzyme
Superficial femoral artery A substance that converts angiotensin I
Common femoral artery to its active form, angiotensin II. Drugs
that reduce the action of angiotensin-
Hollow needle or catheter
converting enzyme are known as ACE
inhibitor drugs and are used in the treat-
ment of hypertension (high blood
How it is done
A hollow needle is inserted
pressure) and heart failure (reduced
into the femoral artery (left). pumping efficiency of the heart).
A guide wire is pushed
through the needle into the angiotensin-II antagonists
artery, then along it (using COMMON DRUGS
X-ray imaging) towards the
blood vessel or heart valve to • Candesartan • Irbesartan • Losartan
be treated. Then the steps • Valsartan
shown below are carried out.
Deep
Spine Pelvis Femur femoral artery A group of drugs used in the treatment
of hypertension (high blood pressure).
Angiotensin-II antagonists have a simi-
Inflated balloon
Guide wire Catheter lar action to ACE inhibitor drugs (in that
they block the action of angiotensin II)
but do not cause the persistent dry
cough that is a common side effect of
treatment with ACE inhibitors.
Stenosis
angular stomatitis
A sausage-shaped
See stomatitis.
1the The thin guide wire is
manoeuvred through
arteries (using X-ray
2thenAcatheter
balloon-tipped
(top right) is
threaded over the
3the catheter
balloon at the end of
is inflated anhedonia
control) until it is just past guide wire and pushed and deflated a few times, Total loss of the feeling of pleasure from
the stenosis (narrowing) to along it until it reaches the to widen the narrowed activities that would normally give plea-
be treated. narrowed area. part, and then withdrawn.
sure. Anhedonia is often one of the
common symptoms of depression.

49
 ANHIDROSIS

anhidrosis protuberances formed by the lower and limitation of movement. In some

A Complete absence of sweating. (See also
hypohidrosis.)
ends of the tibia (shinbone) and the
fibula (outer bone of the lower leg).
cases, DMARDs (see disease-modifying
antirheumatic drugs) are also prescribed.
Strong ligaments on either side of the To prevent curvature of the spine,
animal experimentation ankle joint give it support. The ankle patients are taught breathing exercises
The use of live animals in research and joint allows for up-and-down move- and exercises to improve posture.
safety testing to provide information ment of the foot.
about animal biology or, by inference, DISORDERS ankylosis
human physiology or behaviour. Animal An ankle sprain is one of the most Complete loss of movement in a joint
research has contributed to the develop- common injuries. It is usually caused that results from fusion of the bony
ment of surgical techniques, such as by twisting of the foot over on to its surfaces. Ankylosis may be caused by
transplant surgery and drugs, such as vac- outside edge, which causes overstretch- degeneration as a result of inflamma-
cines. Due to ethical concerns, however, ing and bruising of the ligaments. tion, infection, or injury. The condition
alternative practices, such as cell cul- Severe sprains can result in tearing of can also be produced surgically by an
tures, are now used whenever possible. the ligaments, which may need to be operation to fuse a diseased joint to cor-
repaired surgically. rect deformity or to alleviate persistent
animals, diseases from Violent twisting of the ankle can pain (see arthrodesis). (See also anky-
See zoonosis. result in a combined fracture and dis- losing spondylitis.)
location, known as Pott’s fracture, in
anion which the fibula breaks above the ankle annular
An ion of negative charge, such as a and either the tibia breaks or the lig- A term meaning shaped like a ring.
chloride ion. (See also electrolyte.) aments tear, resulting in dislocation Annular is a description applied to cer-
of the ankle. tain body structures, such as ligaments,
anisometropia and, in dermatology, to the appearance
Unequal focusing power in the two ankylosing spondylitis of skin rashes, such as ringworm. The
eyes, usually due to a difference in size An uncommon inflammatory disease term may also be applied to a cancer
and/or shape of the eyes, that causes affecting joints between the vertebrae of that encircles an organ.
visual discomfort. For example, one eye the spine and the sacroiliac joints (the
may be normal and the other affected joints between the spine and the anodontia
by myopia (shortsightedness), hypermet- pelvis). Ankylosing spondylitis may Failure of some or all of the teeth to
ropia (longsightedness), or astigmatism also affect other large joints, such as develop. Anodontia, which can be par-
(uneven curvature of the cornea). Glas- those in the hips. tial or total, may be due to the absence
ses or contact lenses correct the CAUSES AND INCIDENCE of tooth buds at birth, or it may be the
problem in most cases. The cause of ankylosing spondylitis is result of damage to developing tooth
usually unknown, but in some cases the buds by infection or other widespread
ankle joint disease may be associated with colitis disease. Both primary and permanent
The hinge joint between the foot and (inflammation of the colon) or psoriasis teeth may be affected. Partial anodontia
the leg. The talus (uppermost bone in (a skin disease). Ankylosing spondylitis is far more common than total.
the foot) fits between the two bony may run in families; and about 90 per If only a few teeth are missing, a den-
cent of people with the condition have tal bridge (false teeth that are attached
the genetically determined histocompati- to natural teeth on either side of the
LOCATION OF THE ANKLE JOINT bility antigen (HLA-B27). gap) can be fitted. If all the teeth are
SYMPTOMS missing, a denture is required. Recently,
The hinge joint is formed where the
Ankylosing spondylitis usually starts however, dental implants (see implant,
top of the talus fits in between the
lower ends of the tibia and fibula.
with pain and stiffness in the hips and dental) have become the treatment of
lower back that are worse after resting choice in selected cases (in which the
Tibia
and are especially noticeable in the early individual has the correct anatomy and
morning. Other, less common, symp- bone density).
Fibula toms include chest pain, painful heels
due to additional bone formation, and anomaly
Talus redness and pain in the eyes due to iritis A deviation from what is accepted as
(inflammation of the iris). In time, normal, especially a birth defect such as
inflammation in the spine can lead to a limb malformation.
ankylosis (permanent stiffness and limi-
ted movement) and kyphosis (curvature Anopheles
of the spine). A genus of disease-transmitting mosqui-
DIAGNOSIS AND TREATMENT toes, many species of which are carriers
Ankylosing spondylitis can be diagnosed of malaria. (See also mosquito bites.)
by X-rays and blood tests. There is no
Ligament cure, but treatment with a programme anorexia
Calcaneus
of exercise and physiotherapy and anti- The medical term for loss of appetite
inflammatory drugs can reduce the pain (see appetite, loss of).

50
 ANTENATAL CARE

TREATMENT AND OUTLOOK acids into the oesophagus), oesophagitis

FEATURES OF
ANOREXIA NERVOSA
Hospital treatment is often necessary
and is usually based on a closely con-
(inflammation of the oesophagus), and
peptic ulcer.
A
• Weight loss trolled feeding programme combined HOW THEY WORK
with psychotherapy or family therapy. For Antacids usually contain compounds of
some people, antidepressant drugs may magnesium or aluminium, which neutra-
• Overactivity and obsessive exercising
be helpful. Many sufferers relapse after lize stomach acid. Some also contain
treatment, and long-term psychother- alginates, which protect the oesophagus
• Tiredness and weakness
apy is required. by reducing acid reflux, or dimeticone,
an antifoaming agent, which helps to
• Lanugo (babylike) hair on body, anorgasmia relieve flatulence.
thinning of hair on head
Inability to achieve orgasm (see orgasm, SIDE EFFECTS
lack of). Aluminium may cause constipation,
• Extreme choosiness over food
and magnesium may cause diarrhoea.
anosmia These effects can be avoided, however,
• Binge eating Loss of the sense of smell. if a preparation contains both ingredi-
ents. Antacids interfere with the
• Induced vomiting anovulatory menstruation absorption of many drugs and should
The occurrence of a menstrual cycle therefore not be taken at the same time
• Use of laxatives to promote weight loss during which there is no ovulation as other medications.
(release of an egg from the ovary). Ano- WARNING
vulatory menstruation is often the result Antacids should not be taken regularly
anorexia nervosa of reduced production of the hormone except under medical supervision
An eating disorder that is characterized oestrogen and occurs most commonly at because they may suppress the symp-
by severe weight loss and altered self- the beginning and the end of reproduc- toms of a more serious disorder or
image that leads sufferers to believe that tive life, in which case it is normal. provoke serious complications.
they are fat even when they are, in fact, However, anovulatory menstruation may
dangerously underweight. also be a sign of a hormonal abnorm- antagonist
CAUSES AND INCIDENCE ality. (See also fertility; menstruation.) Having an opposing effect. For exam-
The causes of anorexia are unclear, but ple, antagonist drugs counteract the
the condition may be linked to a lack anoxia effects of naturally occurring chemicals
of self-worth that leads to excessive The total absence of oxygen within a in the body. (See also agonist.)
concern over physical appearance. Suf- body tissue such as the brain or a mus-
ferers may feel that they can have some cle. Anoxia causes disruption of cell antenatal care
control over their lives by controlling metabolism (chemical activity) and The care of a pregnant woman and her
their eating. Normal dieting may deve- results in cell death unless it is corrected unborn baby throughout pregnancy to
lop into starvation. within a few minutes. ensure that both are healthy at delivery.
Anorexia nervosa most commonly Anoxia is rare, occurring during car- Antenatal care involves regular visits to
affects teenage girls and young women, diopulmonary arrest or asphyxiation. It a doctor or midwife, who performs
but the incidence in young men is rising. will cause permanent organ damage or blood and urine tests and abdominal
SYMPTOMS AND SIGNS even death if not corrected. Hypoxia (the examinations and also monitors blood
In the early stages, sufferers may be reduction of oxygen supply to a tissue) pressure and fetal growth in order to
overactive and may exercise excessively. is a more common problem. detect disease or potential problems
They are obsessed with food, and often (see the antenatal screening procedures
make complicated meals for others, but Antabuse chart, overleaf).
are reluctant to eat socially and avoid A brand name for disulfiram, a drug High-risk pregnancies, in which, for
eating the meals themselves. As their used to treat alcohol dependence. Anta- example, the woman suffers from hyper-
weight loss continues, they become buse is a powerful deterrent, which, if tension (high blood pressure) or
tired and weak, the skin becomes dry, taken with even a small amount of alco- diabetes (see diabetic pregnancy), require
lanugo hair (fine, downy hair) grows hol, produces extremely unpleasant side more frequent antenatal visits. In some
on the body, and normal hair becomes effects such as nausea, headache, dizzi- cases, the woman may be admitted to
thinner. Starvation leads to amenorrhoea ness, and palpitations. hospital for closer observation.
(the absence of menstrual periods) in Ultrasound scanning is carried out to
many women. antacid drugs identify any abnormalities in the fetus.
Some sufferers of anorexia nervosa COMMON DRUGS Amniocentesis or chorionic villus sampling
have food binges and then make them- • Aluminium hydroxide • Calcium carbonate may be performed if the fetus is
selves vomit, or take laxative drugs or • Hydrotalcite • Magnesium hydroxide thought to be at increased risk of a chro-
diuretic drugs, to promote weight loss • Sodium bicarbonate mosomal abnormality or a genetic disorder.
(see bulimia). Chemical imbalances as a Electronic fetal monitoring may be car-
result of starvation, with or without Drugs that are taken to relieve the ried out, in order to check the fetal
vomiting, can cause potentially fatal car- symptoms of indigestion, heartburn, acid heartbeat, in pregnancies that are high-
diac arrhythmias. reflux (the regurgitation of stomach risk or overdue.

51
 ANTEPARTUM HAEMORRHAGE

anterior knee pain syndrome

ANTENATAL SCREENING PROCEDURES
A See chondromalacia patellae.
When performed Procedure Reason for procedure
anterior compartment
syndrome
First visit Medical history To look for pre-existing risk factors, such as
See compartment syndrome; shin splints.
and examination long-term illnesses.
anthelmintic drugs
Urine tests To check the urine for glucose, which may COMMON DRUGS
indicate diabetes developing in pregnancy
and for protein, which may indicate pre- • Albendazole • Diethylcarbamazine
existing kidney disease. • Ivermectin • Levamisole • Mebendazole
• Niclosamide • Piperazine • Praziquantel
Blood test To determine the woman’s blood type and • Tiabendazole
to check for anaemia; antibodies to rubella;
hepatitis B virus; and, sometimes, after A group of drugs that are used to
discussion, HIV infection which might be eradicate worm infestation of the body.
transmitted to the baby. Genetic counselling
may be offered to couples with a family Anthelmintic drugs kill or paralyse
history of inherited disease or from ethnic worms in the intestines, preventing
groups at high risk. them from gripping the intestinal wall,
and causing them to pass out of the
Weight and blood To provide initial measurements against body in the faeces.
pressure which later ones are compared. Possible side effects of anthelmintic
drugs include nausea, abdominal pain,
Between Ultrasound scans To check the age of the fetus and to look for rash, headache, and dizziness.
11 and 20 (one or more) fetal abnormalities.
weeks anthracosis
An outdated term for coal workers’
Follow-up visits at Weight (not To assess the growth of the fetus and to see pneumoconiosis. Anthracosis is a lung
regular intervals routine in women which way it is lying in the uterus. disease caused by inhalation of large
from 11 weeks to of normal weight)
delivery and examination amounts of coal dust over many years.

Urine tests To detect diabetes or pre-eclampsia.

anthrax
A serious bacterial infection of livestock
that occasionally spreads to humans.
Blood pressure To detect developing pre-eclampsia.
The most common form of the infec-
tion in humans is cutaneous anthrax,
Blood tests (at To look for anaemia and, in combination which affects the skin. Another form,
some visits only) with ultrasound scanning, to assess the risk
of fetal abnormalities such as neural tube pulmonary anthrax, affects the lungs
defects or Down’s syndrome. A test to and is potentially fatal.
screen for diabetes mellitus in the mother CAUSES
may also be necessary. Anthrax is caused by BACILLUS ANTHRACIS.
This bacterium produces spores that can
remain dormant for years in soil and
The woman is also advised on general SYMPTOMS animal products and are capable of
aspects of pregnancy, such as diet, exer- The bleeding is often painless but may reactivation.
cise, and techniques to help her with be accompanied by abdominal pain if Animals become infected by grazing
childbirth. (See also childbirth, natural.) the placenta becomes partly separated on contaminated land. Infection can
from the uterus. occur in humans via a scratch or a sore
antepartum haemorrhage Investigation and treatment requires if materials from infected animals are
Bleeding from the vagina after the 28th hospital admission. Ultrasound scanning is handled. Pulmonary anthrax occurs as a
week of pregnancy. used to diagnose problems with the pla- result of inhaling spores from infected
Antepartum haemorrhage is most centa. In some cases, it is necessary only animal fibres.
commonly due to a problem with the to keep a careful watch on the condition SYMPTOMS AND TREATMENT
placenta (the organ in the uterus that of the woman and her baby. If the In cutaneous anthrax, a raised, itchy,
sustains the developing fetus), such as bleeding is severe, the woman is given a area develops at the site of entry of the
placenta praevia (in which the placenta is blood transfusion; the baby may be deliv- spores, progressing to a large blister and
positioned too close to the birth canal) ered immediately by caesarean section. finally a black scab, with swelling of the
or placental abruption (detachment of surrounding tissues. Cutaneous anthrax
part of the placenta from the wall of the anterior is treatable in its early stages with antibi-
uterus). Bleeding can also be caused by Relating to the front of the body. In otic drugs. Without treatment, infection
cervical erosion or other disorders of the human anatomy, the term is synony- may spread to lymph nodes and the
cervix or vagina. mous with ventral. bloodstream and may be fatal.

52
 ANTIBODY

Pulmonary anthrax causes severe antibacterial drugs glycosides, cephalosporins, macrolides,

breathing difficulty and may be fatal
despite intensive treatment.
A group of drugs that are used to treat
infection due to bacteria. The term
penicillins, and tetracyclines. Some antibi-
otics are effective against only certain
A
antibacterial was once used to describe types of bacteria; others, which are
antiallergy drugs only those antibiotic drugs that had been known as broad-spectrum antibiotics,
Drugs used to treat or prevent allergic produced synthetically rather than natu- are effective against a wide range.
reactions (see allergy). There are several rally. The two terms are now used ANTIBIOTIC RESISTANCE
types of antiallergy drug, including interchangeably. Some bacteria develop resistance to a
antihistamine drugs, leukotriene receptor previously effective antibiotic drug. This
antagonists, sodium cromoglicate, and antibiotic drugs resistance is most likely to occur during
corticosteroid drugs. COMMON DRUGS long-term treatment. Some alternative
AMINOGLYCOSIDES • Amikacin • Gentamicin antibiotics are available to treat bacteria
antianxiety drugs • Neomycin • Netilmicin • Streptomycin that have become resistant to the more
A group of drugs that are used to relieve • Tobramycin commonly prescribed drugs.
the symptoms of anxiety. Benzodiazepine CEPHALOSPORINS • Cefaclor • Cefadroxil SIDE EFFECTS
drugs, buspirone, and beta-blocker drugs • Cefalexin • Cefamandole • Cefazolin Most antibiotic drugs can cause nausea,
are the three main types of antianxiety • Cefixime • Cefotaxime • Cefoxitin diarrhoea, or a rash. Antibiotics may
drug, although antidepressant drugs are • Cefpodoxime • Cefradine • Ceftazidime disturb the normal balance of “good”
often used. In most cases, the under- MACROLIDES • Azithromycin • Clarithromycin bacteria in the body. This can cause
lying disorder is best treated by • Erythromycin problems such as candidiasis (thrush),
counselling, psychotherapy, or other PENICILLINS • Amoxicillin • Ampicillin in which there is excess growth of fun-
forms of therapy. • Azlocillin • Aztreonam • Benzylpenicillin gus. Some individuals experience a
Benzodiazepine drugs promote men- • Co-amoxiclav • Co-fluampicil • Flucloxacillin severe allergic reaction to the drugs,
tal and physical relaxation by reducing • Imipenem • Phenoxymethylpenicillin resulting in facial swelling, itching, or
nerve activity in the brain; they can also TETRACYCLINES • Doxycycline • Oxytetracycline breathing difficulty.
be used to treat insomnia but their use • Tetracycline WARNING
for this purpose is avoided because they OTHERS • Chloramphenicol • Ciprofloxacin Patients should inform their doctor of
are addictive; buspirone is less addictive. • Colistin • Fusidic acid • Metronidazole any previous allergic reaction that they
Beta-blockers reduce only the physical • Rifampicin • Spectinomycin • Teicoplanin have had to an antibiotic drug.
symptoms of anxiety, such as shaking • Trimethoprim • Vancomycin
and palpitations, and are not addictive. antibody
A group of drugs used to treat infec- A protein that is made by certain
antiarrhythmic drugs tions caused by bacteria and to prevent lymphocytes (white blood cells) to
A group of drugs used to prevent or bacterial infection in individuals who neutralize an antigen (foreign protein)
treat different types of arrhythmia (irreg- are immunocompromized. Most of the in the body. Bacteria, viruses, and other
ular heartbeat). commonly used antibiotic drugs belong microorganisms contain a number of
A number of drugs are used to pre- to one of the following classes: amino- antigens; antibodies that are formed
vent intermittent arrhythmias or slow
the rate if an arrhythmia is persistent.
These include beta-blocker drugs, calcium HOW ANTIBIOTICS WORK
channel blockers, digitalis drugs, amioda-
Antibiotic drugs are either bactericidal or bacteriostatic. Bactericidal antibiotics,
rone, disopyramide, flecainide, lidocaine
such as penicillins and cephalosporins, kill bacteria directly. Bacteriostatic
(lignocaine), mexiletine, and procaina- antibiotics, such as erythromycin, halt growth and multiplication of the bacteria,
mide. Some antiarrhythmic drugs, such allowing the immune system to cope with the infection.
as adenosine and bretyllium, may only
be used in hospital. They may be given Bacterial cell Antibiotic
intravenously to treat arrhythmias that Antibiotic Proteins are Bacterial cell Cell expands
are causing symptoms such as breath- Protein unformed and bursts
lessness or chest pain. and cell dies

HOW THEY WORK

The heart’s pumping action is governed
by electrical impulses. Some antiar-
rhythmics alter these impulses within,
or on their way to, the heart; others
affect the heart muscle’s response to the
impulses received.
Nucleus
SIDE EFFECTS
Side effects of antiarrhythmic drugs are Bacteriostatic antibiotics Bactericidal antibiotics
common, and they often include nausea These drugs prevent the production of proteins These kill bacteria directly by causing the cell
and a rash. Some can result in tiredness that the bacterial cell needs in order to grow wall to disintegrate; water is taken into the cell,
or breathlessness because they reduce and multiply, and the cell eventually dies. which expands and then bursts.
the pumping ability of the heart.

53
 ANTIBODY, MONOCLONAL

against these antigens help the body anticancer drugs drugs are often given in combination
A to neutralize or destroy the invading
microorganisms. Antibodies may also be
COMMON DRUGS
ALKYLATING AGENTS • Chlorambucil
to maximize their effects. Treatment
with cytotoxic drugs is commonly
formed in response to vaccines, thereby • Cyclophosphamide • Melphalan given by injection in short courses
giving immunity against certain infec- ANTIMETABOLITES • Cytarabine • Fluorouracil repeated at intervals.
tions. Antibodies are also known as • Mercaptopurine • Methotrexate SIDE EFFECTS
immunoglobulins. CYTOTOXIC ANTIBIOTICS • Doxorubicin Some cytotoxic drugs cause nausea and
Inappropriate or excessive formation • Epirubicin vomiting and may cause hair loss and
of antibodies may lead to illness, as in HORMONE TREATMENTS • Anastrozole increased susceptibility to infection.
an allergy. Antibodies against antigens in • Bicalutamide • Cyproterone acetate Others (such as tamoxifen for breast
organ transplants may result in rejection • Flutamide • Goserelin • Letrozole cancer) are given continuously by
of the transplanted organ. In some dis- • Leuprorelin • Medroxyprogesterone mouth for months or years and cause
orders, antibodies are formed against • Megestrol • Tamoxifen few side effects.
the body’s own tissues, resulting in an CYTOKINES • Interferon alfa • Interleukin 2
autoimmune disorder. TAXANES • Docetaxel • Paclitaxel anticholinergic drugs
OTHERS • Carboplatin • Cisplatin • Etoposide COMMON DRUGS
antibody, monoclonal • Irinotecan • Rituximab AS BRONCHODILATORS • Ipratropium bromide
An artificially produced antibody that • Oxitropium
neutralizes only one specific antigen Drugs that are used to treat many forms FOR IRRITABLE BOWEL SYNDROME • Atropine
(foreign protein). of cancer. Some tumours respond to • Dicycloverine • Hyoscine • Propantheline
Monoclonal antibodies are produced drug treatment better than others. Anti- FOR PARKINSONISM • Benztropine
in a laboratory by stimulating the cancer drugs are particularly useful in • Biperiden• Orphenadrine • Procyclidine
growth of large numbers of antibody- the treatment of lymphomas, leukaemias, • Trihexyphenidyl (Benzhexol)
producing cells that are genetically breast cancer, cancer of the testis (see FOR URINARY INCONTINENCE • Flavoxate
identical. In effect, this process enables testis, cancer of), and prostate cancer. • Oxybutynin • Propiverine • Tolterodine
antibodies to be tailor-made to react HOW THEY WORK • Trospium
with a particular antigen. Most anticancer drugs are cytotoxic (they
Monoclonal antibodies are used in kill or damage cells or prevent them from A group of drugs, also called antimus-
the study of human cells, hormones, dividing). Cytotoxic drugs fall into sev- carinics, that are used in the treatment
microorganisms, and in the develop- eral classes, including alkylating agents, of irritable bowel syndrome, urinary incon-
ment of vaccines. They are also being antimetabolites, cytotoxic antibiotics, and tinence (see incontinence, urinary), COPD
used in the diagnosis and treatment taxanes. Cytokines (proteins released by (see pulmonary disease, chronic obstructive),
of some forms of cancer. Genetically cells in response to the presence of Parkinson’s disease, and bradycardia (an
engineered monoclonal antibodies are harmful organisms) such as interferon abnormally slow heartbeat). Anticholin-
designed to bind to the proteins on the alpha bind to other cells, activating the ergic drugs are used to dilate the pupil
surface of certain cancer cells, marking immune response (see immune system). before eye examination or surgery. They
them out for destruction. The immune In some cases, drug treatment is used may also be used as premedication before
system can then recognize these marked alone, but it is often combined with general anaesthesia (see anaesthesia,
cells and destroy them. surgery or radiotherapy. Anticancer general) and to treat motion sickness.
HOW THEY WORK
Anticholinergics block the effects of
HOW ANTICHOLINERGICS WORK acetylcholine, a chemical released from
nerve endings in the parasympathetic
Acetylcholine combines with a receptor acetylcholine receptors. This action autonomic nervous system. Acetylcholine
on the cell’s surface. This interaction produces, for example, muscle triggers activity in a number of cells. For
stimulates activity in that cell (e.g. relaxation (e.g. in the bladder,
contraction of a muscle fibre or intestine, and bronchi) and dries up
example, it stimulates muscle contrac-
secretion of a fluid). Anticholinergic secretions in the mouth and lungs. tion, slows the heartbeat, and increases
drugs block the stimulatory action of Anticholinergic drugs are used to treat secretions in the mouth and lungs.
acetylcholine by combining with the COPD and other conditions. SIDE EFFECTS
Possible side effects of anticholinergics
Stimulation may include dry mouth, blurred vision,
of cell
Reduced urinary retention, and confusion.
activity
cell activity
(e.g. gland
(e.g. gland
secretion)
inhibition) anticoagulant drugs
COMMON DRUGS
Nerve ending • Certoparin • Dalteparin • Danaparoid
• Enoxaparin • Heparin • Nicoumalone
Acetylcholine
• Tinzaparin • Warfarin
Receptor Anticholinergic
drug blocking A group of drugs used to treat and pre-
Cell receptor
vent abnormal blood clotting, to treat
thrombosis, and to prevent and treat

54
 ANTIDIABETIC DRUGS

stroke and transient ischaemic attack venting its spread throughout areas of Antidepressants usually relieve the
(symptoms of stroke lasting less than
24 hours). Anticoagulant drugs are also
the brain. If seizures continue following
treatment with an anticonvulsant, two
symptoms of depression, but it often
takes two to three weeks for any benefi-
A
given long-term to prevent abnormal drugs may be used in combination. cial effects to be felt. Treatment usually
blood clotting after major surgery (esp- SIDE EFFECTS lasts for at least six months; and the
ecially heart-valve replacement) or Anticonvulsants may produce various dosage is reduced gradually before
during haemodialysis (see dialysis). side effects, including impaired mem- being stopped altogether.
The most common anticoagulants are ory, reduced concentration, poor SIDE EFFECTS
heparin and the newer heparin-derived coordination, and fatigue. If the side TCAs may cause constipation, a dry
drugs, such as tinzaparin, all of which effects are troublesome, an alternative mouth, drowsiness, blurred vision, uri-
have to be given by injection, and warf- anticonvulsant can be tried. The dose of nary difficulty, and irregular heartbeat.
arin, which is taken orally. Heparin is an anticonvulsant drug may need to be SSRIs may cause nausea, indigestion,
usually given initially and is then with- monitored using blood tests. loss of appetite, or sexual difficulties but
drawn when warfarin therapy has WARNING are less dangerous in overdose than
become effective. The dosage of anticonvulsants should other antidepressants. MAOIs may inter-
HOW THEY WORK not be reduced or the treatment act with foods and other drugs,
Anticoagulant drugs reduce the activity stopped without a doctor being con- although moclobemide is less likely to
of certain enzymes, known as blood sulted first. the doctor will supervise a cause problems.
clotting factors, that are needed for the gradual reduction in dosage. Stopping Antidepressants are not addictive, but
blood to clot. Anticoagulants do not dis- the drugs abruptly could cause with- abrupt withdrawal of some types can
solve clots that have already formed, drawal symptoms and a recurrence of result in physical symptoms and should
which can be treated with thrombolytic the original problem. therefore be avoided.
drugs, however they may help to stabi- WARNING
lize an existing clot so that it does not antidepressant drugs Food and drink containing tyramine
brake away causing an embolism (block- COMMON DRUGS (for example, cheese and red wine) and
age of an artery by a blood clot). SELECTIVE SEROTONIN REUPTAKE INHIBITORS other drugs may cause a dangerous rise
SIDE EFFECTS (SSRIS )• Citalopram • Fluoxetine in blood pressure when taken during
Excessive doses of warfarin or its use • Fluvoxamine • Paroxetine • Sertraline treatment with an MAOI. Always tell your
with other drugs, such as aspirin and TRICYCLICS (TCAS) • Amitriptyline • Amoxapine doctor if you are taking an MAOI.
alcohol, may increase the risk of • Clomipramine • Dosulepin • Doxepin
unwanted bleeding. Regular monitoring • Imipramine • Lofepramine • Nortriptyline antidiabetic drugs
with blood-clotting tests is required. • Trimipramine COMMON DRUGS
WARNING MONOAMINE OXIDASE INHIBITORS (MAOIS) SULPHONYLUREA DRUGS • Chlorpropamide
A doctor should always be consulted • Isocarboxazid • Moclobemide • Phenelzine • Glibenclamide • Gliclazide • Glimepiride
before any other drug is taken during OTHERS • Flupentixol • Maprotiline • Mianserin • Glipizide • Gliquidone • Tolbutamide
anticoagulant treatment. • Mirtazapine • Reboxetine • Trazodone OTHERS • Acarbose • Glucagon• Guar gum
• Venlafaxine • Insulin • Insulin lispro • Metformin
anticonvulsant drugs • Repaglinide • Rosiglitazone
COMMON DRUGS Drugs used in the treatment of depres-
• Carbamazepine • Clobazam • Clomethiazole sion. Most of the commonly used A group of drugs that are used to treat
• Clonazepam • Diazepam • Ethosuximide antidepressant drugs belong to one of diabetes mellitus, in which a lack of
• Gabapentin • Lamotrigine • Lorazepam the following groups: tricyclic antidepres- insulin, or resistance to its actions,
• Phenobarbital • Phenytoin • Piracetam sants (TCAs), selective serotonin reuptake results in hyperglycaemia (high levels of
• Primidone • Sodium valproate • Tiagabine inhibitors (SSRIs), and monoamine oxi- glucose in the blood). A wide range
• Topiramate • Vigabatrin dase inhibitors (MAOIs). of antidiabetics are used to keep the
HOW THEY WORK blood glucose level as close to normal
A group of drugs used to treat or pre- Normally, brain cells release enough as possible, thereby reducing the risk
vent seizures. Anticonvulsant drugs are neurotransmitters (chemical messengers) of complications such as vascular
used mainly in the treatment of epilepsy, in the brain to stimulate nearby brain (blood vessel) disease. Antidiabetic
but they are also prescribed to prevent cells. Neurotransmitters are constantly drugs include insulin, which must be
seizures following serious head injury or being reabsorbed into the brain cells by administered by injection, and oral
some types of brain surgery. They may another chemical, monoamine oxidase. hypoglycaemics (see hypoglycaemics, oral)
be needed to control seizures in children Depression is thought to be due to a such as glibenclamide and metformin.
with a high fever (see convulsions, febrile). reduction in the release of neurotrans- HOW THEY WORK
Different drugs are effective at treating mitters. TCAs increase the level of the Most antidiabetic drugs promote the
different types of seizure. neurotransmitters noradrenaline (norep- uptake of glucose into the body tissues,
HOW THEY WORK inephrine) and serotonin by preventing helping to prevent an excessive rise in
Seizures are caused by an abnormally their reabsorption. MAOIs work by blood glucose levels. However, different
high level of electrical activity in the blocking the action of monoamine oxi- antidiabetics work in different ways.
brain. Anticonvulsant drugs have an dase, which increases neurotransmitter Acarbose and guar gum reduce or slow
inhibitory effect that suppresses this levels. SSRIs only prevent the reabsorp- the absorption of carbohydrate from
excessive electrical activity, thereby pre- tion of serotonin. the intestines after meals. Repaglinide

55
 ANTIDIARRHOEAL DRUGS

stimulates release of insulin from the (see drug dependence), producing nau- Ménière’s disease, radiotherapy,and cer-
A pancreas. Rosiglitazone reduces resis-
tance to the effects of insulin in the
sea, abdominal pain, and diarrhoea if
the drug is stopped suddenly.
tain drugs. Antiemetics are not normally
used in the treatment of food poisoning
tissues and may be used together with WARNING because the body needs to rid itself of
other hypoglycaemics. Antidiarrhoeals should not be taken regu- harmful substances.
SIDE EFFECTS larly except on medical advice since they HOW THEY WORK
Certain antidiabetics may lower the may mask a serious underlying disorder. Antihistamines and anticholinergic drugs
blood glucose level too much, leading reduce vomiting associated with vert-
to hypoglycaemia (low blood glucose antidiuretic hormone igo by suppressing the vomiting reflex
levels). Rarely, these drugs may also See ADH. (in which the stomach muscles con-
cause a decreased blood cell count, a tract to expel the stomach contents),
rash, or intestinal or liver disturbances. antidote which is triggered by nerve activity in
Metformin does not cause hypogly- A substance that neutralizes or counter- the balance centre of the inner ear.
caemia, although treatment with this acts the effects of a poison. Motility stimulants work by increasing
drug may result in nausea, appetite loss, A chemical antidote works by com- movement through the gastrointestinal
abdominal distension, and diarrhoea. It bining with a poison to form an tract. The most powerful antiemetics
should not be taken by people with innocuous substance or by, in some are used to control nausea and vomit-
liver, kidney, or heart problems. way, blocking or diverting the action of ing associated with radiotherapy or
the poison. A mechanical antidote pre- anticancer drugs and include serotonin
antidiarrhoeal drugs vents the absorption of poison into the antagonists, such as ondansetron, and
COMMON DRUGS blood from the stomach and intestine. nabilone. These drugs act on neurotrans-
ANTISPASMODICS • Atropine • Dicycloverine mitters in the brain.
• Hyoscine anti-D(Rh0) immunoglobulin SIDE EFFECTS
OPIOIDS • Codeine • Diphenoxylate An antiserum that contains antibodies Only certain antiemetics are used to
• Loperamide (see antibody), proteins that are manu- treat vomiting in early pregnancy because
BULK-FORMING AGENTS AND ADSORBENTS factured by the immune system against some can damage the developing fetus.
• Ispaghula • Kaolin • Methylcellulose Rhesus (Rh) D factor, a substance pre- Many antiemetics can cause drowsiness.
sent on the red blood cells of people WARNING
Drugs that are used to reduce or stop with Rh-positive blood. Antiemetics should not be taken regu-
diarrhoea and to help regulate bowel Anti-D(Rh0) immunoglobulin is given larly except on medical advice since they
action in people who have had a colos- to all Rh-negative women routinely at may mask a serious underlying disorder.
tomy or ileostomy. In most acute (of intervals during normal pregnancy and
sudden onset) cases of diarrhoea, the at delivery. A dose is also given after an antifreeze poisoning
only treatment recommended is oral amniocentesis, miscarriage, or any event Most antifreeze in the UK contains eth-
rehydration therapy. Antidiarrhoeal drugs in which the baby’s blood may enter the ylene glycol, which is poisonous. Most
are not suitable for children. mother’s circulation. The injected anti- cases of antifreeze poisoning, which is
HOW THEY WORK bodies destroy any red blood cells from extremely rare, occur as a result of acci-
Antidiarrhoeal drugs include adsorbents the fetus that have entered the woman’s dental swallowing.
(such as kaolin), which can absorb the bloodstream. This helps to prevent the SYMPTOMS
toxic substances that cause diarrhoea; woman from forming her own anti- Drinking antifreeze initially produces
bulk-forming agents (such as ispagh- bodies against Rh-positive blood, which effects similar to alcohol intoxication, but
ula), which absorb water from the might adversely affect a subsequent vomiting, stupor, seizures, and coma
faeces thereby making them firmer; pregnancy. (See also haemolytic disease of may follow; acute kidney failure may
and antimotility drugs (including the the newborn; Rhesus incompatibility.) occur within 24 to 36 hours.
opioid drugs, morphine and codeine, and TREATMENT
loperamide, which is chemically similar antiemetic drugs Any person believed to have drunk
to opioids but does not have an opioid COMMON DRUGS antifreeze requires immediate medical
effect), which slow movement through ANTICHOLINERGICS • Hyoscine hydrobromide attention. Until such help arrives, small
the intestine. ANTIHISTAMINES • Cinnarizine • Cyclizine amounts of alcohol (preferably a spirit
SIDE EFFECTS • Dimenhydrinate • Meclozine • Promethazine such as brandy or whisky) should be
Antidiarrhoeal drugs may cause consti- BUTYROPHENONES • Haloperidol given, if possible, because alcohol
pation. In cases of diarrhoea that has PHENOTHIAZINES • Chlorpromazine reduces the rate at which antifreeze is
resulted from an infection, antidiar- • Perphenazine • Prochlorperazine metabolized by the body.
rhoeals may delay recovery by slowing SEROTONIN ANTAGONISTS • Granisetron Hospital treatment may include
down the elimination of the causative • Ondansetron • Tropisetron removing the antifreeze from the stom-
microorganisms. MOTILITY STIMULANTS • Domperidone ach using a stomach pump (see lavage,
Bulk-forming agents may cause • Metoclopramide gastric) and giving diuretic drugs, alcohol,
intestinal obstruction if taken without OTHERS • Betahistine • Nabilone and bicarbonate, intravenously, to correct
sufficient drinking water or if the bowel excess acidity in the body fluids.
is narrowed. A group of drugs used in the treatment Haemodialysis (see dialysis) may be
Prolonged use of opioid antidiar- of the nausea and vomiting that are asso- required to remove ethylene glycol from
rhoeals may lead to physical dependence ciated with motion sickness, vertigo, the blood and to treat kidney failure.

56
 ANTIOBESITY DRUGS

antifungal drugs rhinitis. They are also sometimes inclu- as stroke, heart failure (reduced pumping
COMMON DRUGS
• Amorolfine • Amphotericin • Benzoyl
ded in cough remedies and cold remedies,
and they are used as antiemetic drugs
efficiency of the heart), myocardial infarc-
tion (heart attack), and kidney damage.
A
peroxide • Clotrimazole • Econazole because they suppress the vomiting There are several types of antihyperten-
• Fenticonazole • Fluconazole • Griseofulvin reflex. Antihistamines are usually taken sive, each one working in a different
• Itraconazole • Ketoconazole • Miconazole by mouth but may be given by injection way to lower blood pressure.
• Nystatin • Sulconazole • Terbinafine for anaphylactic shock. HOW THEY WORK
• Tioconazole HOW THEY WORK Antihypertensive drugs work in a var-
Antihistamine drugs block the effect of iety of ways to lower blood pressure.
A group of drugs used to treat infec- histamine on tissues such as the skin, ACE inhibitors and angiotensin-II antag-
tions caused by fungi. Antifungals are eyes, and nose. Without drug treatment, onists act on enzymes in the blood to
commonly used to treat different types histamine dilates small blood vessels, dilate blood vessels; alpha-blockers
of tinea (including athlete’s foot and scalp resulting in inflammation of the sur- block nerve signals that trigger the con-
ringworm); candidiasis (thrush) and rare rounding tissue due to leakage of fluid striction of blood vessels; beta-blockers
infections, such as cryptococcosis, that from the circulation. Antihistamines reduce the force of the heartbeat, there-
affect internal organs. Antifungals are also prevent histamine from irritating by lowering the pressure of blood flow;
available in various forms, including nerve fibres, which causes itching. diuretics increase the amount of salts
tablets, injection, creams, and pessaries. SIDE EFFECTS and water excreted in the urine, thereby
HOW THEY WORK Many antihistamines cause drowsiness, reducing blood volume; calcium chan-
Antifungal drugs work by damaging the but newer drugs have little sedative nel blockers and ACE inhibitors control
cell walls of fungi, causing chemicals effect. Other uncommon side effects the size of blood vessels by preventing
essential for normal cell function and include loss of appetite, nausea, dry constriction of arterial wall muscles;
growth to escape.The fungal cells are un- mouth, blurred vision, and difficulty in and centrally acting hypertensives act
able to survive without these chemicals. passing urine. on the mechanism in the brain that
SIDE EFFECTS WARNING controls the size of blood vessels.
Topical antifungals rarely cause side A person should not drive or operate SIDE EFFECTS
effects but may occasionally increase potentially dangerous machinery while Side effects depend on the type of anti-
skin irritation. Prolonged treatment, by taking an antihistamine drug unless he hypertensive used, but all types can
mouth or injection, of serious fungal or she is certain that the treatment is cause dizziness if the blood pressure
infections can result in side effects not causing dizziness, drowsiness, or falls excessively.
including liver or kidney damage. impaired concentration. WARNING
The dosage of antihypertensives should
antigen antihypertensive drugs not be reduced or the treatment
A substance that can trigger an immune COMMON DRUGS stopped without first consulting a doc-
response, resulting in production of an ACE INHIBITORS • Captopril • Cilazapril tor, who will supervise a gradual
antibody as part of the body’s defence • Enalapril • Fosinopril • Lisinopril • Moexipril reduction in dosage. Abrupt cessation of
against infection and disease. Many anti- • Perindopril • Quinapril • Ramipril the drug could cause a dangerous rise
gens are foreign proteins such as parts • Trandolapril in blood pressure.
of microorganisms and toxins or tissues ALPHA-BLOCKERS • Doxazosin • Prazosin
from another person that have been • Terazosin anti-inflammatory drugs
used in organ transplants. Sometimes, ANGIOTENSIN-II ANTAGONISTS • Candesartan Drugs that reduce inflammation. The
harmless substances (such as pollen) are • Irbesartan • Losartan • Valsartan main groups of these drugs are cortico-
misidentified by the immune system as BETA-BLOCKERS • Acebutolol • Atenolol steroid drugs and nonsteroidal anti-
potentially harmful antigens, which res- • Betaxolol • Bisoprolol • Carvedilol • Celiprolol inflammatory drugs (NSAIDs). (See also
ults in an allergic response (see allergy). • Labetalol • Metoprolol • Nadolol • Pindolol analgesic drugs.)
• Propranolol • Sotalol • Timolol
antihistamine drugs CALCIUM CHANNEL BLOCKERS • Amlodipine antimalarial drugs
COMMON DRUGS • Diltiazem • Nicardipine • Nifedipine Drugs used to treat malaria. One anti-
NON-SEDATING • Acrivastine • Cetirizine CENTRALLY ACTING HYPERTENSIVES • Clonidine malarial drug, chloroquine, is also used to
• Fexofenadine • Loratadine • Mizolastine • Methyldopa • Moxonidine treat arthritis.
SEDATING • Azatadine • Brompheniramine DIURETICS • Amiloride • Bendroflumethiazide
• Chlorphenamine • Clemastine • Bumetanide • Chlorothiazide antimotility drugs
• Dimenhydrinate • Diphenhydramine • Chlortalidone • Cyclopenthiazide See antidiarrhoeal drugs.
• Diphenylpyraline • Doxylamine • Ethacrynic acid • Furosemide
• Promethazine • Trimeprazine • Triprolidine • Hydrochlorothiazide antimuscarinic drugs
• Hydroflumethiazide • Indapamide See anticholinergic drugs.
A group of drugs that block the effects • Metolazone • Spironolactone
of histamine, a chemical released during • Torasemide • Triamterene • Xipamide antiobesity drugs
allergic reactions (see allergy). A group of drugs that includes appetite
Antihistamines are used to treat rashes A group of drugs that are used in the suppressants and orlistat, a drug that acts
such as urticaria (hives) and to relieve treatment of hypertension (high blood on the gastrointestinal tract to prevent
sneezing and a runny nose in allergic pressure) to prevent complications such the digestion of fats.

57
 ANTI-OESTROGEN DRUGS

anti-oestrogen drugs antipruritic drugs phrenia and mania (abnormal elation

A A group of drugs that oppose the action
of the hormone oestrogen. The most
COMMON DRUGS
ANTIHISTAMINES •Antazoline •Diphenhydramine
and overactivity) in bipolar disorder
(see manic–depressive illness). Antipsy-
important of these drugs is tamoxifen, • Trimeprazine chotic drugs may also be used to sedate
which is used in the treatment of cer- CORTICOSTEROIDS • Hydrocortisone people who are suffering from other
tain breast cancers. LOCAL ANAESTHETICS • Tetracaine (amethocaine) mental disorders (such as dementia) and
• Benzocaine • Lignocaine who are very agitated or aggressive.
antioxidant EMOLLIENT AND COOLING PREPARATIONS HOW THEY WORK
A type of chemical that neutralizes • Aqueous cream • Calamine lotion Most antipsychotic drugs block the
potentially damaging oxidizing molec- • Cold cream • Emulsifying ointment action of dopamine, a chemical that
ules known as free radicals (molecules OTHERS • Colestyramine • Doxepin stimulates nerve activity in the brain.
that bind to and destroy body cells). Antipsychotic drugs include pheno-
Some antioxidants occur naturally in Drugs that are used to relieve persistent thiazine drugs, butyrophenones such as
the body; others (vitamin C, vitamin E, itching (pruritus), including pruritus haloperidol, and several new drugs
and beta-carotene, for example) are that occurs as a result of a specific con- including risperidone.
obtained through food intake or from dition. For example, colestyramine (a SIDE EFFECTS
dietary supplements. lipid-lowering drug) is used to relieve Antipsychotic drugs can cause drowsi-
pruritus associated with primary biliary ness, lethargy, dyskinesia (abnormal
antiperspirant cirrhosis. Antipruritic drugs can be muscular movements), and parkinson-
COMMON DRUGS applied as creams and emollients and ism. Other possible side effects include
• Aluminium chloride may contain corticosteroid drugs, antihist- dry mouth, blurred vision, and diffi-
amine drugs, or local anaesthetics. Oral culty in passing urine. However, newer
A substance applied to the skin in the antihistamines may also be used to drugs may have fewer side effects when
form of a lotion, cream, or spray in order relieve itching. used long term.
to reduce sweating. High concentrations HOW THEY WORK
are sometimes used to treat hyperhidro- Irritation of the skin causes the release antipyretic drugs
sis (abnormally heavy sweating). of substances, such as histamine, that Drugs that reduce fever. Examples of
HOW IT WORKS cause the blood vessels to dilate and antipyretic drugs include paracetamol,
An antiperspirant reduces the produc- fluid to accumulate under the skin, aspirin, and other non-steroidal anti-
tion of sweat by the sweat glands and which results in inflammation and inflammatory drugs.
blocks the ducts that drain sweat on to itching. Antipruritic drugs work either
the surface of the skin. by reducing inflammation, and there- antiretroviral drugs
SIDE EFFECTS fore itching, or by numbing the nerve COMMON DRUGS
Antiperspirants may cause skin irrita- impulses that transmit sensation to NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS
tion, particularly if they are used on the brain. • Didanosine • Lamivudine • Stavudine
broken skin. (See also deodorants.) SIDE EFFECTS • Zalcitabine • Zidovudine (AZT)
Prolonged or heavy use of any antipru- PROTEASE INHIBITORS • Indinavir • Nelfinavir
antiphospholipid syndrome ritic, especially antihistamine and local • Ritonavir • Saquinavir
See Hughes’ syndrome. anaesthetic creams, may lead to further NON-NUCLEOSIDE REVERSE TRANSCRIPTASE
skin irritation. Oral antihistamines may INHIBITORS • Efavirenz • Nevirapine
antiplatelet drugs cause drowsiness. Prolonged use of
COMMON DRUGS potent topical corticosteroids may result Drugs that are used to slow or halt
• Abciximab • Aspirin • Dipyridamole in permanent skin changes, most com- the spread of viruses (see retrovirus) in
• Clopidogrel • Ticlopidine monly thinning of the skin. individuals who have HIV infection and
AIDS. There are three main types of
Drugs that reduce the tendency of plate- antipsychotic drugs antiretroviral drug: nucleoside reverse
lets to stick together to form blood clots COMMON DRUGS transcriptase inhibitors, non-nucleoside
(see blood clotting) when blood flow in PHENOTHIAZINES • Chlorpromazine reverse transcriptase inhibitors and
the arteries is disrupted. Antiplatelet • Fluphenazine • Levomepromazine protease inhibitors. A combination of
drugs reduce the risk of thromboembolism (methotrimeprazine) • Pericyazine antiretroviral drugs from different
(in which a clot breaks off and is carried • Perphenazine • Pipotiazine • Thioridazine groups is often used.
in the bloodstream to lodge elsewhere • Trifluoperazine HOW THEY WORK
in the body), which can cause potenti- BUTYROPHENONES • Benperidol • Droperidol Antiretroviral drugs work by interfering
ally fatal disorders such as a myocardial • Haloperidol with the action of enzymes used by the
infarction (heart attack) or stroke. OTHERS • Amisulpride • Clozapine virus to produce genetic material.
Aspirin and dipyridamole are com- • Flupentixol • Olanzapine • Pimozide SIDE EFFECTS
monly used antiplatelet drugs. Others, • Quetiapine • Risperidone • Zotepine Antiretroviral drugs can have a range
such as ticlopidine, are used specifically • Zuclopenthixol of side effects, including nausea, vomit-
to protect against the stroke or forma- ing, diarrhoea, tiredness, and a variety
tion of blood clots in the coronary A group of drugs used to treat psychoses of effects on blood chemistry, partic-
arteries in people who have had a stroke (mental disorders involving loss of ularly those that involve fats. (See also
or heart attack or have angina. contact with reality), particularly schizo- antiviral drugs.)

58
 ANTIVENOM

antirheumatic drugs dressed. Common antiseptics are chlor- antithyroid drugs

COMMON DRUGS
CORTICOSTEROIDS • Dexamethasone
hexidine, cetrimide, hexachlorophene, and
compounds containing iodine.
COMMON DRUGS
• Carbimazole • Iodine • Propylthiouracil
A
• Hydrocortisone • Methylprednisolone
• Prednisolone • Triamcinolone antiserum A group of drugs that are used to treat
GOLD-BASED DRUGS • Auranofin • Sodium A preparation containing antibodies hyperthyroidism, in which the thyroid
aurothiomalate (proteins manufactured by the immune gland is overactive. They may be used as
IMMUNOSUPPRESSANTS • Azathioprine system, see antibody) that combine with the sole treatment for hyperthyroidism
• Cyclophosphamide • Ciclosporin specific antigens (foreign proteins), usu- or may be given prior to thyroid surgery.
• Methotrexate ally components of microorganisms, HOW THEY WORK
NSAIDS • Aspirin • Celecoxib • Diclofenac leading to the deactivation or destruc- Carbimazole and propylthiouracil work pri-
• Etodolac • Felbinac • Ibuprofen • Ketoprofen tion of the microorganisms. marily by interfering with production of
• Mefenamic acid • Meloxicam • Naproxen Antiserum is usually used, along with thyroid hormones by the thyroid gland.
• Piroxicam immunization, as an emergency treat- Radioactive iodine works by destroying
OTHERS • Chloroquine • Hydroxychloroquine ment when an individual has been part of the thyroid tissue in people with
• Penicillamine • Sulfasalazine exposed to a dangerous infection, such hormone-secreting thyroid nodules.
as rabies, and has not previously been SIDE EFFECTS
A group of drugs that are used to treat immunized against it. The antiserum Side effects of carbimazole and propyl-
rheumatoid arthritis and types of arthritis helps to provide some immediate thiouracil include nausea, headaches,
that are the result of other autoimmune protection against the infective micro- mild gastrointestinal disturbances, dizzi-
disorders (in which the immune system organisms while full immunity is ness, joint pain, itching, and rash.
attacks the body’s own tissues) such developing. Such measures are not as Carbimazole can suppress white blood
as systemic lupus erythematosus. Anti- effective in preventing disease as earlier cell production. Iodine can cause hyper-
rheumatic drugs affect the disease (pre-exposure) immunization, however. sensitivity reactions resembling coryza
process and may, therefore, limit joint (nasal symptoms of the common cold).
damage, unlike NSAIDs (see nonsteroidal antisocial personality disorder
anti-inflammatory drugs), which only Impulsive, destructive behaviour that antitoxin
relieve pain and stiffness. The most often disregards the feelings and rights Any of a variety of commercially pre-
commonly used antirheumatic drugs of others. People who have an antisocial pared substances containing antibodies
are corticosteroid drugs, immunosuppres- personality lack a sense of guilt and (proteins manufactured by the immune
sant drugs, chloroquine, penicillamine, cannot tolerate frustration. They may system) that can combine with and
gold, and sulfasalazine. have problems with relationships and neutralize the effect of a specific toxin
HOW THEY WORK are frequently in trouble with the law. that has been released into the blood-
Different types of antirheumatic drug Behaviour therapy and various forms stream by particular bacteria (such as
work in different ways, by suppressing of psychotherapy may help to improve those that cause tetanus and diphtheria).
either the production or the activity of social integration. In general, the effects Antitoxins are usually given by injec-
lymphocytes (white blood cells). All anti- of the condition decrease with age. tion into a muscle. Occasionally, an
rheumatics reduce inflammation caused antitoxin may cause an allergic reaction
by the autoimmune reaction and slow antispasmodic drugs (see allergy); rarely, it may cause anaphy-
down the degeneration of the cartilage COMMON DRUGS lactic shock (a severe allergic reaction
that lines the joints. • Atropine • Dicycloverine • Hyoscine requiring emergency treatment).
SIDE EFFECTS • Mebeverine
Many antirheumatic drugs can have seri- antitussive drugs
ous side effects, and treatment, other A group of drugs that relax spasm in Drugs that suppress or relieve a cough
than with NSAIDs, is therefore given only smooth (involuntary) muscle in the (see cough remedies).
under specialist medical supervision. wall of the intestine or bladder. Anti-
spasmodic drugs are used in the antivenom
antiseptics treatment of irritable bowel syndrome A specific treatment for bites or stings
Chemicals that are applied to the skin in and irritable bladder. inflicted by venomous animals such as
order to destroy bacteria and other HOW THEY WORK snakes, spiders, and scorpions.
microorganisms, thereby preventing Some antispasmodic drugs have an Antivenom is prepared by the inocu-
sepsis (infection). Antisepsis (the use of anticholinergic action (that is, they lation of animals, such as horses, with
antiseptics to prevent infection) is not work by blocking the action of acetyl- venom from a particular poisonous ani-
the same as asepsis, which is the cre- choline, a neurotransmitter chemical mal, thereby provoking the production
ation of a germ-free environment (see released from nerve endings that stimu- of antibodies (proteins manufactured by
aseptic technique). Antiseptics are milder lates muscle contraction). Others work the immune system) that neutralize the
than disinfectants, which decontaminate by direct action on smooth muscle. poisons in the venom. A preparation of
inanimate objects but are too strong to SIDE EFFECTS these antibodies can be produced from
be used on the body. Possible side effects of antispasmodic samples of the animal’s blood.
Antiseptic fluids are generally used drugs include a dry mouth, blurred Antivenoms are given by intravenous
for bathing wounds; antiseptic creams vision, and difficulty in passing urine. injection and may cause allergic reac-
are applied to wounds before they are (See also anticholinergic drugs.) tions (see allergy).

59
 ANTIVIRAL DRUGS

antiviral drugs function of the kidneys, but a much

STRUCTURE OF THE ANUS
A COMMON DRUGS
ANTIRETROVIRALS • Didanosine • Efavirenz
more common cause is a complete
blockage of the flow of urine as a result
The anus is a canal
• Indinavir • Lamivudine • Nelfinavir of enlargement of the prostate gland at the end of the
• Nevirapine • Ritonavir • Saquinavir (see prostate, enlarged), a bladder tumour, alimentary tract, with
• Stavudine • Zalcitabine • Zidovudine or a bladder or kidney stone in the (see internal and external
OTHERS • Aciclovir • Amantadine • Cidofovir calculus, urinary tract). Failure of the kid- sphincters to open and
• Famciclovir • Foscarnet • Ganciclovir neys to produce urine may be due to close the orifice.
• Idoxuridine • Inosine pranobex • Interferon oxygen depletion as a result of reduced
blood flow through the kidneys, as Rectum
• Penciclovir • Ribavirin • Valaciclovir
• Zanamivir occurs in shock, or to severe kidney
damage caused by a disease such as Mucous
membrane
Drugs used in the treatment of infection glomerulonephritis.
by viruses. No drugs have been deve- Anuria requires urgent investigation Fat
loped that can eradicate viruses to establish the cause and to allow treat-
completely, and at present immunization ment (such as rehydration or removal
is the most effective way of preventing of the blockage) to begin. Treatment of
serious viral infections. However, anti- the cause may restore urine production,
viral drugs can reduce the severity of but any delay can result in permanent
some viral infections (most notably kidney damage, leading to uraemia
herpes, influenza, viral hepatitis, and (excess urea and other waste products
cytomegalovirus infections), particularly in the blood).
in people who have reduced immunity.
Advances have also been made in the anus
treatment of HIV infection (see anti- The end of the alimentary tract through
retroviral drugs). which faeces are expelled from the
HOW THEY WORK body. The anus is an extension of
Most antiviral drugs destroy viruses by the rectum as it passes downwards and
disrupting the chemical processes neces- backwards through the pelvic floor.
sary for the virus to grow and multiply The orifice at the end of the anal
within a cell. Some antivirals actually canal is open only during defaecation; Skin Internal External
prevent viruses penetrating the cells. at other times it is kept closed by the sphincter sphincter
muscles of the anal sphincter. These muscle muscle
SIDE EFFECTS
Side effects of antiviral drugs used in muscles are arranged in two layers: the
the treatment of HIV infection and AIDS internal sphincter, which cannot be
may include nausea, diarrhoea, and controlled voluntarily, and the external opening, anal dilation (a procedure to
tiredness. These drugs may also affect sphincter, which can be relaxed at will enlarge the anus) may be required for
blood chemistry, leading to conditions for defaecation. Disorders of the anus several months afterwards.
such as anaemia (a reduced level of the include anal cancer (see anus, cancer of)
oxygen-carrying pigment haemoglobin and imperforate anus (see anus, imper- anxiety
in the blood). forate). (See also digestive system.) An unpleasant emotional state that
Most other antivirals rarely cause side ranges from mild unease to intense fear.
effects. Antiviral creams may cause skin anus, cancer of Anxiety is a normal response to stressful
irritation and those given by mouth or A rare cancer of the skin of the anus. situations and prepares the mind and
injection may lead to nausea, dizziness, Possible early signs of anal cancer are body to respond effectively. However,
and rarely, in prolonged treatment, to the development of swelling or an ulcer anxiety that occurs without reason may
kidney damage. at the anus, accompanied by bleeding be a symptom of an anxiety disorder or
and discomfort. Treatment is by surgical another psychological disorder such
antral irrigation removal and/or radiotherapy. as depression.
Irrigation (flushing out) of the maxil- SYMPTOMS
lary antrum, one of the nasal sinuses. anus, imperforate A variety of physical symptoms are
More commonly known as a sinus A rare congenital (present from birth) associated with anxiety. The most com-
washout, antral irrigation is used to abnormality in which the anal opening mon include palpitations (a more
treat persistent sinusitis. The procedure is missing or covered over. The severity forceful or faster heartbeat), chest
is performed less often nowadays since of the condition varies from complete pains, a feeling of tightness in the chest,
the introduction of nasal endoscopy, absence of the anal canal to only a layer and a tendency to overbreathe (see
(examination of the nasal cavity using a of skin covering the anal opening. hyperventilation). Muscle tension leads to
flexible viewing tube). Treatment is with surgery. In severe headaches and back pains.
cases, a colostomy may be needed initial- Gastrointestinal symptoms of anxiety
anuria ly before definitive surgery to construct include dry mouth (see mouth, dry),
Complete cessation of urine output. an anus. Where surgery simply involves bloating, diarrhoea, nausea, and diffi-
Anuria may be caused by a severe mal- removal of a layer of skin over the anal culty in swallowing. Other symptoms

60
 AORTIC INCOMPETENCE

antianxiety drugs (especially benzodiaz-

DISORDERS OF THE ANUS epine drugs) may be used for short-
term treatment but are addictive.
A
Most anal disorders are minor but Other disorders
may cause considerable discomfort Haemorrhoids are enlarged blood vessels anxiolytics
and concern. Many are aggravated by under the lining of the anus and may
See antianxiety drugs.
constipation and may be helped by cause bleeding during defaecation,
regular toilet habits, an increased intake itching, and pain. aorta
of fluids, wholemeal products, fruits, An anal fistula is an abnormal tunnel
The main artery of the body, which sup-
and vegetables to soften the faeces, and connecting the inside of the anal canal
plies oxygenated blood to all other parts.
the use of glycerine suppositories, with the skin surrounding the anus.
The aorta arises from the left ventricle
if necessary. These fistulas usually result from an
(the main pumping chamber of the
abscess in the wall of the anus.
heart) and arches up over the heart
Congenital defects Itching of the anus (pruritus ani) may
before descending, behind it, through the
Imperforate anus is an uncommon be a direct result of another disorder,
chest cavity. It terminates in the abdo-
birth defect in which the anus is sealed such as an anal fistula, haemorrhoids or
men by dividing into the two common
(see anus, imperforate). threadworm infestation.
iliac arteries of the legs. The aorta is
In anal stenosis, the anus is too Anal warts (see warts, genital) are
thick-walled and has a large diameter to
narrow to allow the normal passage of transmitted by sexual contact and are
cope with the high pressure and large
faeces. This is sometimes a congenital caused by a papillomavirus.
volume of blood passing through it.
abnormality, but it can also result from
DISORDERS
scarring following surgery to treat
INVESTIGATION The aorta, like other arteries, can become
another disorder.
narrowed as a result of atherosclerosis
Investigation of anal disorders is (fat deposits on its walls), which may
Injury usually by visual inspection, cause hypertension (high blood pres-
Anal fissures originate from small sometimes involving proctoscopy sure). Coarctation of the aorta (in which
tears in the lining of the anus, usually (use of a rigid internal viewing tube) the aorta is abnormally narrow at birth)
as a result of straining to pass hard, and digital examination (feeling and aortitis (inflammation of the aorta
dry faeces. with a finger). Sometimes a biopsy
wall) are examples of aorta-specific dis-
(small sample of tissue removed for
microscopic analysis) or swab may
orders. Both aortitis and atherosclerosis
Tumours
be taken for bacteriological culture. may result in an aortic aneurysm (bal-
Cancer of the skin around the anus is looning of the aorta wall), which may
rare (see anus, cancer of). require surgery. (See also arteries, disor-
ders of; circulatory system.)

include lightheadedness, sweating, pal- feature. Anxiety disorders are common aortic incompetence
lor, blushing, and a frequent need to and mainly affect young adults. Leakage of blood through the aortic
urinate or defaecate. TYPES valve (one of the heart valves), resulting
People with anxiety may have a con- In generalized anxiety disorder, the affec- in a backflow of blood from the aorta
stant feeling that something bad is ted individual suffers from persistent into the left ventricle (the heart’s main
going to happen. They may fear illness tension and apprehension that has no pumping chamber).
or worry about the health and safety of specific focus or cause, together with CAUSES
family and friends. Fear of losing con- physical or psychological symptoms Failure of the aortic valve to close pro-
trol is also common. Anxiety often leads that disrupt normal activity. Panic disor- perly may be due to a congenital (present
to increasing dependence on others, der is characterized by sudden and from birth) abnormality in which the
irritability, a sense of fatigue, and frus- recurrent attacks of extreme, unreason- valve has two leaflets (flaps) rather than
tration. Inability to relax may lead to able fear and anxiety. Phobias are three.The valve leaflets can be destroyed
difficulty in sleeping. irrational fears, such as the fear of open by infective endocarditis (inflammation
TREATMENT spaces or of spiders, that lead to avoid- of the membrane lining the heart).
People suffering from anxiety may be ance of certain situations or objects. Long-term hypertension can sometimes
helped by counselling or psychotherapy. Post-traumatic stress disorder is a form of cause the root of the aorta to stretch so
If there is an underlying disorder, such anxiety that develops following a that the valve does not close properly.
as depression, treatment with antidepres- stressful or traumatic event and obses- Aortic incompetence is also associated
sant drugs can help. Antianxiety drugs sive–compulsive disorder is a condition with ankylosing spondylitis (a disorder that
are used for short-term control of symp- in which a person’s obsessions and affects the spine), and Marfan syndrome,
toms but are avoided for long-term fears lead them to carry out repetitive, a congenital disorder of connective tis-
treatment because they are addictive. ritualized acts. sues. Rheumatic fever, which is now rare,
TREATMENT may damage the valve, causing a combi-
anxiety disorders Counselling, psychotherapy, and group nation of aortic stenosis (narrowing of
A group of mental illnesses, including or individual cognitive–behavioural ther- the aortic valve) and incompetence. In
several specific syndromes, in which apy are used to treat anxiety disorders. addition, aortic incompetence may
symptoms of anxiety are the principal Antidepressant drugs are often used, and occur in untreated syphilis.

61
 AORTIC STENOSIS

at a late stage, include a weak pulse and

LOCATION AND STRUCTURE OF THE AORTA
A cardiomegaly, (enlargement of the heart).
DIAGNOSIS AND TREATMENT
From its origin at the left ventricle, the diameter (about 2.5 cm at its origin) to A chest X-ray, an ECG (measurement of
aorta passes upwards, curves behind cope with the high pressure and large
the heart, and runs downwards, passing volume of blood that passes through it.
the electrical activity of the heart), and
through the thorax (chest) and into the The thick walls of the aorta have an echocardiography (imaging of the heart
abdomen, where it terminates by elastic quality that helps to even out structures by measuring the pattern of
dividing into two common iliac arteries. the peaks and troughs of pressure that reflection of sound waves from them)
The aorta is thick-walled and large in occur with each heartbeat. may be carried out to diagnose aortic
incompetence. A cardiac catheter (flexi-
Arteries to head and neck ble tube that is inserted into the heart
Artery to arm via blood vessels) can be used to
Arch of ascending aorta demonstrate the degree of stenosis (see
Descending aorta catheterization, cardiac).
Thorax Heart-valve surgery may be needed to
widen or replace the damaged valve.
aortitis
Inflammation of the aorta (the main
artery of the body). Aortitis is a rare
Abdomen condition that occurs in people with
arteritis (inflammation of the arteries) or
untreated syphilis and in some people
Common with ankylosing spondylitis (a disorder
iliac artery affecting the spine).
Aortitis may cause part of the aorta to
widen and its walls to become thinner.
This may lead to an aneurysm (balloon-
SYMPTOMS AND SIGNS aortic stenosis ing of the artery), which may burst and
Aortic incompetence may not cause Narrowing of the opening of the aortic cause severe, sometimes fatal, blood
symptoms; it is sometimes found during valve (one of the heart valves), causing loss. Aortitis may also damage the ring
a routine medical examination when the obstruction of blood flow into the cir- around the aortic valve in the heart, lead-
doctor hears a murmur (abnormal heart culation. Aortic stenosis makes the heart ing to aortic incompetence (a condition
sound) over the front of the chest wall work harder and causes the muscle in which allows the backflow of blood
to the left of the sternum (breastbone). the wall of the left ventricle (the main into the heart), which may eventually
The heart compensates for the back- pumping chamber of the heart) to result in heart failure (reduced pumping
flow of blood into the left ventricle by thicken. Narrowing of the valve also efficiency of the heart).
working harder, until the combination reduces the amount of blood flowing
of hypertrophy (muscle thickening) and into the coronary arteries (the main aortography
dilatation (ballooning) of the left ven- arteries that supply the tissues of the An imaging technique that enables
tricle wall eventually leads to heart heart with oxygen-rich blood). the aorta (the main artery of the body)
failure (reduced pumping efficiency of CAUSES and its branches to be seen clearly on
the heart); this causes breathing diffi- The most common cause of aortic X-ray film following injection of a con-
culty and oedema (a buildup of fluid). stenosis is deposition of calcium on the trast medium (a substance that is opaque
DIAGNOSIS AND TREATMENT aortic valve. This deposition is usually to X-rays) into the aorta.
A chest X-ray, ECG (measurement of the associated with atherosclerosis (fatty HOW AND WHY IT IS DONE
electrical activity of the heart), and deposits). Aortic stenosis may also be The contrast medium is usually injected
echocardiography (imaging of the heart the result of a congenital (present from into the aorta through a fine catheter (a
structures by measuring the pattern of birth) abnormality. flexible plastic tube) that is inserted
reflection of sound waves from them) SYMPTOMS AND SIGNS either into the femoral artery at the
may be carried out to diagnose aortic Aortic stenosis may not cause any groin, the brachial artery on the inside
incompetence. A cardiac catheter (flexi- symptoms; it is sometimes found dur- of the elbow, or directly into the aorta
ble tube inserted into the heart via ing a routine medical examination within the lower abdomen.
blood vessels) is sometimes used to when the doctor hears a murmur (an Aortography is used if surgery is
demonstrate the degree of incompe- abnormal heart sound) over the front needed to treat an aneurysm (ballooning
tence (see catheterization, cardiac). of the chest wall to the right of the of the aorta).
Heart failure resulting from aortic sternum (breastbone) and sometimes
incompetence can be treated with diur- up into the neck. Symptoms, when apathy
etic drugs or other drugs to remove they do occur, include fainting, lack of The absence of feelings that is often
retained fluid from the lungs. Heart- energy, chest pain on exertion as a associated with a lack of energy. Healthy
valve surgery to replace the damaged result of angina pectoris, and breathing people may be described as apathetic,
valve may eventually be necessary. difficulties. Other features, which occur but true apathy is a feature of certain

62
 APHRODISIAC

APGAR CHART
A
Sign 0 1 2
Colour Blue, pale Body pink; extremities blue Completely pink

Respiratory effort Absent Weak cry; irregular breathing Good strong cry; regular breathing

Muscle tone Limp Bending of some limbs Active motion; limbs well-flexed

Reflex irritability No response Grimace (on nasal stimulation) Cry

Heart rate Absent Slow (below 100 beats per minute) Over 100 beats per minute

mental illnesses, such as schizophrenia. and write, and/or comprehend and read. the more severe the aphasia, the less the
An affected person fails to take interest Related disabilities that may occur as a chances of recovery. Speech therapy is
in everyday activities and tends to be feature of aphasia are alexia (word blind- the main treatment. (See also aphonia;
inactive and lacking in volition (drive). ness) and agraphia (writing difficulty). dysarthria; dysphasia; dysphonia; speech;
CAUSES speech disorders.)
aperient Language function in the brain lies in
A mild laxative drug. the dominant cerebral hemisphere (see apheresis
cerebrum). Two particular areas in this A procedure in which blood is with-
apex hemisphere, Broca’s and Wernicke’s drawn from a donor or patient and
The tip or uppermost surface of an areas, and the pathways connecting the reinfused after one or more selected
organ or structure, such as the lungs or two, are important in language skills. components have been separated and
the heart. The apex of a tooth is the tip Damage to these areas, which most removed. For example, in plasmapher-
of its root. commonly occurs as a result of stroke or esis, antibodies (proteins manufactured
head injury, can lead to aphasia. by the immune system) that are causing a
apex beat TYPES AND SYMPTOMS disease (such as Guillain–Barré syndrome
A normal heartbeat felt through the Broca’s aphasia causes difficulty in or Goodpasture’s syndrome) are removed;
chest wall. As the heart contracts, its tip expressing language. Speech is laboured in leukapheresis, white blood cells (see
hits the chest wall and the beat can be and normal rhythm is lost, but the few lymphocyte) are removed either to re-
felt between the fifth and sixth ribs on words uttered tend to be meaningful. duce their number or to harvest them
the left side of the chest. The apex beat Writing may also be impaired. for use in a blood transfusion.
is displaced when the heart is enlarged. Wernicke’s aphasia causes difficulty
in language comprehension. Speech is aphonia
Apgar score fluent but its content is disturbed, with Complete loss of the voice, which may
A system devised by Virginia Apgar, an errors in word selection and grammar. result from surgery to the larynx (voice-
American anaesthetist, to assess the Writing is also impaired, and spoken box) or may be temporary, sudden in
condition of a newborn baby and help and/or written language may not be onset, and due to emotional stress.
to direct appropriate care. Five features understood. In aphonia, the vocal cords fail to meet
(breathing, heart rate, colour, muscle In associative aphasia, comprehension as normal when an individual tries
tone, and response to stimulation) are is normal, and the affected individual to speak, although they may come
scored one minute, and again five min- can write and speak. However, he or she together when the person coughs.
utes, after birth. is unable to repeat what has been heard There is no particular treatment for
and cannot read aloud. aphonia, but in the temporary form of
aphakia Global aphasia comprises the total, or the condition, the sufferer’s voice
The absence of the lens from the eye. near total, inability to speak, write, usually returns as suddenly as it disap-
Aphakia may be congenital (present or understand language. peared. (See also dysphonia.)
from birth), may result from surgery Nominal aphasia is restricted to diffi-
(for example, cataract surgery), or may culty in naming objects or in finding aphrodisiac
be due to a penetrating injury. words, although the sufferer may be Any substance that is thought to stimu-
Aphakia causes severe loss of focusing able to choose the correct word from late erotic desire and enhance sexual
in the affected eye and requires correc- several offered. performance. Aphrodisiacs are named
tion by implanting a lens or with In jargon aphasia, an affected individ- after Aphrodite, the Greek goddess of
contact lenses or glasses. ual cannot form grammatical sentences love, beauty, and fertility.
and utters meaningless phrases com- For centuries, various substances
aphasia posed of jumbled words or neologism. (most notably oysters and rhinoceros
Complete absence of previously acqui- TREATMENT AND OUTLOOK horn) have been used as aphrodisiacs.
red language skills caused by a brain Some recovery from aphasia is usual In fact, no substance has a proven
disorder that affects the ability to speak following a stroke or head injury, but aphrodisiac effect.

63
 APHTHOUS ULCER

aphthous ulcer Deliberate temporary apnoea occurs in apomorphine

A See ulcer, aphthous. breath-holding attacks. Another type of
apnoea occurs in Cheyne–Stokes respira-
A drug that is used in the treatment of
Parkinson’s disease. Nausea and vomit-
apical tion, in which cycles of deep, rapid ing are common side effects of
A term used to describe the position of breathing alternate with episodes of apomorphine at the start of treatment.
structures that are found at the apex breathing stoppage.
(tip) of particular organs and struc- TREATMENT aponeurosis
tures, including the lungs and heart. Treatment depends on the cause; in new- A wide sheet of tough, fibrous tissue
born babies, apnoea resolves itself as that acts as a tendon by attaching a
apicectomy they mature. In cases of stroke or head muscle to a bone or a joint.
The surgical removal of the tip of a injury, artificial ventilation may be neces-
tooth root in order physically to elimi- sary, temporarily, until recovery occurs. apophysis
nate an infection or an infected cyst at An outgrowth of bone at the site of
the root tip. The procedure was once apocrine gland attachment of a tendon to bone. Inflam-
performed as part of root-canal treatment A gland that discharges cellular material mation may occur, as in Osgood–
but is now used less often because root- in addition to the fluid that it secretes. Schlatter disease.
canal treatment alone usually achieves The term apocrine is usually applied to
the desired result. the type of sweat glands that appear in apoplexy
hairy areas of the body after puberty. An outdated term for a stroke.
aplasia (See also eccrine gland.)
Absent or severely reduced growth and apoptosis
development of any organ or tissue. For apocrinitis The natural process of programmed cell
example, in bone marrow aplasia, the Inflammation of the apocrine glands, death. Apoptosis occurs in embryonic
rate of cell division in the bone marrow which are located in the armpit, groin, development, when the shaping of
is reduced, leading to insufficient and perineum. body parts is taking place, and contin-
blood-cell production (see anaemia, ues throughout life in the constant cycle
aplastic). Some birth defects, such as apolipoprotein of death and renewal of body cells. Fail-
stunted limbs (see phocomelia), occur as Any of a group of proteins that are con- ure of apoptosis is implicated in the
a result of incomplete tissue formation stituents of lipoproteins, the carriers of development of cancers.
during prenatal development. fat in the bloodstream. Apolipoproteins
are also involved in the growth and apothecary
aplastic anaemia repair of nerve tissues. An outdated term for a pharmacist.
See anaemia, aplastic.
apnoea LAPAROSCOPIC APPENDICECTOMY
Cessation of breathing that can occur Sites of
Surgery to remove the appendix can be
either temporarily (for a few seconds or carried out, under general anaesthesia, incision
up to a minute or two) or for a pro- either conventionally or laparoscopically.
longed period. Laparoscopic appendicectomy takes
CAUSES approximately an hour, which is three
Breathing is an automatic process that is Caecum
times as long as conventional surgery,
Appendix
controlled by the respiratory centre in but recovery is quicker.
the brainstem (a stalk of nerve tissue
linking the brain to the spinal cord).
The respiratory centre sends nerve Laparoscope
impulses that regulate contraction of Power source

the diaphragm and muscles in the chest

wall, thereby controlling the rate and Appendix Instrument
depth of breathing. Failure of this centre Caecum
to maintain normal breathing is known
as central apnoea. The condition may Suction tube
occur in babies, particularly those who
are premature, and can be detected by Procedure
an apnoea alarm. Central apnoea can Three or four tiny
also be the result of damage to the incisions are made
brainstem (following a stroke or head in the abdominal wall,
and a laparoscope,
injury, for example).
instruments, and
In obstructive apnoea, breathing is suction tubes are
prevented by a blockage in the airway. inserted. The appendix
The most common type is sleep apnoea, is then clamped, tied
in which blockage of the upper airway off, and removed.
occurs repeatedly during sleep.

64
 APPETITE, LOSS OF

appendage cases, the omentum (fold of periton-

LOCATION OF THE APPENDIX
An additional piece of tissue that is
attached to a main structure. An auric-
eum that covers the intestines) envelops
the inflamed appendix; this prevents the
A
In the lower right-hand
ular appendage is a small tag of tissue side of the abdomen, the spread of infection but may result in a
attached near the ear that may be pre- appendix may lie behind localized abscess around the appendix.
sent from birth. the caecum, or in front of
or behind the ileum. appendix
appendicectomy A small, narrow tube that projects out
Surgical removal of the appendix to treat of the caecum (the first part of the
acute appendicitis (inflammation of the Liver Stomach colon) at the lower right-hand side of
appendix). the abdomen. The appendix may lie
WHY IT IS DONE behind or below the caecum, or in
Appendicectomy is performed to pre- front of or behind the ileum (part of
vent an inflamed appendix bursting and the small intestine).
causing peritonitis (inflammation of the The appendix has no known func-
peritoneum, the lining of the abdomi- tion, but it contains a large amount
nal cavity) or an abdominal abscess. of lymphoid tissue, which provides a
HOW IT IS DONE defence against localized infection. The
The two methods of appendicectomy position of an individual’s appendix
are conventional appendicectomy and partly determines the symptoms produ-
minimally invasive surgery. Conventional ced by acute appendicitis (inflammation
surgery involves making a hole in the of the appendix).
abdominal wall that is large enough for
the surgeon’s instruments and finger- appendix abscess
tips to be introduced. In minimally Caecum Large An abscess (a collection of pus) that
intestine
invasive surgery, three or four small Ileum may form after the rupture of an
holes are made in the abdominal wall; a inflamed appendix (see appendicitis).
Appendix Rectum
laparoscope (viewing instrument) that
incorporates a video camera is inserted appetite
into one of the openings, and instru- A desire for food; a pleasant sensation
ments and suction tubes into the others. becomes inflamed, swollen, and infec- that is felt in anticipation of eating.
In both types of operation, the appen- ted. This may lead to gangrene (tissue Appetite is distinct from hunger, which
dix is identified, clamped, tied off at its death) in the appendix wall, which may is a disagreeable feeling caused by the
base, and removed. perforate (burst). need for food.
If the appendix has burst, the infected The first symptom is usually vague Appetite, which is regulated by two
area of the abdominal cavity is washed discomfort around the navel. Within a parts of the brain (the hypothalamus and
out with saline and drained via a tube few hours, this develops into severe, cerebral cortex), is learned by enjoying
inserted into one of the incisions. more localized pain, which is usually a variety of foods that smell, taste, and
Antibiotic drugs may also be given to most intense in the lower right-hand side look good. It combines with hunger to
prevent peritonitis. of the abdomen. Symptoms may differ ensure that the right amount of a wide
COMPLICATIONS AND OUTLOOK if the appendix is not in the most com- range of foods is eaten in order to stay
Possible complications are infection of mon position. For example, if the healthy. (See also appetite, loss of.)
the incision wound, an abscess at the appendix impinges on the ureter, the
site from which the appendix was urine may become bloodstained. appetite, loss of
removed, or localized peritonitis. DIAGNOSIS AND TREATMENT Loss of appetite, known medically as
In the absence of complications, nor- Diagnosis may be difficult because the anorexia, is usually temporary and due
mal physical activities can usually be symptoms of appendicitis are similar to to an emotional upset or minor illness.
resumed within two to three weeks. those of many other abdominal disor- Persistent loss of appetite may be a
ders. Sometimes a laparotomy (surgical symptom of a more serious underlying
appendicitis investigation of the abdomen) is neces- physical or psychological disorder and
Acute inflammation of the appendix (a sary in order to confirm or exclude a requires investigation by a doctor.
narrow, finger-shaped tube that branches diagnosis of appendicitis. CAUSES
off the large intestine), which is a com- The usual treatment for appendicitis In adolescents and young adults, loss of
mon cause of abdominal pain and is appendicectomy, which is often per- appetite may be due to anorexia nervosa
peritonitis (inflammation of the lining formed endoscopically (see minimally (an eating disorder) or to drug abuse,
of the abdominal cavity). invasive surgery). particularly of amphetamine drugs. De-
CAUSE AND SYMPTOMS COMPLICATIONS pression or anxiety may result in loss of
The cause of appendicitis is usually not If treatment is delayed, an inflamed appetite at any age.
known, but the condition is sometimes appendix may burst, releasing its con- Possible physical causes of appetite
caused by obstruction of the appendix tents into the abdomen. At this point, loss include a stroke (damage to part of
by a lump of faeces. The closed end of the pain ceases abruptly, but the perfo- the brain caused by an interruption to
the appendix beyond the obstruction ration leads to peritonitis. In some its blood supply), a brain tumour, or a

65
 APPETITE STIMULANTS

head injury that has damaged the hypo- The use of sibutramine is strictly arachidonic acid
A thalamus or cerebral cortex (the parts
of the brain that control appetite).
controlled and is limited to a maximum
of one year.
One of the fatty acids in the body that
are essential for growth.
Other physical causes include intestinal
disorders, such as gastritis (inflamma- appliance arachis oil
tion of the stomach lining, which is See orthodontic appliances. Peanut or ground-nut oil. Arachis oil is
common in problem drinkers), stomach used in enemas to lubricate and soften
cancer, a gastric ulcer, and liver disorders apraxia impacted faeces and to make bowel
such as hepatitis. Many infectious dis- The inability to carry out purposeful movements easier. It can also be applied
eases, such as influenza, can also lead to movements despite normal muscle to the scalp, followed by shampooing,
loss of appetite. power and coordination. Apraxia is in the treatment of cradle cap.
Between the ages of about two and caused by damage to nerve tracts in the
four, some children go through a per- cerebrum (the main mass of the brain) arachnodactyly
iod of refusing food. If there are no that translate the idea for a movement A term for long, thin, spiderlike fingers
other symptoms, this phase should be into an actual movement. People with and toes. Arachnodactyly sometimes
regarded as a normal part of a child’s apraxia usually know what they want to occurs spontaneously but is also charac-
development. do but are unable to recall from memo- teristic of Marfan syndrome, an inherited
For an otherwise healthy person, a ry the sequence of actions necessary to connective tissue disease.
period of two or three days without food achieve the movement. Damage to the
is not harmful, provided that plenty of cerebrum may be caused by a head arachnoiditis
nonalcoholic fluids are drunk. A doctor injury, an infection, a stroke (damage to A rare condition that is characterized by
should always be consulted, however, if part of the brain caused by interruption chronic inflammation and thickening of
there are other health problems (par- to its blood supply), or a brain tumour. the arachnoid mater, which is the mid-
ticularly diabetes mellitus) or if regular TYPES dle of the three meninges (membranes)
medication is being taken. Apraxia takes various forms, and each is that cover the brain and spinal cord.
All cases of appetite loss that last for related to damage in different parts of The cause of arachnoiditis is often
more than a few days should be investi- the brain. Ideomotor apraxia is the inab- unknown. However, the condition may
gated by a doctor. Appetite generally ility to carry out a spoken command to develop following an episode of menin-
returns to normal once any underlying make a certain movement, but to make gitis (inflammation of the meninges) or
illness has been treated. (See also the same movement unconsciously at a subarachnoid haemorrhage (a type of
appetite stimulants.) other times. In sensory apraxia, a person brain haemorrhage). It may also be a
may not be able to use an object due to feature of syphilis or ankylosing spondy-
appetite stimulants loss of ability to recognize its purpose. litis (a disorder affecting the spine).
Various tonics and remedies that have Agraphia (difficulty in writing) and Arachnoiditis may also result from
been traditionally prescribed to stim- aphasia (severe difficulty in expressing injury or certain medical procedures.
ulate the appetite. None are proven to language) are special forms of apraxia. Symptoms may include headache,
be effective. OUTLOOK epileptic seizures, blindness, or diffi-
Some drugs, such as corticosteroid Recovery from apraxia is highly variable culty with movements due to increased
drugs, may stimulate the appetite when and is dependent on the cause. Lost muscle tension. There is no effective
used to treat unrelated disorders. skills may need to be relearned. treatment for arachnoiditis.
appetite suppressants APUD cell tumour arachnoid mater
A group of drugs that reduce the desire A growth composed of cells that pro- The middle of the three layers of mem-
to eat. Sibutramine is the only appetite duce various hormones. APUD (amine brane (see meninges) that cover the brain
suppressant now commonly prescribed. precursor uptake and decarboxylation) and spinal cord.
Appetite suppressants may be used in cells occur in different parts of the body.
the treatment of severe obesity, along Some tumours of the thyroid gland, arbovirus
with dieting and exercise, when serious pancreas, and lungs are APUD cell Any of the many viruses transmitted by
attempts at dieting and exercise have tumours, as are carcinoid tumours a member of the arthropod group of
previously failed to bring about suffi- (tumours of the intestine or lung, see animals, including insects, mites, and
cient weight loss. carcinoid syndrome) and phaeochromo- ticks. (See also insects and disease; mites
HOW THEY WORK cytoma (a type of adrenal tumour). and disease; ticks and disease).
Sibutramine works by inhibiting the
reuptake of noradrenaline (norepineph- aqueous cream ARC
rine) and serotonin. An emollient preparation that is com- An abbreviation for AIDS-related complex.
SIDE EFFECTS monly used to treat dry, scaly, or itchy (See also AIDS.)
Common side effects of sibutramine skin in conditions such as eczema.
include constipation, a dry mouth (see arcus senilis
mouth, dry), insomnia, nausea, palpita- aqueous humour A grey-white ring near the edge of the
tions, hypertension (high blood pressure), A watery fluid that fills the front cham- cornea (the transparent front part of
headache, anxiety, sweating, and distur- ber of the eye, behind the cornea (the the eyeball) overlying the iris (the
bance of the sense of taste. transparent front part of the eyeball). coloured part of the eye).

66
 ARRHYTHMIA, CARDIAC

hormones (male sex hormones) that Tachycardias In sinus tachycardia, the

cause virilization (development of male
characteristics). Treatment of arrheno-
rate is raised, the rhythm is regular, and
the beat originates in the sinoatrial
A
blastoma is by surgical removal of node (see pacemaker). Supraventricular
the affected ovary. tachycardia is faster and the rhythm is
regular. It may be caused by an abnor-
arrhythmia, cardiac mal electrical pathway that allows an
An abnormality of the rhythm or the impulse to circulate continuously in the
rate of the heartbeat. Arrhythmias are heart and take over from the sinoatrial
the result of a disturbance in the elec- node. A rapid, irregular beat that origi-
Arcus senilis
trical impulses within the heart (see nates in the ventricles is known as a
The arcus senilis is the lighter ring that overlies the Cardiac arrhythmia box, below). Any iso- ventricular tachycardia. In atrial flutter, the
edge of the iris (the coloured part of the eye). lated irregular beat is known as an atria beat regularly and very rapidly, but
ectopic heartbeat. Ectopic beats do not not every impulse reaches the ven-
Arcus senilis, which is caused by degen- necessarily indicate the presence of an tricles, which beat at a slower rate.
eration of fatty material in the cornea, abnormality, however. Uncoordinated, fast beating of the atria
develops gradually during adult life. The TYPES is known as atrial fibrillation and pro-
ring never spreads to the centre and Arrhythmias can be divided into two duces totally irregular ventricular beats.
does not affect eyesight. The deve- main groups: tachycardias, in which Ventricular fibrillation is a form of cardiac
lopment of the condition in early the rate of the heartbeat is faster than arrest in which the heart does not
adulthood may be associated with an normal, and bradycardias, in which pump blood because the ventricles
abnormally high level of fats in the the rate is slower. The rhythm may be are twitching very rapidly in a dis-
blood (see hyperlipidaemia). regular, with each beat of the atria organized manner.
(upper chambers, see atrium) being fol- Bradycardias Sinus bradycardia is a slow,
areola lowed by one beat of the ventricles regular beat. In heart block, the conduc-
The pigmented circular area surround- (lower chambers). tion of electrical impulses through the
ing the nipple. The term is also used to
describe an inflamed area around a
pimple (see pustule). CARDIAC ARRHYTHMIA

Aricept Any disorder that interferes with the generation or transmission of impulses
through the heart’s electrical conducting system (below) can lead to a disturbance
A brand name for donepezil, an acetyl- of cardiac rate or rhythm. These ECG recordings show two kinds of arrhythmia:
used to treat
cholinesterase inhibitor sinus bradycardia and atrial fibrillation.
Alzheimer’s disease.
Sinoatrial node
aromatherapy This is the heart’s natural Right atrium
A form of complementary medicine that pacemaker from which
electrical impulses
uses aromatic oils extracted from plants originate. The impulses Left atrium
to treat a wide range of disorders. Prac- spread over the atria,
causing them
titioners claim that aromatherapy is to contract.
particularly effective in treating stress-
related and psychosomatic conditions. Atrioventricular node
Impulses from the
The oil is applied in small quantities sinoatrial node travel to
through massage; it may also be Left ventricle this second node, from
inhaled, incorporated into creams or which they spread to the
ventricles, causing
lotions, or, very occasionally, taken Right ventricle contractions that follow
internally. There is no conclusive scien- the atrial beats.
tific evidence of the benefits.
arousal
Sinus bradycardia
The awakening of a person from The heart rate is slow, but the rhythm normal,
unconsciousness or semiconsciousness. with each atrial beat (small rise) followed by
The term is also used to describe any a ventricular beat (spike). Sinus bradycardia
state of heightened awareness, such as is common in athletes but can also be caused
by hypothyroidism.
that caused by sexual stimulation or
fear. Arousal is regulated by the reticular
Atrial fibrillation
formation in the brainstem. The atria beat rapidly and irregularly.
Ventricular beats (spikes) do not follow each
arrhenoblastoma atrial beat and are irregularly spaced. This
A rare tumour of the ovary that occurs arrhythmia is common in the elderly and in
people with hyperthyroidism.
in young women. The tumour is non-
cancerous, but it secretes androgen

67
 ARROWROOT

heart muscle is either partially or com- traditionally used an an easily digestible Arteritis is inflammation of artery walls
A pletely blocked, leading to a slow,
irregular heartbeat. Periods of bradycar-
invalid or baby food, being either
mixed to a paste with milk or water or
that causes narrowing and sometimes
blockage.
dia may alternate with periods of used as an ingredient in biscuits. Aneurysm is ballooning of an artery
tachycardia due to a fault in impulse wall caused by the pressure of blood
generation (see sick sinus syndrome). arsenic flowing through a weakened area.
CAUSES A poisonous metallic element that Thrombosis occurs when a thrombus
A common cause of arrhythmia is occurs naturally in its pure form and (blood clot) forms in a blood vessel,
coronary artery disease, in which the various compounds. Arsenic poisoning, causing obstruction of the blood flow.
coronary arteries are narrowed by which is now rare, once occurred as a An embolism is blockage of an artery
atherosclerosis (fat deposits on the artery result of continuous industrial or pesti- by a fragment of blood clot or other
walls), particularly when following cide exposure. material travelling in the circulation.
myocardial infarction (heart attack). Some Raynaud’s disease is a disorder in
tachycardias are the result of a congenital arterial reconstructive surgery which there is intermittent spasm of
(present from birth) defect in the An operation to repair arteries that are small arteries in the hands and feet,
heart's conducting system. narrowed, blocked, or weakened. usually precipitated by the cold.
Caffeine can cause tachycardia in WHY IT IS DONE
some people. Amitriptyline and some Arterial reconstructive surgery is most arteriography
other antidepressant drugs can cause seri- often performed to repair arteries that An alternative name for angiography, an
ous cardiac arrhythmias if they are taken have been narrowed by atherosclerosis X-ray technique for imaging arteries.
in high doses. (fatty deposits on artery walls). It is also
SYMPTOMS used to repair aneurysms (ballooning of arteriole
An arrhythmia may be felt as pal- arteries) and arteries damaged as a A blood vessel that is a branch from an
pitations, in which the individual result of injury. artery and which branches further to
becomes aware of an abnormally rapid HOW IT IS DONE form capillaries. Arterioles have mus-
heartbeat. However, in some cases, A narrowed or blocked section of artery, cular walls, and their nerve supply
arrhythmias cause fainting and diz- particularly a coronary artery, can be enables them to be narrowed or
ziness as a result of reduced blood bypassed by sewing in a length of vein widened to meet the blood-flow needs
flow to the brain, or chest pain and above and below the constricted area. of tissues they supply.
breathlessness if there is a reduction in Elsewhere in the body. the affected sec-
blood flow to the lungs. These may be tion is commonly replaced using an arteriopathy
the first symptoms. artificial tube or a section of vein. (See Any disorder of an artery (see arteries,
DIAGNOSIS also angioplasty, balloon; coronary artery disorders of).
Arrhythmias are diagnosed by an ECG, bypass; endarterectomy.)
which shows the pattern of electrical arterioplasty
activity within heart muscle. If the arteries, disorders of Surgical repair of an artery (see arterial
arrhythmia is intermittent, a continuous Disorders of the arteries may take the reconstructive surgery).
recording may need to be made using form of abnormal narrowing (which
an ambulatory ECG. reduces blood flow and may cause tis- arteriosclerosis
TREATMENT sue damage), complete obstruction A group of disorders that cause thicken-
Treatments for arrhythmias include anti- (which may cause tissue death), or ing and loss of elasticity of artery walls.
arrhythmic drugs, which prevent or slow abnormal widening and thinning of an Atherosclerosis is the most common type
tachycardias. With an arrhythmia that artery wall (which may cause rupture of arteriosclerosis, and the two terms are
has developed suddenly, it may be pos- of the blood vessel). often used synonymously.
sible to restore normal heart rhythm by TYPES Other types are medial arteriosclero-
using electric shock to the heart (see Atherosclerosis, in which fat deposits sis (in which muscle and elastic fibres
defibrillation). build up on the lining of artery walls, is in larger arteries are replaced by fibrous
Repeated attacks of tachycardia can the most common arterial disease. It tissue) and Monckeberg’s arteriosclero-
sometimes be treated by radio frequency can involve arteries throughout the sis (in which there are calcium deposits
ablation (the removal of dead or diseased body, including the brain (see cere- in the arterial lining).
tissue) of the heart’s abnormal conduc- brovascular disease), heart (see coronary
tion pathway. This may be carried out artery disease), and legs (see peripheral arteriovenous fistula
during cardiac catheterization (see vascular disease). Atherosclerosis is the An abnormal communication directly
catheterization, cardiac). In some cases, a main type of arteriosclerosis, a group of between an artery and a vein. An arteri-
pacemaker can be fitted to restore nor- disorders that cause thickening and loss ovenous fistula may be present at birth
mal heartbeat by overriding the heart’s of elasticity of artery walls. or may result from injury. A fistula can
abnormal rhythm. Hypertension (high blood pressure) is also be created surgically for easy access
another common cause of thickening to the bloodstream, as occurs in dialysis.
arrowroot and narrowing of arteries. Hyperten- If the fistula is close to the skin sur-
A starchy substance that is obtained sion predisposes people to coronary face it may cause a small, pulsating
from the roots of the West Indian plant artery disease and increases the risk of a swelling. If several are present in the
MARANTA ARUNDINACEA. Arrowroot was stroke or kidney failure. lungs, uptake of oxygen into the blood

68
 ARTHRITIS

may be impaired, resulting in cyanosis over the temples and may also affect the
(blue skin colour) and breathing diffi-
culty on exertion.
retinal artery in the eye. Takayasu’s
arteritis is thought to be an autoim-
A
An isolated fistula that is causing mune disorder.This rare type of arteritis
symptoms can often be cut away and usually affects young women and
the ends of the blood vessels stitched involves the arteries that branch from
closed. However, if there are many fistu- the aorta into the neck and arms.
las, surgery is not practicable.
artery
arteritis A blood vessel that carries blood away
Inflammation of an artery wall, which from the heart. Systemic arteries carry
causes narrowing or complete blockage blood that has been pumped from the
of the affected artery, reduced blood left ventricle (lower chamber) of the
flow, and, in some cases, thrombosis heart to all other parts of the body
and tissue damage. except the lungs. The largest systemic
Arthritis in the hands
TYPES artery is the aorta, which emerges from The joints in the hands of a person suffering from
There are several types of arteritis. the left ventricle; other major systemic rheumatoid arthritis are painful, swollen, and stiff.
Buerger’s disease is an arteritis that arteries branch off from the aorta. The In severe cases, the joints become deformed.
affects the limbs, causing pain, numb- pulmonary arteries carry blood from
ness, and, in severe cases, gangrene. the right ventricle to the lungs. system attacks the body’s own tissues)
Polyarteritis nodosa, a serious autoimmune STRUCTURE that causes inflammation in the joints
disorder (in which the immune system Arteries are tubes with thick, elastic, and other body tissues such as the peri-
attacks the body’s own tissues), can muscular walls able to withstand the cardium (the membrane covering the
affect arteries in any part of the body, high pressure of blood flow, to which heart), the lungs, and the eyes. The dis-
especially the heart and kidneys. Tempo- they are subjected on each heartbeat. The order has different effects in children
ral arteritis affects arteries in the scalp structure of arteries helps to even out (see juvenile chronic arthritis).
the peaks and troughs of blood pressure Ankylosing spondylitis is another per-
caused by the heartbeat, so that the sistent type of arthritis that initially
STRUCTURE OF AN ARTERY blood is flowing at a relatively constant affects the spine and the joints between
pressure by the time it reaches the the base of the spine and the pelvis.
The walls of an artery consist of three
smaller blood vessels (arterioles, which Other tissues, such as the eyes, may
layers: a smooth inner lining, a thick,
muscular, elastic middle layer, and a branch directly off the arteries and con- also be affected. Eventually, the disorder
tough, fibrous outer covering. Veins nect to the even smaller capillaries). The may cause the vertebrae (the bones of
have thinner walls, and most of them pulmonary arteries are thinner-walled the spine) to fuse.
contain valves. than systemic arteries and contain Reactive arthritis typically develops in
blood at a lower pressure. (See also susceptible people following an infec-
Artery Thin, arteries, disorders of.) tion, most commonly of the genital
elastic
layers tract or intestines.
arthralgia Gout and pseudogout are types of
Pain in the joints or in a single joint. arthritis in which crystals are deposited
(See also arthritis; joint.) in a joint, causing swelling and pain.
Septic arthritis is a relatively rare con-
arthritis dition that can develop when infection
Tough Inflammation of one or more joints enters a joint either through a wound
outer layer that is characterized by pain, swelling, or from the bloodstream.
Muscular and stiffness. Arthritis can vary in seve- DIAGNOSIS
middle layer Inner coat rity from a mild ache and joint stiffness Diagnosis of particular types of arthritis
to severe pain and, subsequently, de- is made from blood tests and, in some
Vein formity of the joints. cases, microscopic examination of fluid
TYPES AND CAUSES from the affected joint. X-rays or MRI (a
Muscular
middle layer There are several different types of technique that produces cross-sectional
arthritis, each having different charac- or three-dimensional images of body
teristics. The most common type is structures) can indicate the type and
osteoarthritis, which most often involves extent of joint damage.
the knees, hips, and hands. It usually TREATMENT
affects middle-aged and older people Physiotherapy and exercises can help to
because it results principally from wear minimize the effects of arthritis, and
and tear on the joints. Cervical osteo- there are specific treatments for certain
arthritis is a form of osteoarthritis that types (antibiotic drugs for septic arth-
Tough affects the joints in the neck. ritis, for example).
outer layer Inner coat
Rheumatoid arthritis is a damaging auto- In severe cases, one or more of the
immune disorder (in which the immune diseased joints may require arthroplasty

69
 ARTHRODESIS

(replacement of a joint with an artificial arthrogryposis arthroscopy

A substitute) or arthrodesis (fusion of the
bones in a joint).
See contracture. Inspection through an endoscope (a
viewing tube) of the interior of a joint,
arthropathy usually for diagnostic purposes.
arthrodesis A medical term for any disease or disor- WHY IT IS DONE
A surgical procedure in which the two der that involves the joints. (See also Arthroscopy is most often used to diag-
bones in a diseased joint are fused to diabetic arthropathy.) nose disorders of the knee joint but can
prevent the joint from moving, which also be used in other joints such as the
relieves pain in the affected area. arthroplasty shoulder, hip, or wrist. The procedure
HOW AND WHY IT IS DONE Replacement of a joint or part of a joint allows the surgeon to see the surface of
Arthrodesis is performed if a joint is by metal or plastic components. A hip the bones, the ligaments, the cartilages,
painful or unstable and other treat- replacement is one of the most common and the synovial membrane. Specimens
ments, such as drugs or arthroplasty operations of this type, as is a knee-joint can be taken for examination.
(replacement of the joint with an arti- replacement. Replacement of other Some surgical procedures that used to
ficial substitute), have failed or are joints, such as the finger (see finger-joint involve making a large incision, such as
inappropriate. replacement), shoulder, and elbow, is removal of damaged cartilage, repair of
Arthrodesis of a small joint, such as a also common. ligaments, and shaving of the patella
finger joint, may be carried out under
local anaesthetic (see anaesthesia, local).
Otherwise, a general anaesthetic (see HOW ARTHROSCOPY IS DONE
anaesthesia, general) is used. In most
The procedure is usually performed under general anaesthesia. The joint is
cases, cartilage (smooth, shock-absorb-
distended by injecting air or a saline solution, and the arthroscope and a probe
ing tissue) is removed from the ends of are inserted into it through small skin incisions. While watching the monitor, the
the two bones, along with a surface surgeon can repair or remove tissue, such as damaged cartilage, or drill or shave
layer of bone from each. The two ends the surface of the patella (kneecap).
are then joined so that they will fuse
Surgeon
when fresh bone cells grow. The bones
Femur
may need to be kept in position with
plates, rods, or screws; a bone graft may Patella
also be carried out in some cases. Arthroscope
In arthrodesis of the knee or ankle Ligaments
joints, additional immobilization of the
Probe
joint (by transfixing it with pins inserted
through the skin) may be necessary to Tibia

keep the area stable until healing is

Fibula
complete.
RECOVERY AND OUTLOOK Arthroscope
Complete union of the bones can take
up to six months but may be much Power cable Monitor
quicker. In some cases the bones fail to
fuse, but fibrous tissue usually fills the Probe
gap between them and is strong enough
to provide the same effect and strength
as bone fusion.
Following arthrodesis, no movement
can take place in the affected joint,
unlike after arthroplasty. However, the
advantage of arthrodesis over arth-
roplasty is that, once it has been
performed, it requires no regular sur-
veillance or further care; and the patient
can be reasonably confident that the
problem with the joint has been
resolved permanently.
arthrography Eyepiece Hollow steel tube
Arthroscope
A diagnostic technique in which the An arthroscope is a type of
interior of a damaged joint is X-rayed rigid endoscope – a hollow
following the injection of a radiopaque stainless steel tube
(visible on X-ray) solution. The proce- containing optical fibres,
a lens, and a light source. Air or water stopcocks
dure is gradually being replaced by MRI,
ultrasound scanning, and arthroscopy.

70
 ASCARIASIS

(kneecap), are now usually performed artificial limb

arthroscopically. Arthroscopic surgery
substantially reduces the amount of
See prosthesis. A
recovery time required. artificial respiration
See rescue breathing.
Arthrotec
The brand name of an antirheumatic drug artificial rupture of membranes
containing diclofenac and misoprostol. See amniotomy.
articulation artificial saliva
The junction point of two or more A preparation used to relieve a persis-
bones (see joint). tently dry mouth, which may be a side
effect of certain drugs or radiotherapy or
artificial feeding may be due to Sjögren’s syndrome (an
See feeding, artificial. autoimmune disorder in which the im-
mune system attacks the body’s own
artificial heart tissues). Artificial saliva, as a spray, gel,
See heart, artificial. or pastilles, is formulated to resemble
natural saliva as closely as possible.
artificial insemination Electron micrograph of asbestos fibre in lung
An inhaled asbestos fibre impales and kills a
A form of assisted conception in which artificial sweeteners macrophage (a scavenger cell that would normally
semen is introduced artificially into the Synthetic substitutes for sugar that are engulf and destroy foreign particles in the lungs).
uterus, instead of by sexual intercourse, used by people on slimming diets and
with the aim of inducing conception by the food industry. is usually at least 20 years. Diagnosis is
and pregnancy. Saccharin and aspartame are often by chest X-ray. Asbestosis increases the
TYPES recommended for use in calorie- risk of developing lung cancer.
There are two types of artificial insemi- controlled diets. They are, however, of Mesothelioma is a cancerous tumour
nation: AIH, artificial insemination with questionable value because the appetite of the pleura (the membrane surround-
the semen of the woman’s male partner; compensates for the lack of calories ing the lungs) or the peritoneum (the
and AID, insemination with a donor’s from sugar, therefore other foods are membrane lining the abdominal cav-
sperm. AIH is usually used for couples eaten to maintain the calorie intake. ity). In the pleura, mesotheliomas cause
who are unable to have intercourse, or pain and breathlessness; in the peri-
if the man has a low sperm count or a artificial tears toneum they cause enlargement of the
low volume of ejaculate. It is also used Preparations that are used to supplem- abdomen and intestinal obstruction.
when a man’s semen has been stored ent tear production in disorders, such as The condition cannot be treated and
prior to his having treatment (such as keratoconjunctivitis sicca, that cause dry usually leads to death within one or two
chemotherapy) that has made him sterile. eye and to relieve irritation. years. The average interval between ini-
AID is available to couples if the man is tial exposure to asbestos and death is
infertile or a carrier of a genetic disease. arytenoid between 20 and 30 years. Mesothe-
It may also be used by a woman who One of two pyramid-shaped cartilages lioma affects people who have been
wants children but has no male partner. that form part of the larynx (voice-box). exposed to blue or brown asbestos.
HOW IT IS DONE Diffuse pleural thickening is a condi-
Artificial insemination is carried out at asbestos-related diseases tion in which the outer and inner layers
centres that are specially staffed and A variety of diseases that are caused by of the pleura become thickened, and
equipped to obtain, test, and store inhalation of asbestos fibres. Asbestos is excess fluid may accumulate in the cav-
semen, to carry out the insemination, a fibrous mineral formerly used as a ity between them. This combination
and to give counselling before and after heat- and fire-resistant insulating mat- restricts the ability of the lungs to
the procedure. Semen donors are erial. There are three main types of expand, resulting in shortness of breath.
screened for a wide variety of physical asbestos fibre: white, which is widely The condition may develop even after
and mental disorders. used, blue, and brown. Blue and brown short exposure to asbestos.
Insemination is performed by inject- are the most dangerous types of
ing a sample of semen into the asbestos. The use of all types is now asbestosis
woman’s cervix using a small syringe. carefully controlled. See asbestos-related diseases.
The procedure is timed to coincide TYPES
with her natural ovulation (the devel- In asbestosis, widespread fine scarring ascariasis
opment and release of an egg from the occurs in the lungs. The disease causes Infestation with the roundworm ASCARIS
ovary), or it may be combined with breathlessness and a dry cough, eventu- LUMBRICOIDES , which lives in the small
treatment to stimulate ovulation. ally leading to severe disability and death. intestine of its human host. Ascariasis is
Asbestosis develops mostly in industrial common worldwide, especially in the
artificial kidney workers who have been heavily exposed tropics. One or several worms may be
The common name for the machine to asbestos. The period from initial present, but symptoms usually only
used in dialysis. exposure to development of the disease occur with heavy infestation.

71
 ASCITES

ASD
LIFE CYCLE OF THE ASCARIS WORM
A The abbreviation for atrial septal defect.
The person aseptic necrosis
becomes infested Food gr
o
ces soil car wn in Death of an area of bone tissue in the
by swallowing the n fae
o ut i e soil r c
the hos ies eg onta absence of infection. The cause of asep-
eggs, which ss at t gs m
pa min to in tic necrosis is almost always damage to
hatch into larvae gs onta

at
c

Eg
the blood supply to bone, often as a

ed
in the intestine.

to
The larvae travel result of a fracture. In some cases, the

Eg rvae i e
la testin
gs
in the blood condition is associated with treatment

in

hat the
through the wall gs with corticosteroid drugs.
numbers of eg

ch int
n
Female worms
produce large

of the intestine to Aseptic necrosis often results in

the lungs, up the

o
chronic (long-term) pain and may
windpipe, and cause stiffness in adjacent joints. Early
are swallowed treatment of fractures reduces the risk
back into the of the condition developing.
small intestine.
Larv t wor stin
adu ll inte
sma

The head of the femur (thigh-bone)

un the
There they
ae ms e
l

and the scaphoid (a bone in the wrist)

gs
become adult

th s in
ma in

are particularly likely to be affected.

tu t

to pas
el
worms.
re

in
he to a Aseptic necrosis may be diagnosed from

e
rv
L a o od X-rays; the affected area of bone appears
bl
Lar vae pass up the
wind pip e and are denser than the surrounding bone.
then swa lowed
l
aseptic technique
The creation of a germ-free environ-
ment to protect a patient from infection.
Aseptic technique is used during sur-
CAUSES CAUSES gery and other minor procedures, such
The parasite that causes ascariasis is a Ascites may occur in any condition that as the insertion of a urinary catheter. It
pale, cylindrical, tapered roundworm, causes generalized oedema (excessive is also used during the care of people
which reaches between 15 and 35 cm accumulation of fluid in the body tis- suffering from diseases in which the
in length in its adult form. sues), such as in congestive heart failure, immune system is suppressed, such as
Ascariasis is spread by ingestion of nephrotic syndrome, and cirrhosis of the leukaemia. Such conditions result in a
worm eggs, usually from food grown in liver. Ascites may occur in cancer if weakening of the body’s natural def-
soil that has been contaminated by metastases (secondary growths) from a ences against infection.
human faeces. In some dry, windy cli- cancer elsewhere in the body develop in All people who come in contact with
mates, airborne eggs may be swallowed the peritoneum. The condition also oc- the patient must scrub their hands and
after being blown into the mouth. curs if tuberculosis affects the abdomen. wear disposable gloves and masks and
SYMPTOMS SYMPTOMS pre-sterilized gowns. Surgical instru-
Light infestation may cause no symp- Ascites causes abdominal swelling and ments are sterilized in an autoclave. The
toms, although mild nausea, abdominal discomfort. Additionally, it may cause patient’s skin is cleaned with antiseptic
pain, and irregular bowel movements breathing difficulty as a result of pres- solutions of, for example, iodine or
may occur. A worm may be passed via sure on, and the immobilization of, the chlorhexidine. In operating theatres, spe-
the rectum, or it may be vomited. A diaphragm, the sheet of muscle that cial ventilation systems purify the air.
large number of worms may compete separates the thorax (the chest) from (See also barrier nursing; isolation.)
with the host for food, leading to mal- the abdomen.
nutrition and anaemia, which, in DIAGNOSIS aspartame
children, can retard growth. The doctor diagnoses the cause of asci- An artificial sweetener used in some
TREATMENT tes by removing and analysing a sample foods and drugs.
The worm infestation is treated with of ascitic fluid via a sterile needle
anthelmintic drugs, such as levamisole, inserted through the abdominal wall. Asperger’s syndrome
which usually bring about complete TREATMENT A developmental disorder that is usually
recovery. The worms are passed out of The underlying cause is treated if first recognized in childhood because
the body via the rectum some days after possible. Diuretic drugs, particularly spir- of stilted speech, difficulties with social
the drug is taken. onolactone, are often used to treat ascites interactions, and very specialized inter-
associated with cirrhosis. If the ascites is ests. Intelligence is normal or high.
ascites causing discomfort or breathing diffi- Asperger’s syndrome is one of a group
Excess fluid in the peritoneal cavity, culty, fluid can be drained from the of conditions known as pervasive devel-
the space between the two layers of peritoneal cavity. opmental disorders; it is considered to
the peritoneum (the membranes that be an autism spectrum disorder (a deve-
line the inside of the abdominal wall ascorbic acid lopmental disorder characterized by
and cover the abdominal organs). The chemical name for vitamin C. obsessive behaviour and impaired com-

72
 ASTHMA

munication and social skills). Special aspiration pneumonia association area

educational support may be necessary,
often within mainstream education. Asp-
A form of pneumonia that results from
accidental inhalation of vomit. Aspiration
One of a number of areas in the cortex
(outer layer) of the brain that are con-
A
erger’s syndrome is a lifelong condition. pneumonia usually occurs in people cerned with higher levels of mental
whose cough reflex is not functioning, activity. Association areas interpret infor-
aspergillosis such as those who have drunk excessive mation received from sensory areas and
An infection caused by inhalation of amounts of alcohol, taken certain illegal prompt appropriate responses, such as
spores of aspergillus, a fungus that grows drugs, or suffered a head injury. voluntary movement.
in decaying vegetation. Aspergillus is
harmless to healthy people but may aspirin associative aphasia
proliferate in the lungs of people with A nonopioid analgesic drug (painkiller) Also known as conductive aphasia, a
tuberculosis. It can also worsen the that may be given in tablet or supposi- form of aphasia (loss of language skills,
symptoms of asthma and may produce tory form to treat disorders such as including comprehension and/or speech
serious, even fatal, infection in people headache, menstrual pain, and muscle production) in which comprehension is
with reduced immunity, such as those discomfort. Aspirin has an anti-inflamma- normal, and the affected individual can
taking immunosuppressant drugs. tory action. It also reduces fever and is write and speak, but he or she is unable
included in some cold remedies. to repeat what has been heard and can-
aspermia In small doses, aspirin reduces the not read aloud. Associative aphasia is
See azoospermia. stickiness of platelets (blood particles caused by damage to a localized area in
involved in clotting). This has led to its the brain, often as a result of a stroke.
asphyxia use in preventing thrombosis (abnormal
The medical term for suffocation. blood clots) in people at risk of devel- astereognosis
Asphyxia may be caused by the obstruc- oping stroke or myocardial infarction The inability to recognize objects by
tion of a large airway, usually by a (heart attack) and as an initial treatment touch when they are placed in the
foreign body (see choking), by insuffi- of chest pain that may be due to myocar- hand, even though there is no defect of
cient oxygen in the surrounding air (as dial infarction. Aspirin may also reduce sensation in the fingers or difficulty in
occurs when, for example, a closed the risk of colon cancer and slow the holding the object. Astereognosis is
plastic bag is put over the head), or by progress of dementia. either left- or right-sided; tactile recog-
poisoning with a gas, such as carbon In children, aspirin can cause Reye’s nition is normal on the other side. If
monoxide, that interferes with the syndrome, a rare but serious brain and both sides are affected, the condition is
uptake of oxygen into the blood. liver disorder. For this reason, it should called tactile agnosia.
The person initially breathes more not be given to children under the age Astereognosis and tactile agnosia are
rapidly and strongly to try to overcome of 16 years, except on the advice of a caused by damage to parts of the cere-
the lack of oxygen in the blood. There doctor. Aspirin may cause irritation brum (the main mass of the brain) that
is also an increase in heart rate and of the stomach lining, resulting in indi- are involved in recognition by touch.
blood pressure. gestion or nausea. Prolonged use may The conditions may occur as a result of
First-aid treatment is by clearing the cause bleeding from the stomach due to a stroke or a head injury.
airway of obstruction followed by res- gastric erosion (disruption of the stom-
cue breathing. Untreated asphyxia leads ach lining) or peptic ulcer. asthenia
to death within a few minutes. An outdated term for loss of strength
Aspro and energy (see weakness).
aspiration A brand name for aspirin.
The withdrawal of fluid or cells from asthenia, neurocirculatory
the body by suction. The term also assay See cardiac neurosis.
refers to the act of accidentally inhaling The analysis or measurement of a sub-
a foreign body, usually food or drink. If stance to determine its presence or asthma
consciousness is impaired, for example effects. A qualitative assay determines A lung disease in which there is inter-
by a head injury or excess alcohol only whether or not a substance is mittent narrowing of the bronchi
intake, aspiration of the stomach con- present, whereas a quantitative assay (airways), causing shortness of breath,
tents is common. determines the actual amount present. wheezing, and a cough. The illness
Aspiration biopsy is the removal of Biological assays (known as bioassays) often starts in childhood but can develop
cells or fluid, using a needle attached to measure the response of an animal or at any age. At least one child in seven
a syringe, for examination. Aspiration organ to particular substances. Assays suffers from asthma, and the number
biopsy is commonly used to obtain cells can be used, for example, to assess affected has increased dramatically in
from a fluid-filled cavity (such as a the effects of a drug or to measure hor- recent years. Childhood asthma may be
breast cyst). The procedure is also used mone levels. (See also immunoassay; outgrown in about half of all cases.
to obtain cells from the bone marrow radioimmunoassay.) During an asthma attack, the muscle
(see bone marrow biopsy), or from inter- in the walls of the airways contracts,
nal organs, when a fine needle is guided assisted conception causing narrowing. The lining of the
to the site of the biopsy by CT scanning Treatment for infertility involving tech- airways also becomes swollen and in-
or ultrasound scanning.(See also aspir- niques that assist the fertilization and flamed, producing excess mucus that
ation pneumonia.) implantation of eggs. can block the smaller airways.

73
 ASTHMA

THE CAUSE OF ASTHMA

A
Breathlessness and wheezing in
asthma are caused by narrowing of TREATMENT OF AN ASTHMA ATTACK
the bronchioles (small airways in the
lungs). Asthma can be triggered by a Attacks are treated by inhalation of a bronchodilator drug from an inhaler. For a
wide variety of stimuli, including severe attack, a nebulizer can be used to dispense the drug as fine mist through
exercise, infection, pollen, and dust, a face mask or mouthpiece. Babies, young children, or any adults who are
which would have no effect on non- unable to coordinate their breathing, require a spacer.
asthmatic people.
Inflammation of the linings
of these bronchioles results in
increased production of sputum
(phlegm), which makes the
obstruction worse. A dry cough
often develops as the sufferer
attempts to clear the airways.

Using an inhaler
To use the inhaler correctly, exhale first then Using a spacer
tilt the head back. Take in a slow, deep breath The inhaler, fitted with a spacer and face
Effect of while releasing the drug by depressing the mask, is placed over the baby’s nose and
asthma on canister. Two puffs should increase air flow mouth. This allows the baby to inhale the
the lungs Trachea
within 15 minutes. drug while breathing normally.
Bronchus

Grass

Tree Moulds

J F M A M J J A S O N D
Healthy bronchiole Obstructed bronchiole
Inhalation of the Before treatment, the Seasonal asthma
bronchodilator widens airflow is obstructed When symptoms occur only during a few
the bronchiole and by a narrowing of the months, the cause is likely to be allergy to
improves airflow. bronchiole. pollen or spores.

TYPES AND CAUSES When asthma starts in adulthood, there substance for weeks, months, or even
In some people, an allergic response are usually no identifiable allergic trig- years before the symptoms of asthma
triggers the swelling and inflammation gers. The first attack is sometimes begin to appear.
in the airways. This allergic type of brought on by a respiratory tract infec- Factors that can provoke attacks in a
asthma tends to occur in childhood, tion, stress, or anxiety. person with asthma include cold air,
and it may develop in association with In some cases, a substance that is exercise, smoke, and occasionally emo-
the allergic skin condition, eczema or inhaled regularly in the work environ- tional factors such as stress and anxiety.
certain other allergic conditions such as ment can result in the development Although industrial pollution and
hay fever (see rhinitis, allergic). Suscep- of asthma in a previously healthy per- exhaust emission from motor vehicles
tibility to these conditions frequently son. This is known as occupational do not normally cause asthma, they do
runs in families. asthma, and it is one of the few occupa- appear to worsen symptoms in people
Some substances are known to trigger tional lung diseases that are still who already have the disorder. Pollution
attacks of allergic asthma (see allergens). increasing in incidence. in the atmosphere may also trigger
These include pollen, house-dust mites, There are currently about 200 sub- asthma in susceptible people.
mould, feathers, and dander (tiny stances used in the workplace that are SYMPTOMS
scales) and saliva from furry animals known to trigger symptoms of asthma, Asthma attacks can vary in severity from
such as cats and dogs. Rarely, certain including glues, resins, latex, and some mild breathlessness to respiratory failure.
foods, such as milk, eggs, nuts, and chemicals, especially isocyanate chemi- The main symptoms are wheezing,
wheat, provoke an allergic asthmatic cals used in spray painting. However, breathlessness, dry cough, and a tight-
reaction. Some people with asthma are occupational asthma can be difficult to ness in the chest. In a severe attack,
sensitive to aspirin, and taking it may diagnose because a person may be reg- breathing becomes increasingly diffi-
trigger an attack. ularly exposed to a particular trigger cult, resulting in a low level of oxygen

74
 ATELECTASIS

in the blood. This causes cyanosis (a framed at a precise angle; contact lenses asystole
bluish discoloration) of the face, partic-
ularly of the lips. Left untreated, such
that can give an even spherical surface
for focusing; or by undergoing laser
A term meaning absence of the heart-
beat (see cardiac arrest).
A
attacks can be fatal. treatment on the cornea.
TREATMENT ataxia
There is no cure for asthma, but attacks astringents Incoordination and clumsiness that may
can be prevented to a large extent if a COMMON DRUGS affect balance and gait (see walking),
particular allergen can be identified and • Aluminium acetate • Potassium limb and eye movements, and/or speech.
consequently avoided. permanganate • Silver nitrate • Zinc sulphate CAUSES
Treatment involves inhaled broncho- Ataxia may be the result of damage to
dilator drugs (sometimes known as Substances that causes tissue to dry and the cerebellum (the part of the brain
relievers) to widen the airways, thereby shrink by reducing its ability to absorb concerned with coordination) or to
relieving symptoms. When symptoms water. Astringents are widely used in nerve pathways in the brainstem (a stalk
occur frequently, or are severe, inhaled antiperspirants and to promote healing of nerve tissue linking the brain to the
corticosteroids are also prescribed. These of broken or inflamed skin. They are spinal cord) and/or spinal cord.
drugs (also known as preventers) are also used in some eye or ear prepara- Possible causes include injury to the
used continuously to prevent attacks by tions. Astringents may cause burning or brain or spinal cord. In adults, ataxia
reducing inflammation in the airways. stinging when applied. may be caused by alcohol intoxication; a
Other drug treatments include sodium stroke or brain tumour affecting the cere-
cromoglicate and nedocromil sodium, astrocytoma bellum or brainstem; a disease of the
both of which are useful in the preven- A type of cancerous brain tumour. Astro- balance organ in the ear; or multiple
tion of exercise-induced asthma. The cytomas are the most common type of sclerosis or other types of nerve degener-
use of a leukotriene receptor antagonist in glioma, a tumour that arises from the ation. In children, causes include acute
combination with a corticosteroid drug glial (supporting) cells within the ner- infection, brain tumours, and the inher-
may enable the required dose of cortico- vous system. ited condition Friedreich’s ataxia.
steroid to be reduced. Theophylline or Astrocytomas most commonly devel- SYMPTOMS
the inhaled anticholinergic drug ipratro- op in the cerebrum (the main mass of Symptoms of ataxia depend on the site
pium bromide may also be used as the brain) and are classified in four of damage within the nervous system,
bronchodilators. An asthma attack that grades (I to IV) according to their rate although a lurching, unsteady gait is
has not responded to treatment with a of growth and malignancy. A grade I common to most forms. In addition,
bronchodilator needs immediate assess- astrocytoma is a slow-growing tumour damage to certain parts of the brain
ment and treatment in hospital. that may spread widely throughout the may cause nystagmus (jerky eye move-
brain but may be present for many ments) and slurred speech.
asthma, cardiac years before causing symptoms. The DIAGNOSIS AND TREATMENT
Breathing difficulty in which broncho- most severe and fast-growing type is CT scanning or MRI (techniques that
spasm (narrowing of the airways) and called glioblastoma multiforme (a grade produce cross-sectional or three-dimen-
wheezing occur as a result of fluid IV astrocytoma). sional images of body structures) may
accumulation in the lungs (pulmonary Symptoms are similar to those of be used to determine the cause of ataxia.
oedema). Cardiac asthma is usually due other types of brain tumour. Diagnostic Treatment of the condition depends on
to reduced pumping efficiency of the tests include CT scanning or MRI. Treat- the cause.
left side of the heart (see heart failure) ment is with surgery as well as, in some
and is not true asthma. Treatment is cases, radiotherapy. atelectasis
with diuretic drugs or other drugs for Collapse of part or all of a lung caused
heart failure. asylum by obstruction of the bronchus (the
An outdated term for an institution that main air passage through the lung) or
astigmatism provides care for the mentally ill. the bronchioles (smaller air passages).
A condition in which the front surface When obstruction occurs, air already in
of the cornea does not conform to the asymptomatic the lung cannot be breathed out and is
normal “spherical” curve, even though A medical term meaning without symp- therefore absorbed into the blood, lead-
the eye is perfectly healthy. Because the toms (indications of illness noticed only ing to the collapse of all or part of the
cornea is unevenly curved, it refracts by the patient). For example, hyperten- lung. After collapsing, the lung loses its
(bends) the light rays that strike it to sion (high blood pressure) is often elasticity and cannot take in air; conse-
differing degrees.The lens is then unable asymptomatic and is usually discovered quently, the blood passing through it
to bring all the rays into focus on the during a routine blood pressure test and can no longer absorb oxygen or dispose
light-sensitive retina. A minor degree of diabetes mellitus is often diagnosed from of carbon dioxide.
astigmatism is normal and does not a routine blood or urine test. In an adult, atelectasis is not normally
require correction. More severe astigma- Most disorders have no symptoms in life-threatening because unaffected parts
tism causes blurring of lines at a certain their early stages. In the case of cancer, of the lung and/or the other lung can
angle and does require correction. much effort has been made to devise compensate for the loss of function in
TREATMENT screening tests for the detection of the collapsed area. However, when a
Correction may be achieved by using tumours at their early, asymptomatic, newborn baby’s lung collapses, the
special “cylindrical” glasses that can be stage. (See also sign.) baby’s life is at risk.

75
 ATENOLOL

CAUSES atenolol may collect in clumps on the surface of

A Obstruction of a bronchus or bronch-
iole may be caused by the accumulation
A beta-blocker drug that is commonly
used to treat hypertension (high blood
the deposits and initiate the formation
of blood clots. A large clot may com-
of mucus. This buildup of mucus most pressure), angina pectoris (chest pain pletely block the artery, resulting in the
commonly occurs in a baby at birth; in caused by an impaired blood supply organ it supplies being deprived of
people with asthma; following an to the heart muscle), and certain types oxygen. A complete blockage in a coro-
abdominal or chest operation that has of arrhythmia (irregular heartbeat) in nary artery can cause a sudden, often
made coughing difficult because of which the heart beats too rapidly. fatal, heart attack.
pain; in certain infections such as per- CAUSES
tussis (whooping cough) in children or atheroma The risk of developing atherosclerosis is
chronic bronchitis (inflammation of the Fatty deposits on the inner lining of an determined largely by the level of cho-
bronchi) in adults. artery that occur in atherosclerosis and lesterol in the bloodstream, which
Obstruction may also result from an restrict blood flow. The deposits are also depends on dietary and genetic factors.
accidentally inhaled foreign body, a known as atheromatous plaques. Atherosclerosis is more common in
tumour in the lung, or enlarged lymph developed countries, where most people
nodes (which occur in tuberculosis, atherosclerosis eat a diet high in fat. Some disorders
some other lung infections, or certain The accumulation of cholesterol and such as diabetes mellitus can be asso-
forms of cancer) exerting pressure on other fatty substances (lipids) in the ciated with a high cholesterol level,
the airway. The collapsed lung may walls of arteries, causing the arteries to regardless of diet.
become infected. narrow. Atherosclerosis can affect arter- SYMPTOMS
SYMPTOMS ies in any area of the body and is a Atherosclerosis usually produces no
The main symptom of atelectasis is major cause of stroke, heart attack (see symptoms in its early stages. As the con-
shortness of breath. There may also be a myocardial infarction), and poor circu- dition progresses, symptoms occur as a
cough and chest pain, depending on lation in the legs. result of reduced, or total absence of,
the underlying cause. The arteries become narrowed when blood supply to the organs supplied by
DIAGNOSIS AND TREATMENT fatty substances carried in the blood the affected arteries.
Atelectasis can be diagnosed by chest accumulate on the inside lining of the Partial blockage of the coronary art-
X-ray, and treatment is aimed at rem- arteries and form yellow deposits eries (which supply the heart muscle)
oving the cause of the blockage. The known as atheromatous plaques. These may produce symptoms such as the
treatment may include physiotherapy or deposits restrict the blood flow through chest pain of angina pectoris. Narrowing
bronchoscopy, a procedure that involves the arteries. In addition, the muscle of the arteries supplying blood to the
removal of the blockage using a rigid or layer of the artery wall becomes thick- brain may cause transient ischaemic
flexible viewing tube (see endoscope). If ened, which narrows the artery even attacks (symptoms and signs of a stroke
the obstruction can be removed, the further. Platelets (tiny blood cells that that last for less than 24 hours) and
lung should reinflate normally. are responsible for blood clotting) episodes of dizziness.

ARTERIAL DEGENERATION IN ATHEROSCLEROSIS

Atherosclerosis is narrowing of the arteries due to plaques of atheroma on their inner

linings. The plaques are composed mainly of fats, deposited from the bloodstream, Direction of
blood flow
that disrupt normal blood flow through the artery. Men are affected earlier than women
because premenopausal women are protected by natural oestrogen hormones.
Normal artery

RISK FACTORS
• Cigarette smoking
Atheromatous
plaque
• Hypertension
Lumen
• Male gender

• Obesity Artery
wall
muscle
• Physical inactivity
Atheromatous
• Diabetes mellitus plaque
Micrograph of artery in atherosclerosis Atherosclerotic artery
• Heredity The artery shown here has an atheromatous A deposit of atheromatous plaque disrupts
(fibrous and fatty) plaque deposit on its inner normal blood flow through the artery at the
• High cholesterol wall. The lumen (channel) has been narrowed, point where it branches. This occurs because
disrupting blood flow. of the greater level of turbulence in this area.

76
 ATRIAL FIBRILLATION

Intermittent claudication (a cramplike Causes of athetosis include brain dam- muscles may become atonic after injury
pain on walking) is often the first
symptom of atherosclerosis in the leg
age prior to or at birth (see cerebral
palsy), encephalitis (brain infection),
to the brachial plexus (nerve roots in the
neck passing into the arm).
A
arteries. If the condition is associated degenerative disorders such as Hunting-
with an inherited lipid disorder (see ton’s disease, or as a side effect of atopic eczema
hyperlipidaemias), fatty deposits may phenothiazine drugs or levodopa. If drug Atopic eczema is the most common
develop on tendons or as visible lumps treatment is the cause of the condition, form of eczema (an inflammatory skin
under the skin. the abnormal movements may stop condition). It usually begins in infancy
DIAGNOSIS AND TREATMENT when the drug is withdrawn. but may flare up during adolescence and
Blood flow through an artery can be adulthood. The cause of atopic eczema
investigated by angiography (X-rays after athlete’s foot is unknown, but people with atopy (a
injection of a radiopaque substance) or A common condition in which the skin predisposition to allergic reactions) are
Doppler ultrasound scanning between the toes becomes itchy and more susceptible.
The best treatment for atherosclerosis sore and may crack, peel, or blister.
is to prevent it from progressing by the atopy
maintenance of a healthy lifestyle. This A predisposition to various allergic reac-
includes adoption of a low-fat diet, not tions (see allergy). Atopic individuals
smoking, regular exercise, and main- have a tendency to suffer from one or
tenance of the recommended weight more allergic disorders, such as asthma,
for height. These measures lead to a eczema, urticaria (nettle rash), and aller-
reduced risk of developing significant gic rhinitis (hay fever).
atherosclerosis. The mechanism that underlies the
Those individuals found to have high predisposition is unclear, but atopy
blood cholesterol levels but who are seems to run in families.
otherwise in good health will be
advised to adopt a low-fat diet. They ATP
may also be given drugs that decrease An abbreviation for the compound
Athlete’s foot
blood cholesterol levels (see lipid-lower- The typical appearance of athlete’s foot is of
adenosine triphosphate, the principal
ing drugs). For people who have had a fissuring in the cleft between the fourth and fifth energy-carrying chemical in the body.
heart attack, research has shown that toes. There is usually an annoying itch. (See also ADP; metabolism.)
there may be a benefit in lowering
blood cholesterol levels, even if the CAUSES atresia
level is within the average range for Athlete’s foot is usually the result of a Congenital (present from birth) absence
healthy people. fungal infection known medically as or severe narrowing of a body opening
People with atherosclerosis and those tinea pedis, but the condition may also or tubular organ due to a failure of
at risk may be prescribed a drug such as be caused by bacteria. development in the uterus. Examples
aspirin to reduce the risk of blood clots Because the fungi thrive in humid are biliary atresia, in which the bile ducts
forming on the damaged artery lining. conditions, athlete’s foot is more com- between the liver and duodenum are
Surgical treatment of atherosclerosis, mon in people with particularly sweaty absent; oesophageal atresia, in which the
such as coronary angioplasty (see angio- feet and those who wear shoes and oesophagus comes to a blind end; and
plasty, balloon), may be recommended socks made from synthetic fibres, anal atresia (see anus, imperforate), in
for those people thought to be at high which do not absorb sweat. which the anal canal is shut off. Most
risk of severe complications. If blood TREATMENT forms of atresia require surgical correc-
flow to the heart is severely obstructed, Self-treatment with topical antifungal tion early in life.
a coronary artery bypass may be carried drugs is usually effective and should be
out to restore blood flow. combined with careful washing and atrial fibrillation
drying of the feet. A type of abnormality of the heartbeat
athetosis (see arrhythmia, cardiac) in which the
A disorder of the nervous system that atlas atria (see atrium), the upper chambers
is characterized by involuntary slow, The topmost cervical vertebra in the of the heart, beat irregularly and very
writhing movements, most often of the human spine. The atlas is attached to rapidly. The ventricles (the heart’s lower
face, head, neck, and limbs. These and supports the skull. A pivot joint chambers) also beat irregularly but at a
movements commonly include facial attaching the atlas to the second cervical slower rate. As a result, the pumping
grimacing, with contortions of the vertebra, the axis, allows the atlas to ability of the heart is reduced.
mouth. There may also be difficulty in rotate, thereby turning the head from CAUSES
balancing and walking. side to side. Atrial fibrillation can occur in almost
Athetosis tends to be combined with any longstanding heart disease, but it is
chorea (involuntary irregular, jerky atony most often associated with heart-valve
movements). Both athetosis and chorea Loss of tension in a muscle, so that it is disorders or coronary artery disease.
arise from damage to the basal ganglia, completely flaccid. Atony can occur in SYMPTOMS AND SIGNS
clusters of nerve cells in the brain that some nervous system disorders or after Sudden onset of atrial fibrillation can
control movement. injury to nerves. For example, the arm cause palpitations (awareness of a fast

77
 ATRIAL FLUTTER

heartbeat), angina pectoris (chest pain as atrioventricular node (as in ovarian atrophy, for example,
A due to impaired blood supply to the
heart muscle), or breathlessness. The
A small knot of specialized muscle cells
in the right atrium (upper chamber) of
which occurs in women who have
passed the menopause.
inefficient pumping action of the heart the heart. Electrical impulses from the
reduces the output of blood into the sinoatrial node (a cluster of muscle cells atropine
circulation. Blood clots may form in that act as the heart’s natural pacemaker) An anticholinergic drug that is derived
the atria and may enter the bloodstream pass through the atrioventricular node from the deadly-nightshade plant (see
and lodge in an artery (see embolism). and along conducting fibres to the ven- belladonna). Atropine is used to dilate
DIAGNOSIS AND TREATMENT tricles (the lower chambers of the the pupil in eye conditions such as iritis
Diagnosis of atrial fibrillation is con- heart), causing them to contract and (inflammation of the iris) and corneal
firmed by an ECG, which shows the pump blood around the body. ulcer. It is also used in young children,
electrical activity of the heart. in the form of eye-drops, to dilate
Digoxin or beta-blocker drugs may be atrium (widen) the pupil for examination.
given to control the heart rate. If the Also known as an auricle, either of Atropine was often given (by injec-
atrial fibrillation is of recent onset, it the two (right and left) upper chambers tion) as a premedication before a general
may be reversed by defibrillation (the of the heart. The atria open directly anaesthetic (see anaesthesia, general) to
application of a short electric shock to into the ventricles (the lower chambers reduce secretions from the lungs, but it
the heart). In most cases, anticoagulant of the heart). Deoxygenated blood from is now rarely used for this purpose. It is
drugs or aspirin are also given to reduce the body enters the right atrium used as emergency treatment for brady-
the risk of an embolism occurring. through the venae cavae. Oxygenated cardia (abnormally slow heartbeat) and is
blood from the lungs enters the left also sometimes prescribed for its anti-
atrial flutter atrium through the pulmonary veins. cholinergic effects; it is combined with
A type of abnormality of the heartbeat an antidiarrhoeal drug to relieve the abdo-
(see arrhythmia, cardiac) in which the minal cramps that accompany diarrhoea.
atria (see atrium), the heart’s upper ANATOMY OF THE ATRIUM Side effects include dry mouth, blur-
chambers beat regularly but very rapidly. red vision, retention of urine, and, in the
Symptoms and treatment of atrial flutter Deoxygenated blood flows into the elderly, confusion. Atropine eye-drops
right atrium through the venae cavae;
are the same as for atrial fibrillation. are rarely given to adults because they
oxygenated blood flows into the left
atrium via the pulmonary veins. cause disturbance of vision that lasts for
atrial natriuretic peptide two to three weeks and may precipitate
A substance that is produced in special Superior acute glaucoma in susceptible people.
vena
cells in the muscular wall of the atria cava
Pulmonary
(see atrium), the upper chambers of the veins attachment
heart. Atrial natriuretic peptide is rel- An affectionate bond between individu-
eased into the bloodstream in response als, especially between a parent and
to swelling of the atrial muscle due, for child (see bonding) or between a person
example, to heart failure or hypertension and an object, such as a young child
(high blood pressure). and a security blanket.
Left
Atrial natriuretic peptide increases atrium The term attachment is also used to
the amount of sodium excreted in the refer to the site at which a muscle or
urine. Sodium draws water out with it, Right tendon is attached to a bone.
atrium
which decreases the volume of the
blood, thereby reducing blood pressure. attempted suicide
Children who have congenital (pre- See suicide, attempted.
sent from birth) heart disorders that Inferior
result in heart disease (see heart disease, vena cava attention deficit hyperactivity
congenital) possess high levels of atrial disorder (ADHD)
natriuretic peptide. Following suc- A behavioural disorder in which a child
cessful surgery to correct the heart atrophy has a consistently high level of activity
abnormality, the levels of atrial natri- The wasting away or shrinkage of a nor- and/or difficulty in attending to tasks.
uretic peptide fall. mally developed tissue or organ that Attention deficit hyperactivity, or
results from a reduction in the size or hyperkinetic, disorder affects up to five
atrial septal defect (ASD) number of its cells. per cent of children in the UK.
A congenital (present from birth) heart Atrophy is commonly caused by dis- The disorder, which is more com-
abnormality (see heart disease, con- use (such as when a limb has been mon in boys, should not be confused
genital) in which there is a hole in the immobilized in a plaster cast) or inade- with the normal boisterous conduct of
dividing wall (see septal defect) between quate cell nutrition as a result of poor a healthy child. Children with ADHD
the heart’s two upper chambers, or atria blood circulation. Atrophy may also show abnormal patterns of behaviour
(see atrium). occur during prolonged illness, when over a period of time. An affected child
the body needs to use up the protein is likely to be constantly restless, unable
atrioventricular block reserves in the muscles. In some cir- to sit still for more than a few
A type of heart block. cumstances, atrophy is a normal process moments, inattentive, and impulsive.

78
 AUSCULTATION

CAUSES audiology auriscope

The causes of ADHD are not fully
understood, but the disorder often runs
The study of hearing, especially im-
paired hearing.
Also called an otoscope, an instrument
for examining the ear.
A
in families, which suggests that genetic
factors may be involved. ADHD is not, audiometry auscultation
as popularly believed, a result of poor Measurement of the sense of hearing. A procedure that involves listening to
parenting or abuse. The term audiometry often refers to sounds within the body, using a stetho-
SYMPTOMS AND SIGNS hearing tests in which a machine is used scope, to assess the functioning of an
Symptoms of the condition develop in to produce sounds of a defined inten- organ or to detect disease.
early childhood, usually between the sity (loudness) and frequency (pitch), AUSCULTATION OF THE HEART
ages of three and seven, and may and in which the hearing in each ear To listen to the heart, the doctor places
include the inability to finish tasks; is measured over the full range of the stethoscope on the chest at four
inability to concentrate in class; a short normally audible sounds. (See also points which correspond to the location
attention span; difficulty in following impedance audiometry.) of the heart valves. With the patient
instructions; a tendency to talk exces- either sitting up, lying in a semi-reclin-
sively, frequently interrupting other auditory nerve ing position, or lying on his or her left
people; difficulty in waiting or taking The part of the vestibulocochlear nerve side, the doctor listens for any abnor-
turns; inability to play alone, quietly; (the eighth cranial nerve) concerned mality in the rate and rhythm of the
and physical impulsiveness. with hearing. The auditory nerve is also heartbeat and for a heart murmur or
Children with ADHD may have diffi- known as the acoustic nerve. other abnormal heart sound that may
culty in forming friendships. Self-esteem indicate a heart defect.
is often low because an affected child is aura AUSCULTATION OF THE LUNGS
frequently scolded and criticized. A peculiar “warning” sensation that When listening to the lungs, the doctor
TREATMENT AND OUTLOOK precedes or marks the onset of a mig- places the stethoscope on numerous
Treatment of ADHD includes behaviour raine attack or a seizure in epilepsy. areas of the chest and back. The patient
modification techniques, both at home A migraine attack may be preceded breathes normally, and then takes deep
and at school. In some children, avoid- by a feeling of elation, excessive energy, breaths, so that the doctor can compare
ance of certain foods or food additives or drowsiness; thirst or a craving for the sounds on the right and left sides.
seems to reduce symptoms. In severe sweet foods may develop. A migraine Abnormal breath sounds may indicate
cases, stimulant drugs, usually methylphen- may also be heralded by flashing lights pneumonia, bronchitis, and pneumothorax
idate, may be prescribed. Paradoxically, before the eyes, blurred or tunnel (in which air enters the space between
the use of stimulant drugs in the treat- vision, or difficulty in speaking. There the pleura, the membranes lining the
ment of ADHD reduces hyperactivity may also be weakness, numbness, or outside of the lungs and the inside of
and improves concentration. tingling in one half of the body. As these the chest cavity). Cracking or bubbling
In general, the condition improves by symptoms subside, the migraine head- sounds (known as crepitations) are
adolescence but may be followed by ache begins. caused by fluid in the lungs; wheezing
antisocial behaviour and drug abuse or An epileptic aura may occur as a sounds result from spasm of the air-
substance abuse. distorted perception, such as a hallu- ways, usually as a result of asthma.
cinatory smell or sound or a sensation Pleurisy (inflammation of the pleura)
attenuated of movement in a part of the body. One causes a scratching sound as inflamed
A term used to refer to microorganisms type of attack (in people who have tem- areas of the lung rub together.
that have been treated to reduce their poral lobe epilepsy) is often preceded by The doctor may also test for vocal
ability to cause disease. Attenuated a vague feeling of discomfort in the resonance by asking the patient to
organisms are used in some vaccines. upper abdomen, sometimes followed whisper something. The sound is louder
by borborygmi (rumbling or gurgling if there is pus in the lung due to a con-
atypical bowel sounds, and by a sensation of dition such as pneumonia.
A term used to describe something that fullness in the head. AUSCULTATION OF THE BLOOD VESSELS
is not the usual type or that does not fit Blood vessels near the skin surface (usu-
into the usual pattern. The atypical auranofin ally the carotid artery in the neck, the
presentation of a disease or disorder is A gold preparation used as an anti- abdominal aorta, or the renal artery)
one in which the early symptoms and rheumatic drug in the treatment of may be listened to for bruits (sounds
signs differ from those that normally rheumatoid arthritis. Unlike other gold made by turbulent or abnormally fast
occur, which may make diagnosis of preparations, which are given as intra- blood circulation). Bruits occur when
the condition more difficult. muscular injections, auranofin can be blood vessels are narrowed (for exam-
taken by mouth. ple by fatty deposits in atherosclerosis)
audiogram or widened (by an aneurysm, for exam-
A graph that is produced as a result of auricle ple). They may also be present if heart
audiometry (measurement of the sense Another name for the pinna, the exter- valves have been narrowed or damaged
of hearing). An audiogram shows the nal flap of the ear. The term is also used (for example by endocarditis).
hearing threshold (the minimum audi- to describe the earlike appendages of AUSCULTATION OF THE ABDOMEN
ble decibel level) for each of a range of the atria (the upper chambers of the The abdomen is auscultated for borbo-
sound frequencies. heart, see atrium). rygmi (loud rumbling, gurgling sounds

79
 AUTISM

PROCEDURE FOR AUSCULTATION

A
A doctor’s examination often includes auscultation (listening lungs and airways, are made during normal functioning of
to sounds within the body using a stethoscope). Some sounds, organs. The presence of abnormal sounds usually indicates
such as movement of fluid through the stomach and intestine, disease of that tissue, however. An obstetrician listens for the
opening and closing of heart valves, and flow of air through the baby’s heartbeat as part of routine antenatal examination.

Using a stethoscope
STETHOSCOPE The end is held against the skin. The diaphragm
picks up most noises, while the bell detects
quiet, deep noises.

The heart
The stethoscope is
usually placed at four
places on the chest
overlying the sites of
the heart valves. The
doctor listens for the
presence of murmurs,
clicks, and extra heart
sounds that may
indicate disease of
a heart valve.

Carotid artery and The lungs

abdominal aorta The doctor places
The doctor may listen The abdomen the stethoscope over
to the flow of blood The doctor may listen several different
through a blood to the abdomen for the areas of the chest and
vessel that passes sounds made by the back to listen to the
just beneath the skin. movement of fluid sounds made during
The presence of through the intestine. breathing. The
bruits (sounds of A disorder of the presence of crackles
turbulence) usually intestine may cause and dry or moist
indicates abnormal these sounds to be wheezes indicates
narrowing or absent, abnormal, or various types of lung
widening of an artery. very loud. disease.

that are made by the movement of air to form relationships, avoids eye con- and, sometimes, behaviour therapy (such
and fluid in the intestine), and also for tact, and has a preference for playing as to reduce violent self-injury) can be
abnormal bowel sounds that may indi- alone. Extreme resistance to change of helpful. Medication is useful only for
cate intestinal obstruction (see intestine, any kind is an important feature of the specific problems, such as hyperactivity.
obstruction of). condition, which can make it very diffi- The outlook depends on the intel-
cult to teach the autistic child new skills. ligence and language ability of the
autism Rituals develop in play, and there is individual. The majority of autistic peo-
A rare condition in which an affected often attachment to unusual objects or ple need special care.
person has difficulty with social rela- obsession with one particular idea.
tionships, communication, and with Delay in speaking is common and most autism spectrum disorders
imagination, together with repetitive autistic children have a low IQ. Other A range of developmental disorders that
patterns of behaviour. Autism is more behavioural abnormalities may include are characterized by obsessive behavi-
common in boys. The condition is, by walking on tip-toe, rocking, self-injury, our and impaired communication and
definition, evident before the age of 30 screaming fits, and hyperactivity. social skills (see Asperger’s syndrome;
months and is usually apparent in the Appearance and coordination are autism). Autism spectrum disorders are
first year of life. The precise causes of normal. Some autistic people have an usually diagnosed during childhood.
autism are unknown. isolated special skill, such as musical
SYMPTOMS AND SIGNS ability or an outstanding rote memory. autoantibody
Autistic children often seem normal for TREATMENT AND OUTLOOK An antibody (a protein that is manufac-
the first few months of life, before There is no cure for autism, which is a tured by the immune system) that reacts
becoming increasingly unresponsive to lifelong condition. Special schooling, against the body’s own cells (see auto-
parents or other stimuli. The child fails support and counselling for the families, immune disorders).

80
 AUTONOMIC NERVOUS SYSTEM

autoclave there is interruption of the normal con- nesses in which a particular mental
A piece of apparatus that produces
steam at high pressure within a sealed
trol process, allowing such lymphocytes
to escape from suppression, or when
function is lost), drug or alcohol in-
toxication, or hypoglycaemia (low blood
A
chamber; the heat of the water vapour there is alteration in a particular body sugar levels).
destroys microorganisms. Autoclaving is tissue meaning that it is no longer rec-
used in hospitals for the sterilization of ognized as self and is attacked. autonomic nervous system
surgical equipment. Bacteria, viruses, and drugs may play Also called the involuntary nervous sys-
a role in initiating an autoimmune dis- tem, the part of the nervous system that
autograft order in someone who already has a controls the involuntary activities of a
Tissue that has been transplanted from genetic (inherited) predisposition, but variety of body tissues, including blood
one part of an individual’s body to in most cases the trigger is unknown. vessels, organs, and glands. The auto-
another (see grafting). Autografting is TYPES nomic nervous system consists of a
often used to treat severe burns. Autoimmune processes can have various network of nerves divided into the
results, such as the destruction of a par- sympathetic and parasympathetic ner-
autoimmune disorders ticular type of cell or tissue, stimulation vous systems.
Any of a number of disorders caused by of an organ into excessive growth, or The two systems act in conjunction
a reaction of the body’s immune system interference in an organ’s function. and normally balance each other. How-
against its own cells and tissues. Such Autoimmune disorders are classified ever, during exercise or at times of
disease-producing processes, known as into organ-specific and non-organ-spe- stress, the activity of the sympathetic
hypersensitivity reactions, are similar to cific types. In organ-specific disorders, system predominates, while during
the reactions that occur in allergy, except the autoimmune process is directed sleep the parasympathetic system exerts
that in autoimmune disorders the hyper- mainly against one organ. Examples greater control.
sensitivity response is to the body itself include Hashimoto’s thyroiditis (thyroid SYMPATHETIC NERVOUS SYSTEM
rather than to an external substance. gland), pernicious anaemia (stomach), The sympathetic nervous system com-
CAUSES Addison’s disease (adrenal glands), and prises two chains of nerves that pass
The immune system normally distin- type 1 diabetes mellitus (pancreas). from the spinal cord throughout the
guishes “self” from “nonself”. Some In non-organ-specific disorders, auto- body tissues. Into these tissues, the
lymphocytes (a type of white blood cell) immune activity is towards a tissue, nerve endings release the neurotrans-
are capable of reacting against self, but such as connective tissue, that is wide- mitters (chemical messengers) adrenaline
these lymphocytes are generally suppres- spread in the body. Examples of such (epinephrine) and noradrenaline (nor-
sed. Autoimmune disorders occur when disorders are systemic lupus erythemato- epinephrine). The sympathetic nervous
sus and rheumatoid arthritis. system also stimulates the release of
TREATMENT adrenaline from the adrenal glands.
AUTOIMMUNE DISORDERS Initial treatment for any autoimmune In general, the actions of the sympa-
disorder is to reduce the effects of the thetic nervous system heighten activity
Specific (organs or cells affected)
disease by, for example, replacing hor- in the body. This activity is known as
• Addison’s disease (adrenal glands) mones, such as insulin, that are not the fight-or-flight response. Among the
• Autoimmune haemolytic anaemia being produced. most important effects produced are
(red blood cells) In cases in which the disease is having the acceleration and strengthening of
• Autoimmune chronic active hepatitis (liver) widespread effects, treatment is also the heartbeat, widening of the airways,
directed at diminishing the activity of widening of the blood vessels in mus-
• Autoimmune infertility (sperm or ovary) the immune system while maintaining cles and narrowing of those in the skin
• Diabetes mellitus type 1 (pancreas) the body’s ability to fight disease. Corti- and abdominal organs (in order to
costeroid drugs are most commonly used increase the blood flow through the
• Goodpasture’s syndrome (lung and kidney)
for this purpose but may be combined muscles), and the inducement of sweat-
• Graves’ disease (thyroid gland) with other immunosuppressant drugs. ing. In addition, the activity of the
• Hashimoto’s thyroiditis (thyroid gland) digestive system is decreased and the
autologous blood transfusion pupils are dilated.
• Idiopathic thrombocytopenia purpura
(platelets) See blood transfusion, autologous. PARASYMPATHETIC NERVOUS SYSTEM
The parasympathetic nervous system
• Myasthenia gravis (muscle receptors) automatism is composed of a chain of nerves that
• Pernicious anaemia (stomach lining) A state in which behaviour is not passes from the brain and another that
• Vitiligo (melanocytes) controlled by the conscious mind. An leaves the lower spinal cord. The nerves
individual carries out activities without are distributed to the same tissues that
Nonspecific being aware of doing so, and later he or are supplied by the sympathetic nerves.
she has no clear memory of what hap- The parasympathetic nerves release the
• Behcet’s syndrome
pened. Episodes of automatism start neurotransmitter acetylcholine, which
• Rheumatoid arthritis abruptly and are usually no more than a has the opposite effect to those of
• Sjogren’s syndrome few minutes in duration. adrenaline and noradrenaline.
Automatism is uncommon and may The parasympathetic system is con-
• Systemic lupus erythematosus
be a symptom of temporal lobe epilepsy, cerned mainly with everyday functions
dissociative disorders (psychological ill- such as digestion and excretion.

81
 AUTONOMIC NERVOUS SYSTEM

FUNCTIONS OF THE AUTONOMIC NERVOUS SYSTEM

A
The autonomic nervous system (also known as the involuntary The system affects smooth muscles, such as those of the
nervous system) is responsible for controlling the involuntary airways and the intestine, rather than the striated muscles,
body functions, such as sweating, digestion and heart rate. which are under the body’s voluntary control.

SYMPATHETIC SYSTEM PARASYMPATHETIC SYSTEM

Dilates Contracts
pupils pupils

Medulla
oblongata

Inhibits Stimulates
salivation salivation
Cranial nerves

Dilates Constricts
Cervical
bronchi nerves bronchi
Ganglia
chain

Accelerates Slows
heart rate heart rate

Inhibits Stimulates
gastric juice Thoracic gastric juice
nerves
production production

Inhibits Speeds up
digestive digestive
process process

Lumbar
Relaxes Stimulates secretion nerves Contracts
bladder of adrenaline and bladder
muscles; noradrenaline muscles;
contracts relaxes
bladder neck bladder neck
Spinal cord
Sacral
Contracts nerves Relaxes
rectal rectal
sphincter sphincter

The autonomic nervous system

The autonomic nervous system is divided into two separate systems: the the parasympathetic nervous system is concerned mainly with the body’s
sympathetic nervous system and the parasympathetic nervous system. everyday functions such as digestion and the excretion of waste products;
The sympathetic system is primarily concerned with preparing the body for this system dominates during sleep. The parasympathetic system slows the
action; it predominates at times of stress or excitement. The sympathetic heart rate and stimulates the organs of the digestive tract. Most of the time,
system stimulates functions such as heart-rate and sweating and dilates activity is balanced between the two systems, with neither dominating.
the blood vessels to the muscles so that more blood is diverted to them. Both of the systems play an important part in sexual arousal and orgasm
Simultaneously, it subdues the activity of the digestive system. In contrast, in both men and women.

82
 AVIATION MEDICINE

EFFECT OF DRUGS avascular AIR TRAVEL-RELATED PROBLEMS

Certain disorders can be treated by
administration of drugs that affect the
A term meaning without blood vessels. Increasing altitude causes a fall in air
pressure and with it a fall in the pres-
A
autonomic nervous system. Anticholiner- avascular necrosis sure of oxygen. Hypoxia (a seriously
gic drugs, for example, block the effect Cell death in body tissues as a result of reduced oxygen concentration in the
of acetylcholine, which can reduce mus- damage to the blood vessels that supply blood and tissues) is a threat to anyone
cle spasms in the intestine. Beta-blocker the area. who flies at altitude. Aviator’s decom-
drugs block the action of adrenaline pression sickness has the same causes as
(epinephrine) and noradrenaline (nor- aversion therapy the related condition that affects scuba
epinephrine) on the heart, thus slowing An outdated form of behaviour therapy in divers but it is not normally a risk for
the rate and force of the heartbeat. which unpleasant stimuli, such as elec- passengers on regular flights. Rapid
tric shocks, are administered at the same decompression (a sudden drop in air
autopsy time as an unwanted behaviour in an pressure) in civil aircraft is extremely
A postmortem examination of the body, attempt to alter behavioural patterns. rare, but passengers and crew are pro-
including the internal organs, which is Other forms of therapy are now gener- vided with oxygen masks for use in
usually undertaken to determine the ally considered to be more appropriate. emergencies while the aircraft descends
precise cause of death. An autopsy is to a safe altitude.
sometimes required by law. aviation medicine Hypoxia or, more commonly, anxiety
When the cause of death is known The medical speciality concerned with during flight can lead to hyperventilation
and there are no legal requirements for the physiological effects of air travel, (overbreathing), in which increased
an autopsy to be carried out, hospitals such as the effects of reduced oxygen, breathing results in excess loss of car-
and/or doctors may seek the next-of- pressure changes, and accelerative bon dioxide. This loss alters the body’s
kin’s permission to perform an autopsy forces, as well as with the causes and acidity and gives rise to symptoms such
in order to advance knowledge of the treatment of medical problems that may as tingling around the mouth, muscle
disease that caused death, thereby help- occur during a flight. spasms, and lightheadedness. If such
ing in the care of future patients with Aviation medicine includes assess- symptoms develop, the treatment is to
the same condition. Relatives are free to ment of the fitness of the aircrew, and rebreathe air from a paper bag held over
refuse such consent. sometimes of passengers, to fly, the the nose and mouth, which reduces the
management of medical emergencies in loss of carbon dioxide.
autoregulation the air, the consequences of special The changes in altitude or cabin pres-
Processes occurring within the body types of flights (such as in helicopters sure during a flight affect the body’s
that maintain ideal conditions for nor- and spacecraft), and the investigation of gas-containing cavities, principally the
mal function. Such processes include aircraft accidents. middle ears, the facial sinuses, the
the distribution of blood between dif-
ferent organs, and balance of the body’s
salt and water content. CONDITIONS AFFECTING PASSENGER SUITABILITY FOR AIR TRAVEL
Conditions Comments
autosomal disorders
See genetic disorders.
Lung disease (such as chronic The lowered cabin pressure (and thus the oxygen
bronchitis or emphysema) level) at higher altitudes aggravates an already
autosome impaired ability to oxygenate the blood and/or
Any chromosome that is not a sex Severe anaemia tissues and may cause severe respiratory
chromosome. Of the 23 pairs of chro- distress or collapse. Seek your doctor’s advice.
mosomes in each human cell, 22 pairs Heart condition (such as angina pectoris, Flying may be possible if you are able to walk 50
heart failure, or recent heart attack) metres without breathlessness or chest pain.
are autosomes.
autosuggestion Recent stroke Seek your doctor’s advice. You may need to wait
some weeks before flying.
Putting oneself into a receptive hypnot-
ic-like state as a means of stimulating Recent surgery to inner or middle ear, Seek your doctor’s advice. You may need to wait
the body’s ability to heal itself. The idea abdomen, chest, or brain; a recently before flying to avoid damage to your hearing
that symptoms could be relieved merely collapsed lung or a fractured skull. mechanism from the expansion of gas trapped in
through attitude was put forward by the the chest, abdomen, or skull.
Frenchman Emile Coué at the end of
the nineteenth century. Pregnancy No flying after 34 to 36 weeks on most airlines.
Although, autosuggestion enjoyed
only brief popularity, some techniques Newborn baby An infant should not fly until at least 48 hours old.
used today are based on its premise. For
example, in one method used to control Psychiatric disorder May need trained escort.
anxiety symptoms, people are taught
muscular relaxation techniques (see Infectious disease, terminal illness, May be refused entry to aircraft: Check with
biofeedback) and learn to summon up or vomiting airline.
calming imagery or pleasant thoughts.

83
 AVITAMINOSIS

lungs, and the intestines. When pressure otherwise washed, and treatment is develops later in life. It can also occur
A drops during ascent, the volume of gas
in these cavities increases and usually
sought immediately, reimplantation (see
reimplantation, dental) may be possible.
following a vasectomy.
CAUSES
escapes freely. On descent, the gas vol- Congenital azoospermia may be due to
ume decreases as pressure outside the avulsion a chromosomal abnormality such as Kline-
body rises. Unless preventative mea- The tearing away of a body structure felter’s syndrome (the presence of an
sures are taken, this may cause pain from its point of attachment. Avulsion extra sex chromosome); failure of the
and, rarely, damage (see barotrauma). may be due to an injury, for example testes to descend into the scrotum;
There is increasing concern about the excessive contraction of a tendon may absence of the vasa deferentia (ducts
risk of developing deep vein thrombosis avulse a small piece of bone at its that carry sperm from the testes to the
(see thrombosis, deep vein) during air attachment point. Avulsion may also be seminal vesicles, where it is stored prior
travel. The condition may be caused by performed as part of a surgical proce- to ejaculation); or cystic fibrosis (a
long periods of sitting in one position dure, as in the surgical removal of genetic disease of the lungs and pan-
or compression of the tissues, both of varicose veins. creas that may also cause defects of the
which occur during long-haul flights. vasa deferentia).
The accelerative forces experienced axilla In some males, azoospermia may be
by civil aircraft passengers are mild, The medical name for the armpit. the result of hormonal disorders affect-
even during take-off and landing, and ing the onset of puberty. Another cause
no medical precautions are necessary. axis is blockage of the vasa deferentia, which
Military aircraft pilots, on the other The second cervical vertebra in the may follow a sexually transmitted infec-
hand, may experience severe accelera- human spine. The axis is attached by a tion, tuberculosis, or surgery on the groin.
tions and must wear special suits and pivot joint to the atlas, the topmost ver- Azoospermia can also be the result of
use a reclined seat to prevent pooling of tebra, which in turn is attached to the damage to the testes. This can follow
blood in the feet, which would cause base of the skull. The pivot joint allows radiotherapy, treatment with certain
immediate loss of consciousness. the head to turn to either side. drugs (for example, anticancer drugs),
Motion sickness usually causes fewer prolonged exposure to heat, or the
problems during air travel than during axon effects of occupational exposure to
road or sea travel. Passengers who are The thin, elongated part of a neuron toxic chemicals. In some cases, produc-
prone to motion sickness may benefit (nerve cell) that conducts nerve impuls- tion of sperm ceases permanently for
from taking an anti-motion sickness es. Many axons in the body are covered no known reason.
preparation. with a fatty myelin sheath. TREATMENT AND OUTLOOK
Air travel allows the rapid crossing of If the cause is treatable (with hormones
several time zones within a short period Ayurvedism to bring on puberty or surgery to
of time, which can affect sleep-waking See Indian medicine. unblock ducts closed by infection, for
cycles, causing jet-lag. example), sperm production may restart.
AVIATION MEDICINE SPECIALISTS azathioprine However, in some cases the testes will
Most large airlines have doctors who are An immunosuppressant drug used to treat have been permanently damaged.
specially trained in aviation medicine severe rheumatoid arthritis and other
who are responsible for the healthcare autoimmune disorders (in which the im- AZT
of the airline staff. The doctors also mune system attacks the body’s own The abbreviation for azidothymidine,
give advice on the transportation of sick tissues). The drug is also used to prevent the former name for zidovudine.
passengers, the provision of training organ rejection after transplant surgery.
and equipment to deal with illness Azathioprine may be injected or given aztreonam
during flight, and the maintenance of in tablet form. Side effects include An antibiotic drug used to treat some
airline hygiene. increased susceptibility to infection. types of meningitis and infections by
certain types of bacteria, including
avitaminosis azelaic acid PSEUDOMONAS.
See hypovitaminosis. A topical (applied to the skin) drug that
is used to treat mild to moderate acne. azygous
Avloclor A term meaning not paired. Azygous
A brand name for chloroquine, a drug azithromycin describes a structure such as the heart,
that is used to prevent and treat malaria. A macrolide antibiotic drug used to treat which does not have a twin organ on
Avloclor is also used in the treatment of infections of the skin, chest, throat, and the opposite side of the body. The azy-
some rheumatic disorders, such as ears. Azithromycin is also used to treat gous vein drains blood from the
rheumatoid arthritis. genital infections due to chlamydia (see abdomen and chest and travels along
chlamydial infections). the right side of the spine.
avulsed tooth
A tooth that has become completely azoospermia
dislodged from its socket following an The absence of sperm from semen, caus-
injury. If the tooth is kept clean and ing infertility in males. Azoospermia may
moist (ideally by being stored in milk, be caused either by a congenital (pre-
saliva, or contact-lens solution), is not sent from birth) disorder or by one that

84
 BACK PAIN

bacitracin

B
a wider area. This can result in tem-
A type of antibiotic drug used in combin- porary scoliosis (an abnormal sideways
ation with other drugs to treat infections curvature of the spine).
of the eyes and skin. Bacitracin is most Abnormalities of a facet joint and
commonly applied as an external skin prolapse of an intervertebral disc can B
preparation or as eye-drops. both cause sciatica (pain in the buttock
and down the back of the leg into the
back foot). This condition is the result of
The area between the shoulders and pressure on a sciatic nerve root as
buttocks. The back is supported by the it leaves the spinal cord. Coughing,
spinal column (see spine), which is sneezing, or straining will increase the
babesiosis bound together by ligaments (bands of pain. Pressure on the sciatic nerve can
A general term covering a number of tough, fibrous tissue) and supported by also cause a pins-and-needles sensation
diseases that are caused by the BABESIA muscles that also help to control pos- in that leg as well as weakness in mus-
genus of protozoa (single-celled para- ture and movement. cles that are activated by the nerve.
sites). Babesiosis is mainly a disease of DISORDERS Rarely, pain may radiate down the
animals; it may affect sheep, cattle, Back problems are numerous and may femoral nerve at the front of the thigh.
horses, and other domestic animals. be the result of a variety of factors Osteoarthritis in the joints of the spine
Babesiosis can be transmitted from ani- affecting the spine. They can be related can cause persistent back pain. Ankylosing
mals to humans by tick bites, producing to disorders of bones, muscles, liga- spondylitis (an inflammatory disorder in
symptoms similar to those of malaria. ments, tendons, nerves, and joints in which arthritis affects the spine) causes
Treatment is with the antimalarial the spine, all of which can cause back back pain and stiffness with loss of back
drug quinine and an antibiotic drug. (See pain. (See also spine disorders box.) mobility. Coccydynia (pain and tender-
also ticks and disease.) ness at the base of the spine) may occur
background radiation after a fall in which the coccyx has
Babinski’s sign The small amounts of natural radiation struck the ground, during pregnancy, or
A reflex movement in which the big toe that emanate from such sources as rocks spontaneously for unknown reasons.
bends upwards when the outer edge and the soil. Fibrositis is an imprecise term that is
of the sole of the foot is scratched. In sometimes used to describe pain and
babies, Babinski’s sign is a normal reflex back pain tenderness in muscles, which may affect
action. In adults, Babinski’s sign is an Most people suffer from back pain at the back. Fibrositis is often worse in
indication of damage to, or disease of, some time in their lives. In many cases, cold and damp weather and is occasion-
the brain or the spinal cord. no exact diagnosis is made because the ally associated with feeling generally
pain gets better with rest and because unwell. Unlike other causes of back pain,
baby blues analgesic drugs (painkillers) are used fibrositis is not accompanied by muscle
A common name for a mild form of before any tests, such as X-rays, are car- spasm or restriction of back movement.
depression that sometimes occurs in ried out. In such cases, doctors may use It often improves when treated with
women after childbirth. The baby blues the term “nonspecific back pain” to nonsteroidal anti-inflammatory drugs.
almost always disappear without treat- describe the condition. Pyelonephritis can cause back pain as
ment but can occasionally develop into CAUSES well as pain and tenderness in the loin,
a more serious depressive illness (see Nonspecific back pain is one of the fever, chills, and pain when passing
postnatal depression). largest single causes of working days urine. Cancer in the spine can cause
lost through illness in the UK. The peo- persistent back pain that disturbs sleep
baby teeth ple most likely to suffer from back pain and is not relieved by rest.
Also known as milk teeth, an alternative are those whose jobs involve a lot of SELF-HELP
term for the first teeth (see primary teeth). heavy lifting and carrying or those who People with back pain and sciatica are
spend long periods sitting in one posi- usually advised to remain as mobile as
bacillary dysentery tion or bending awkwardly. Overweight possible. Sleeping on a firm mattress and
A type of dysentery (infection of the people are also more prone to back pain taking analgesic drugs can help to relieve
intestinal tract) caused by bacteria of – their backs carry a heavier load and pain. However, if pain persists, is very
the SHIGELLA genus (see shigellosis). they tend to have weaker abdominal severe, or is associated with weakness in
muscles, which usually help to provide a leg or bladder control problems, imme-
bacille Calmette-Guérin support to the back. diate medical advice should be sought.
See BCG vaccination. Nonspecific back pain is thought INVESTIGATION
to be caused by a mechanical disorder Examination of the back may show ten-
bacilli affecting one or more structures in the derness in specific areas or loss of back
Rod-shaped bacteria. Bacilli (singular: back. This may be a ligament strain, a mobility. Weakness or loss of sensation
bacillus) are responsible for causing a muscle tear, damage to a spinal facet in the legs implies pressure on a nerve
variety of diseases, including infectious joint, or disc prolapse (slipped disc). root, which needs prompt investigation.
diseases such as tuberculosis, tetanus, In addition to pain from a damaged X-rays of the spine may reveal nar-
typhoid fever, pertussis (whooping structure, spasm of surrounding mus- rowing between the intervertebral discs;
cough), and diphtheria. cles will cause pain and tenderness over osteoarthritis; osteoporosis; ankylosing

85
 BACLOFEN

bacteria
BACK PAIN Single-celled microorganisms that are
invisible to the naked eye. The singular
Most people experience back pain
B at some time in their lives, but in
most cases it is not serious and
Fibrositis
form of the term is bacterium. Abun-
dant in the air, soil, and water, most
Pain and tenderness
the problem corrects itself before in the larger back
bacteria are harmless to humans. Some,
investigation takes place. However, muscles. such as those that live in the intestine,
some kinds of back pain can be are beneficial and help to break down
related to a specific disorder. food for digestion.
The most common sites affected
by back pain are shown in Nucleus Cell wall Pilus
this diagram. Capsule

Nonspecific Cytoplasmic
Osteoarthritis membrane
Pain and stiffness in the back pain
back due to degeneration of Pain that commonly
Flagellum
the joints between the affects the lower back
vertebrae in one (or more) but may occur in other
of the cervical, thoracic, or parts due to ligament,
Cytoplasm
lumbosacral regions. muscle, joint, or disc
damage.
Magnified bacterium
A typical bacterial cell enlarged to approximately
Pyelonephritis
Pain in the loin due to 20,000 times its normal size.
infection of the kidney.
DISEASE-CAUSING TYPES
Coccydynia Disease-causing bacteria are known as
Sciatica Pain and tenderness
at the base of the pathogens and are classified, according
Pain in the buttock and
down the back of the spine, sometimes to shape, into three main groups: cocci
leg into the foot due to after a fall. (spherical); bacilli (rod-shaped); and
pressure on a nerve.
spirochaetes or spirilla (spiral-shaped).
Among the wide range of diseases
caused by cocci are pneumonia, tonsilli-
spondylitis; compression fracture; stress such as multiple sclerosis, or by a stroke. tis, bacterial endocarditis (inflammation
fracture; bone cancer; or spondylolisthesis The drug does not cure the underlying of the lining inside the heart), menin-
(displacement of vertebrae). X-rays will disorder but helps to facilitate move- gitis (inflammation of the membranes
not reveal ligament, muscle, facet joint, ment and allows physiotherapy to be surrounding the brain and spinal cord),
or disc damage. To detect pressure on a more effective. The drug is taken in toxic shock syndrome, and various dis-
nerve root (due to disc prolapse, for either tablet or liquid form. orders of the skin.
example), myelography, CT scanning, or Side effects of baclofen may include Diseases that are caused by bacilli
MRI is performed. drowsiness and muscle weakness. These include tuberculosis, pertussis (whoop-
TREATMENT effects can be reduced if the dose of the ing cough), typhoid fever, diphtheria,
If a specific cause is found for the back drug is increased gradually under med- tetanus, salmonellosis, shigellosis (bacil-
pain, treatment will be for that cause. ical supervision until the desired degree lary dysentery), legionnaires’ disease,
Research has shown that acute nonspe- of relaxation is achieved. and botulism.
cific back pain is best treated by early Bacteria from the third, and smallest,
return to normal activity, helped by bacteraemia group, the spirochaetes, are responsible
analgesic drugs. Bed rest should not be The presence of bacteria in the blood- for causing syphilis, yaws, leptospirosis,
continued for more than two days. stream. Bacteraemia commonly occurs and Lyme disease.
Chronic nonspecific back pain is often for a few hours after minor surgical GROWTH AND MOVEMENT
more difficult to treat. Treatment may operations and dental treatment and The bacteria that colonize the human
include use of aspirin and related drugs, may also occur in infections such as body thrive in warm, moist conditions.
nonsteroidal anti-inflammatory drugs, mus- tonsillitis. The immune system, the body’s
cle-relaxant drugs, acupuncture, or spinal natural defence mechanism, usually Common types of bacteria
injection. Exercise, spinal manipulation, prevents the bacteria from multiplying
or wearing a surgical corset may also be and causing damage. However, in peo-
helpful; and spinal surgery may some- ple with abnormal heart valves (due to
times be necessary. conditions such as a congenital defect
or scarring from rheumatic fever), the Staphylococcus Streptococcus
baclofen bacteria may cause endocarditis (inflam-
(causes boils) (causes sore throat)

A muscle-relaxant drug that blocks nerve mation of the heart lining and valves).
activity in the spinal cord. Baclofen is If bacteraemia affects a person whose
used to relieve muscle spasm and stiff- immune system is weakened by illness
ness caused by injury to either the brain or major surgery, septicaemia (an infec- Salmonella typhi Spirochaete
or spinal cord, by neurological disorders tion of the blood) may develop. (causes typhoid fever) (causes syphilis)

86
 BACTERIOSTATIC

Some of these bacteria are aerobic (they sending various types of white blood
need oxygen to grow and multiply) and CULTURING AND TESTING cell to seek and destroy the bacteria.
BACTERIA
are therefore most commonly found on Immunity can also be generated by
the skin or within the respiratory sys- immunization. This involves injecting a
tem. Others are anaerobic, thriving weakened form of the bacterium or its B
where there is no oxygen, deep within poison into the body to stimulate an
tissue or wounds. immune response. Immunization is now
Some types of bacteria are naturally routine for a number of conditions,
static; if they move around the body at including diphtheria, tetanus, and some
all, they do so only when carried in forms of meningitis.
currents of air or fluid. However, there TREATMENT OF BACTERIAL DISEASES
are also highly motile types of bacteria, The immune response is sometimes
such as salmonella, which move through enough to bring about recovery, and
fluids by lashing with their whiplike mild bacterial infections may not need
tails (known as flagella) and can anchor any treatment. However, antibiotic drugs
themselves to other cells with filamen- are the main form of treatment for more
tous threads called pili. severe infections. Superficial infected
REPRODUCTION wounds may be treated with antiseptics.
Bacteria reproduce by simple cell divi-
sion, which can occur every few minutes 1agarThe bacteria are introduced
on to a nutrient plate (i.e.
or blood agar) and placed in
Some bacteria, such as MRSA, are now
becoming resistant to treatment with
in ideal conditions (exactly the right an incubator at body temperature. antibiotics. In these circumstances, bac-
temperature and sufficient nourishment terial infections can be difficult or even
for all cells). Some bacteria multiply by impossible to treat and may be life-
each producing a spore (a single new threatening. (See also infectious disease.)
bacterium). Spores, which are protected
by a tough membrane, can survive high bacterial endocarditis
temperatures, dry conditions, and lack See endocarditis.
of nourishment.
HOW BACTERIA ENTER THE BODY bacterial food poisoning
Bacteria can enter the body through the See food poisoning.
lungs if they are inhaled in infected
droplets spread by coughs and sneezes. Any bacteria present multiply rapidly
bacterial vaginosis
The digestive tract may become infected 2studied
to form visible colonies that can be
under the microscope and
An infection of the vagina that causes a
if contaminated food is eaten. Some greyish-white discharge and itching.
bacteria cause diseases, such as sexually identified by different patterns of growth. The disorder is due to excessive growth
transmitted infections, by entering the of bacteria that normally live in the
genitourinary system. vagina. Bacterial vaginosis occurs most
Bacteria can also penetrate the skin in commonly in sexually active women
various ways: through hair follicles; by and is treated with antibiotic drugs.
way of superficial cuts and abrasions;
through burns; and via deep, pene- bactericidal
trating wounds. A term that is used to describe any
HOW BACTERIA CAUSE DISEASE substance that kills bacteria. (See also
Some bacteria release poisons (toxins) antibiotic drugs; bacteriostatic.)
that are harmful to human cells. The
toxins either destroy the cell or disrupt bacteriology
its chemical processes. Less commonly, The study of bacteria, particularly of the
certain types of bacteria directly enter, 3discsTospecific
test sensitivity to
antibiotics,
of different
types that cause disease. Bacteriology
and multiply within, body cells, causing includes techniques used to isolate and
tissue damage as they spread. antibiotics are identify bacteria from specimens such
placed within the
THE BODY’S DEFENCES colonies of bacteria. as a throat swab or urine. Bacteria are
The body’s first defences against dis- identified by their appearance under a
ease-causing bacteria are the skin and microscope, including their response to
the mucous membranes lining the res- stains (see Gram’s stain; staining), and by
piratory tract, the digestive tract, and the use of culture. Testing for sensitivity
the genitourinary system. The eyes are to antibiotic drugs may be performed.
protected by an enzyme in tears and Any clear areas
the stomach secretes hydrochloric acid,
which kills many of the bacteria found
4indicate
around each disc
that the
bacteriostatic
A term used to describe a substance that
in food and water. bacteria are being killed stops the growth or multiplication of
by a particular antibiotic.
If bacteria pass through these barriers, bacteria but does not kill them. (See also
the body’s immune system responds by antibiotic drugs; bactericidal.)

87
 BACTERIURIA

bacteriuria balance ball-and-socket joint

The presence of bacteria in the urine. It The ability to remain upright and move A highly mobile joint, such as the shoul-
is common for small, harmless numbers without falling over. Keeping one’s bal- der or hip.
B of bacteria to be found in the urine of
healthy people. Bacteriuria is of signi-
ance is a complex process that relies on
a constant flow of information to the ballismus
ficance only if more than 100,000 brain about body position. The integra- Violent jerking and twitching of the
bacteria are present in each millilitre of tion of all of this information, and limbs that is caused by brain damage
urine, or if 100 white blood cells (pus continual instructions from the brain, within the area below the thalamus (a
cells) per millilitre of urine are present enable the body to make the changes structure that relays sensory informa-
(which is an indication of the body’s needed to maintain balance. tion). In most cases, only one side of
response to the infection). The brain receives data on body posi- the body is affected, in which case the
tion from various sources: the eyes; the condition is known as hemiballismus.
Bacteroides sensory organs (called proprioceptors)
A genus of anaerobic (capable of living in the skin, muscles, and joints; and the balloon angioplasty
without oxygen) bacilli (rod-shaped three semicircular canals of the labyrinth See angioplasty, balloon.
bacteria) that normally inhabit the intes- of the inner ear. The part of the brain
tines. One particular type, BACTEROIDES called the cerebellum collates this infor- ballottement
FRAGILIS , is commonly found in abdomi- mation and sends instructions to muscles A technique occasionally used during a
nal wound infections and in the blood to contract or relax to maintain balance. physical examination (see examination,
when the intestines are diseased. DISORDERS physical) to check the position of an
Balance can be affected by various dis- organ, particularly in a fluid-filled area
bad breath orders, particularly inner-ear disorders of the body. It involves flicking or tap-
See halitosis. such as labyrinthitis (inflammation of ping the area with the fingers, causing
the ear’s labyrinth) and Ménière’s disease the organ to move up and down. The
bagassosis (an abnormally high pressure of fluid in technique was once widely used to con-
An occupational disease affecting the the labyrinth). Less commonly, otitis firm pregnancy; when the wall of the
lungs of workers who handle mouldy media (a disorder of the middle ear) uterus is tapped, the fetus moves away
bagasse (the fibrous residue of sugar- may disturb balance. and floats back with a responding tap.
cane after juice extraction). Bagassosis is Damage to nerve tracts in the spinal
one cause of allergic alveolitis, a reaction cord that carry information from posi- balloon catheter
of the lungs to inhaled dust containing tion sensors in the joints and muscles to A flexible tube with a balloon at its tip,
fungal spores. Symptoms develop four the brain can also impair balance. This which, when inflated, keeps the tube in
to five hours after inhalation of the dust damage to the nerves may result from place or applies pressure to an organ or
and may include shortness of breath, spinal tumours, circulatory disorders, vessel. One type of balloon catheter is
wheezing, fever, headache, and cough; nerve degeneration due to deficiency of
typically, they last for about 24 hours. vitamin B12, or, rarely, tabes dorsalis (a
Repeated exposure to dust may lead complication of syphilis). A tumour or BALLOON CATHETER
to permanent lung damage. Protective stroke that affects the cerebellum in the
Sterile water tube
measures taken by industry have made brain may cause clumsiness of the arms to inflate balloon
the disease rare. and legs as well as other features of
impaired muscular coordination.
Baker’s cyst
A firm, fluid-filled lump behind the balanitis
knee. A Baker’s cyst occurs as a result of Inflammation of the foreskin and the Irrigation tube for fluid
to wash out bladder
increased pressure in the knee joint due glans (head) of the penis. Balanitis
to a buildup of fluid. Such a buildup is results in pain and/or itchiness, and the
a feature of disorders such as rheumatoid entire area may be red and moist. Causes
arthritis. The cyst is created by a back- of balanitis include bacterial or fungal Tube to drain
ward ballooning-out of the synovial infection, phimosis (tightness of the urine from bladder
membrane covering the knee joint. foreskin), or chemical irritation by con-
Inflatable balloon
Most Baker’s cysts are painless, and traceptive creams (see contraception) or filled with water
some disappear spontaneously, some- laundry products.
times after many months. Occasionally, Treatment is usually with antibiotic
a cyst may rupture, causing fluid to seep drugs or antifungal drugs (either applied
down between the layers of the calf mus- to the skin as cream or taken orally) and Hole through
cles. This can produce pain and swelling careful washing of the penis and foreskin. which urine
enters
in the calf that may mimic a deep vein If balanitis recurs frequently, or is due to
thrombosis (see thrombosis, deep vein). phimosis, circumcision (surgical removal
Diagnosis of a Baker’s cyst is con- of the foreskin) may be recommended.
firmed by ultrasound scanning. Treatment
is rarely needed, but in a few cases baldness URINARY CATHETER
surgery may be performed. See alopecia.

88
 BAROTRAUMA

used to drain urine from the bladder an anticonvulsant drug in the treatment barium X-ray examinations can be used
(see catheterization, urinary). Balloon cath- of epilepsy. In the past, barbiturates as an alternative to endoscopy (internal
eters are sometimes used to expand were widely used as antianxiety drugs examination using a rigid or flexible
narrowed arteries (see angioplasty, bal- and sleeping drugs, but they have been viewing tube), although endoscopy is
loon). They may also be used to control largely replaced by benzodiazepine drugs often the preferred form of investigation. B
bleeding from widened veins in the and other nonbarbiturates. Because bar- Barium X-rays may be single- or dou-
lower part of the oesophagus (known as biturates are habit-forming and are ble-contrast. Single-contrast X-rays use
oesophageal varices) before surgery. widely abused for their sedative effect, barium sulphate alone. The barium fills
they are now classed as controlled drugs. the section of the tract under examina-
balm HOW THEY WORK tion and provides an outline image that
A soothing or healing medicine applied The sedative action of barbiturate drugs shows up any prominent abnormalities.
to the skin. is produced by the drug molecules In double-contrast barium X-rays, the
blocking the conduction of stimulatory barium forms a thin film over the inner
balsam chemical signals between the nerve cells surface of the tract and the tract is sub-
An aromatic oily liquid that is obtained of the brain and reducing the ability of sequently filled with air so that any
from various evergreen trees. Balsam is the cells to respond. Barbiturates, espe- small surface abnormalities can be seen.
an antiseptic substance and was once cially phenobarbital, also reduce the TYPES OF EXAMINATION
also widely used in remedies for respir- sensitivity of brain cells to abnormal Various types of barium X-ray exam-
atory disorders. electrical activity. ination are used to investigate different
POSSIBLE SIDE EFFECTS parts of the gastrointestinal tract. A
bambuterol The possible adverse effects of barbitu- barium swallow involves drinking a sol-
A bronchodilator drug that is taken orally rate drugs include excessive drowsiness, ution of barium; this procedure is used
for the relief of asthma. staggering gait, and, in some cases, to investigate the swallowing mechan-
excitability. An overdose of barbiturates ism or the oesophagus. A barium meal
bandage can be fatal, particularly when taken in is carried out to look at the lower
A strip or tube of fabric used to keep combination with alcohol, which dan- oesophagus, stomach, and duodenum.
dressings in position, to apply pressure, gerously increases their depressant effect A barium follow-through examination
to control bleeding, or to support a on the brain (including suppression of can be used to investigate disorders of
sprain or strain. Roller and tubular ban- the respiratory centre). the small intestine; after barium has been
dages are the type most widely used. Barbiturates are likely to produce drug swallowed, a series of X-rays are taken
Tubular gauze bandages require a spe- dependence if used for longer than a few at intervals as the barium travels down
cial applicator and are used mainly for weeks, and withdrawal effects, such as the oesophagus to the intestine. A barium
areas that are awkward to bandage, such sleeplessness and twitching, may then enema can be used to investigate disor-
as a finger. Triangular bandages are used occur when treatment is stopped. ders of the large intestine and the rectum;
to make slings. (See also wounds.) the barium is introduced into the body
Bardet–Biedl syndrome through a tube inserted in the rectum.
banding A very rare genetic disorder characterized Any barium that remains in the intes-
A procedure for treating haemorrhoids by learning difficulties, retinopathy (an eye tine may be a cause of constipation. For
(piles) that are large or are causing defect), obesity, polydactyly (the presence this reason, it is important to ensure
particular discomfort. Using a special of extra fingers or toes) and hypogonadism that a patient has a high-fibre diet and
instrument, a doctor places a rubber (underactivity of the testes or ovaries). drinks plenty of water following a bar-
band around the base of the haemor- ium examination, until all the barium
rhoid, which causes it to shrink and, barium sulphate has passed through. (See also Barium
eventually, to fall off. Banding is virtually A salt that is used in solution as a X-ray procedures box, overleaf.)
painless and the procedure can be per- contrast medium in X-ray examinations
formed in a doctor’s surgery. of the intestinal tract (see barium X-ray barotrauma
examinations). Barium is opaque to X- Damage or pain, mainly affecting the
barber’s itch rays and is used to view the outline of middle ear and the facial sinuses, that is
See sycosis barbae. hollow internal organs, which would caused by changes in surrounding air
otherwise not be visible. pressure. Air travellers are at the greatest
barbiturate drugs risk of barotrauma, but scuba divers
COMMON DRUGS barium X-ray examinations face similar problems.
• Amobarbital • Butobarbital • Phenobarbital Procedures used to detect and follow CAUSE
• Secobarbital • Thiopental the progress of some disorders of the Aircraft cabin pressure decreases as the
gastrointestinal tract. Because barium (a plane ascends and increases as it des-
A group of sedative drugs that work by metallic element) is opaque to X-rays, it cends. As the aircraft ascends, the ears
depressing activity within the brain. is used to outline organs, such as the may seem to “pop” as the air in the
Barbiturate drugs include thiopental, stomach, which are not normally visi- middle ear expands and is expelled via
which is very short-acting and is used ble on an X-ray image. Barium sulphate the eustachian tubes, which connect the
to induce anaesthesia (see anaesthesia, mixed with water is passed into the part middle ear to the back of the throat. On
general), and phenobarbital, which is of the tract requiring examination descent, the higher pressure may push
long-acting and is sometimes used as before X-rays are taken. In some cases, the eardrum inwards and cause pain.

89
 BAROTRAUMA

BARIUM X-RAY PROCEDURES

Barium X-ray examinations are used to reveal abnormalities barium meals are used for the examination of areas such as
B or disorders within the upper and lower gastrointestinal tract.
Barium swallows are used to investigate the oesophagus, and
the stomach and duodenum. The large intestine is examined
by means of a barium enema.

BARIUM SWALLOW/MEAL
Barium swallows and meals Monitor Barium solution Barium swallow result
are used to investigate the This contrast X-ray has
upper gastrointestinal tract. revealed a narrowed
No food or drink is permitted area, known as an
oesophageal stricture, in
for six to nine hours before-
the lower section of the
hand. At the examination, oesophagus.
the patient swallows a glass
of barium mixed with a
Narrowed
flavoured liquid, or is given oesophagus
a piece of bread or a biscuit
soaked in barium if a disorder
of the swallowing mechanism Spinal column
is being investigated.
Spine Stomach
X-ray machine
Barium
Taking the X-ray meal result
The radiographer takes X-ray Radiographer In this X-ray,
pictures while the patient a thin film of
swallows. For a barium swallow, barium has
the patient stands; for a barium Patient outlined the
meal, the patient lies on the stomach lining.
table in different positions; for The introduction
a barium follow-through, the of air into the
patient lies on the right side and stomach has
X-rays are taken at intervals until revealed the
the barium has progressed Stomach Outline presence of a
through the small intestine. X-ray table outlet of tumour large tumour.

BARIUM ENEMA
A barium enema is carried out for examination of the large a polyp or tumour. For this reason, the patient’s intake of
intestine and rectum. In order for an examination to be food and fluids is sometimes restricted for a few days
successful, the large intestine needs to be as empty and before the examination, and laxatives are given to make
clean as possible because faeces can obscure or simulate sure that the bowel is empty prior to the procedure.

Air-filled
Colon colon coated
with barium

Small
intestine Small
intestine

Colon filled
Rectum with liquid
barium

Tube to
deliver Barium in
barium rectum

The procedure Single-contrast result Double-contrast result

The radiographer or radiologist introduces In single-contrast barium enemas, the In double-contrast, barium and air are
the barium into the patient’s intestine via a section of intestine to be examined is introduced into the tract. The barium
tube inserted into the rectum. The patient filled with liquid barium. Because forms a film on the tract’s inner surface
lies on his or her left side while the barium is barium is opaque to X-rays, it provides only, providing an image of small
infused. He or she then turns on to the other an outline image that shows up prominent surface abnormalities that would not
side, front, and back, and X-rays are taken. abnormalities such as narrowing. be visible using single-contrast.

90
 BASAL CELL CARCINOMA

SYMPTOMS chest, thereby resulting in a change in Bartholin’s abscess

Minor pressure damage in the middle ear the shape of the chest wall. (See also The formation of pus in one or both of
may cause pain, hearing loss, and tinni- pulmonary disease, chronic obstructive.) the Bartholin’s glands, which are located
tus (ringing in the ears) for a few days; on either side of the vulva (the folds of
damage in the facial sinuses may also Barrett’s oesophagus flesh that surround the opening of the B
cause pain, and possibly a discharge of A complication of long-term gastro- vagina). Bartholin’s abscesses develop as
mucus or blood. Symptoms usually wear oesophageal reflux (see acid reflux), in a result of bacterial infection of the
off within hours or days, but treatment which the cells that line the lower part glands (see bartholinitis).
may be needed if they worsen or persist. of the oesophagus are replaced by cells
Large changes in pressure can rupture that are normally found in the stomach. Bartholin’s glands
the eardrum (see eardrum, perforated). People with Barrett’s oesophagus are at A pair of oval, pea-sized glands whose
PREVENTION increased risk of developing cancer of ducts open into the vulva (the folds of
Barotrauma can be avoided by vigorous the oesophagus (see oesophagus, cancer flesh that surround the opening of the
swallowing or by forcibly breathing out of). The condition may be monitored vagina). During sexual arousal, the Bar-
with the mouth closed and the nose regularly by endoscopy (internal exam- tholin’s glands secrete a fluid that
pinched, which is known as the Valsalva ination using a viewing instrument) of lubricates the vulval region. Infection
manoeuvre. This action serves to equal- the oesophagus. of these glands causes bartholinitis or the
ize the internal and external pressures development of a Bartholin’s abscess.
in the middle ear and sinuses. barrier cream
If the eustachian tubes are blocked, as A cream that is used to protect the skin
BARTHOLIN’S GLANDS
commonly occurs with a cold, use of a against the effects of irritant substances
nasal spray containing a decongestant and excessive exposure to water. (See These glands are located on each
drug is recommended shortly before the also sunscreens.) side of the entrance to the vagina.
descent of the aircraft. Anyone with a
severe head cold should avoid air travel barrier method
if possible. Infants should be breast- or A method of preventing pregnancy by
bottle-fed during descent to encourage blocking the passage of sperm to the
swallowing. (See also aviation medicine; uterus (see contraception, barrier methods
scuba-diving medicine.) of). An example of a barrier method is
the use of a condom or a diaphragm.
Vagina Vulva
barrier nursing Duct of gland
The nursing technique by which a
Bartholin’s
patient with an infectious disease is pre- glands
Anus
vented from infecting other people (see
Increased
air isolation). In reverse barrier nursing, a
pressure patient with reduced ability to fight
infections (for example, because of an
Eardrum immunodeficiency disorder or following
bulging
inwards certain types of surgery) is protected basal cell carcinoma
Low air against outside infection. (See also asep- A type of skin cancer, also known as a
pressure tic technique.) rodent ulcer or BCC, that occurs most
commonly on the face or neck, but can
bartholinitis affect any part of the body. The cells of
An infection of the Bartholin’s glands at the tumour closely resemble, and are
the entrance to the vagina. The disorder, possibly derived from, cells in the basal
which may be due to a sexually transmit- (innermost) skin layer.
Blocked ted infection such as gonorrhoea, causes Basal cell carcinoma is caused by skin
eustachian an intensely painful red swelling at the damage from the ultraviolet radiation
tube
opening of the gland ducts. Treatment in sunlight. Fair-skinned people over
Mechanism of barotrauma is with antibiotic drugs, analgesic drugs, the age of 50 are most commonly
The diagram above shows the location of the
middle ear and the pressure changes that occur
and warm baths. affected by this form of cancer; dark-
when the eustachian tube is blocked and there Bartholinitis sometimes leads to the skinned people are protected by the
is an increase in surrounding air pressure. formation of an abscess (see Bartholin’s larger amount of melanin (a pigment
abscess) or a painless cyst, known as a that absorbs ultraviolet radiation) in
barrel chest Bartholin’s cyst, which may become their skin. The incidence of basal cell
A prominent, rounded chest that is infected. Abscesses are drained under carcinoma is much higher among peo-
sometimes the result of lung distension general anaesthesia (see anaesthesia, ple living in sunny climates, especially
in people with longstanding emphysema general). Recurrent abscesses or infected those who have outdoor occupations;
(enlarged air sacs in the lungs). Lung cysts may require surgery to convert the in parts of the US and Australia, over
distention leads to an increase in dis- duct into an open pouch (see marsupial- half the white population has had a
tance between the front and back of the ization) or remove the gland completely. basal cell carcinoma by the age of 75.

91
 BASAL GANGLIA

SYMPTOMS lines most hollow structures within it). B-cell

The majority of basal cell carcinomas The basement membrane is composed See B-lymphocyte.
occur on the face, often at the side of an of protein fibres and carbohydrates.
BCG vaccination
B eye or on the nose. It starts as a small,
flat nodule and grows slowly, eventually base pair A vaccine that gives immunity against
breaking down at the centre to form a Part of a DNA molecule comprising two tuberculosis. The BCG vaccine is prepared
shallow ulcer with raised edges. chemicals known as nucleotide bases from an artificially weakened strain of
Diagnosis is confirmed through a that are linked together by means of bovine (cattle) tubercle bacilli, the rod-
biopsy (removal of a small sample of hydrogen bonds. A base pair forms one shaped bacteria that are responsible for
cells for microscopic analysis). Without “rung” of the DNA “ladder”. There are causing tuberculosis. The letters BCG
treatment, the tumour gradually invades only two possible pairings of the four stand for “bacille Calmette–Guérin”,
and destroys the surrounding tissues, bases: guanine always pairs with cyto- after the two men who developed the
but it virtually never spreads to other sine and adenine with thymine. The tuberculosis vaccine.
parts of the body. sequence of base pairs in each DNA WHY IT IS DONE
TREATMENT chain provides the code for the activi- The BCG vaccine is given to people who
Treatment of basal cell carcinoma is ties of the cell (see genetic code). (See are at risk of tuberculosis and to those
usually with surgery (or in some cases also nucleic acids.) whose tuberculin test is negative, indi-
radiotherapy) and is often completely cating that they are likely to have no
successful. Plastic surgery may also be basic life support immunity to the disease. People at risk
required, however, depending on the Resuscitation techniques that may be include health workers, contacts of peo-
size and site of the tumour. performed by a first aider (see rescue ple with tuberculosis, and immigrants
PREVENTION breathing; cardiopulmonary resuscitation). from countries where there is a high
The risk of developing this form of skin If basic life support measures fail to rate of tuberculosis. Infants born to
cancer can be reduced by avoiding over- restore a normal heartbeat and sponta- immigrants in this category are immu-
exposure to strong sunlight, by using neous breathing, advanced life support nized, without having a tuberculin test,
sunscreens, and by wearing protective must then be administered by trained within a few days of birth. The vaccine
clothing such as sun hats. People who medical personnel. is also recommended for children aged
have previously had a basal cell carcin- 10 to 14 years for whom the tuberculin
oma may develop further tumours and basilar membrane test is negative.
should be especially alert to any new A membrane within the cochlea (the HOW IT IS DONE
changes in their skin. (See also melan- inner ear structure containing the recep- The vaccine is usually injected into the
oma, malignant; squamous cell carcinoma; tor for hearing). Sound waves cause the upper arm. About six weeks later, a
sunlight, adverse effects of.) basilar membrane to vibrate, stimulat- small pustule appears. This normally
ing sensory hair cells to send electrical heals completely, leaving a small scar,
basal ganglia signals to the brain. but can occasionally develop into a
Paired nerve cell clusters deep within chronic ulcer (open sore).
the cerebrum (the main mass of the basophil
brain) and the upper part of the brain- A type of white blood cell that plays a part Becker’s muscular dystrophy
stem. The basal ganglia play a vital part in inflammatory and allergic reactions. A type of muscular dystrophy.
in producing smooth, continuous mus-
cular actions and in stopping and Batten’s disease beclometasone
starting movement. Any disease or One of a group of hereditary metabolic A corticosteroid drug that is used in the
degeneration affecting the basal ganglia diseases (see metabolism, inborn errors treatment of asthma and hay fever (see
and their connections may lead to the of) to which Tay–Sachs disease also rhinitis, allergic). When prescribed as a
appearance of involuntary movements, belongs. In Batten’s disease, abnormal nasal spray, beclometasone controls the
trembling, and weakness, as occur in fatty substances accumulate in the cells symptoms of these conditions by redu-
Parkinson’s disease. of the nervous system, causing progres- cing inflammation and the production
sive dementia, worsening seizures, and of mucus in the lining of the nose. Pre-
basal metabolic rate (BMR) loss of vision. Symptoms of the condi- scribed as an inhaler for the treatment
The rate at which energy is used by the tion usually first appear during early of asthma, the drug reduces inflamma-
body just to maintain vital functions. childhood. tion of the airways, thereby controlling
Such vital functions include breathing, There is no known treatment for Bat- wheezing and coughing.
circulation, and digestion. (See also ten’s disease, which is generally fatal Beclometasone is often given with
energy requirements; metabolism). during childhood. bronchodilator drugs in the management
of asthma. A severe asthma attack may
base Bazin’s disease require the dose to be increased. The
See alkali. A rare disorder, mainly affecting young action of beclometasone is slow, how-
women, in which tender swellings ever, and its full effect takes several days
basement membrane develop under the skin in the calves. In to occur. Possible adverse effects of the
The thin membrane that lies directly most cases no cause can be found, drug include hoarseness, throat irrita-
beneath the epithelium (the layer of cells although Bazin’s disease may sometimes tion, and, on rare occasions, fungal
that covers surfaces of the body and be linked to tuberculosis. infections in the mouth.

92
 BEHAVIOURAL PROBLEMS IN CHILDREN

Beclometasone is also prescribed in the vulnerable areas, and use of cushions

form of a cream or as an ointment to PREVENTING BEDSORES and special mattresses, should prevent
treat inflammation of the skin resulting bedsores from developing in most cases.
Once a bedsore has developed it
from eczema. will heal only if pressure on it is
minimized, so good nursing care of
bedwetting B
beclomethasone a bedridden or immobile patient is The common name for poor bladder
The former name for the corticosteroid crucial. The patient’s position should control at night (see enuresis, nocturnal).
drug beclometasone. be changed at least every two hours;
and it is important to wash and dry bee stings
Beconase pressure areas carefully, especially if See insect stings.
A brand name for a nasal spray that there is incontinence. Barrier creams
contains the corticosteroid drug beclo- can be used for additional protection. behavioural problems
metasone. Beconase is used to treat hay in children
fever (see rhinitis, allergic) and also some Behavioural problems range from mild
other nasal allergies. and short-lived periods of unacceptable
behaviour, which are common in most
Becotide children, to more severe problems such
A brand name for an inhaled form of as conduct disorders and refusal to go
the corticosteroid drug beclometasone to school. Behavioural problems may
that is used to treat asthma. Common sites occasionally occur in any child; special-
These include the ist management is called for when the
becquerel shoulders, elbows,
problems become frequent and disrupt
lower back, hips and
A unit of radioactivity (see radiation buttocks, knees, ankles, school and/or family life. Some behavi-
units). and heels. oural problems can occur whatever the
family or home situation of the child. In
bed bath some cases, however, stressful external
A method of washing a bedridden per- events, such as moving home or parental
son. A small area is washed and dried at divorce, may produce periods of prob-
a time, while the rest of the body is kept lem behaviour.
covered to prevent chilling. bedridden Behavioural problems that are com-
A term used to describe a person who is mon in young children include sleeping
bedbug unable to leave bed due to illness or problems, such as waking repeatedly
A flat, wingless, brown insect that is injury. People most likely to be bedrid- in the night. In toddlers, breath-holding
about 5 mm long and 3 mm wide. Bed- den are the very elderly, the terminally attacks, tantrums, separation anxiety, and
bugs live in furniture and furnishings, ill, and those paralysed as the result of head-banging are problems best dealt
especially in beds and carpets, emerging an accident. with by a consistent and controlled
at night to feed on humans by sucking approach. Problems with toilet-training
their blood. Bedbugs are not known to bedsore
transmit disease, but their bites are Also known as a decubitus ulcer or
itchy and they may develop into sores pressure sore, an ulcer that forms on the BEHAVIOURAL PROBLEMS
BY AGE
that become infected. skin of patients who are unconscious or
immobile. Common sites for bedsores • Babies up to 18 months
bedpan include the shoulders, elbows, lower Sleeping and feeding difficulties,
A metal, plastic, or fibre container into back, hips, buttocks, ankles, and heels. colic, crying
which a patient can defaecate or urinate CAUSES
without getting out of bed. Bedsores may develop following a stroke • Toddlers and children 1–4 years
or spinal injuries that result in loss of Head-banging, tantrums, biting, breath-
bed rest sensation. Incontinence (see incontinence, holding attacks, separation anxiety, poor
social interaction, difficulty in changing
A term used to describe periods spent urinary), if it results in constantly wet from one activity to another, toilet
in bed. Bed rest is sometimes part of the skin, may also be a causative factor. training problems
treatment for certain illnesses, such as SYMPTOMS
rheumatic fever, and for some types of Bedsores start as red, painful areas that • Early childhood 4–8 years
injury, such as a fractured vertebra. become purple before the skin starts to Nail-biting, thumb-sucking, aggression,
clinginess, anxiety about illness and
Prolonged bed rest carries risks such break down, producing open sores. At death, nightmare, enuresis
as muscle wasting, bedsores, and devel- this stage, the sores may become infected
opment of blood clots in the legs. Bed and take a long time to heal.
• Middle childhood/adolescence
rest was once considered an essential TREATMENT AND PREVENTION 9–18 years
part of the treatment of many common Deep, chronic ulcers may require treat- Lying, stealing, smoking, truancy,
conditions, but it is now avoided when ment with antibiotic drugs and, in some disobedience, aggression, low
possible. Patients are usually encouraged cases, plastic surgery. Good nursing care, achievement in school, drug or alcohol
use, running away, sexual promiscuity
to be mobile as soon as they are able including changing the patient’s posi-
following illness or surgery. tion regularly, skin care, protection of

93
 BEHAVIOURISM

are usually avoided if the training is can be emotionally traumatic and is as atropine, that are used as antispasmodic
delayed until the child is physically and now used less commonly. drugs to treat gastrointestinal disturban-
emotionally ready. Response prevention The patient is pre- ces. (See also anticholinergic drugs.)
B In children between the ages of four
and eight years, minor behavioural
vented from carrying out an obsessional
task. For example, someone with a Bell’s palsy
problems, such as thumb-sucking and handwashing compulsion is prevented The most common form of facial palsy
nail-biting, clinginess, bedwetting (see from carrying out the washing rituals. (facial muscle weakness).
enuresis, nocturnal), and disruption dur- This technique is used in combination
ing the night due to nightmares, are so with other methods. Bence–Jones protein
common as to be almost normal. Such Modelling In this approach, the therapist An abnormal protein found in the urine
problems are best dealt with by using a acts as a model for the patient, perform- of people with multiple myeloma, which
positive approach that concentrates on ing the anxiety-provoking activity first, is a cancer affecting one type of cell in
rewarding good behaviour. In most and encouraging the patient to copy. the bone marrow.
cases, the child grows out of the prob-
lem, but medical help from a child behaviour, types A and B bendrofluazide
guidance counsellor or a child psych- Behaviours characteristic of two person- The former name for the diuretic drug
iatrist may occasionally be needed. ality types described in the early 1970s, bendroflumethiazide.
when studies were performed to exam-
behaviourism ine the behaviour patterns of people bendroflumethiazide
An American school of psychology with coronary artery disease. A thiazide diuretic drug that is used to
founded by John Broadus Watson early It was proposed that a particular treat hypertension (high blood pressure)
in the 20th century. He argued that, behaviour pattern (called Type A) was and heart failure.
because behaviour, rather than experi- associated with increased vulnerability
ence, was all that could be observed in to stress-related illnesses, such as hyper- bends
others, it should constitute the sole tension (high blood pressure). Type A The nonmedical term for decompression
basis of psychology. personalities are said to feel constantly sickness. The term is used especially to
under pressure to perform many tasks at refer to the severe bone and joint pains
behaviour therapy the same time, and to be competitive that are a common symptom in divers
A collection of techniques, based on and self-critical. They are also impatient who rise to the surface too rapidly.
psychological theory, that are used to and easily irritated by others. In contrast
change abnormal behaviour or to treat to this, people with Type B personalities benign
anxiety. Behaviour therapy is based on are said to be calmer and more relaxed. A term used to describe a disease that is
two main ideas: that repeated exposure relatively harmless. When used to refer
to a feared experience under safe condi- Behçet’s syndrome to tumours, benign means noncancer-
tions will render it less threatening, and A rare, multisystem disorder with recur- ous tumours that do not invade or
that desirable behaviour can be encour- rent mouth ulcers and genital ulcers and destroy local tissues and do not spread
aged by using a system of rewards, inflammation of the eyes, skin, joints, to other sites within the body.
often self-administered. blood vessels, brain, and intestines.
TYPES The cause of Behçet’s syndrome is benign prostatic hyperplasia (BPH)
Specific behaviour therapy techniques unknown, but the disorder is strongly A medical term for noncancerous en-
include exposure therapy (also known associated with HLA-B51, a genetically largement of the prostate gland (see
as desensitization), flooding, response determined histocompatability antigen. It prostate, enlarged).
prevention, and modelling. affects twice as many men as women.
Exposure therapy A technique that is Treatment of Behçet’s syndrome is often Bennett’s fracture
commonly used to treat phobic disor- difficult and may involve corticosteroid A fracture of the base of the thumb,
ders, such as agoraphobia (a fear of open drugs and immunosuppressant drugs. The which is often accompanied by partial
spaces and/or public places), animal condition often becomes long term. dislocation of the joint.
phobias, and fear of flying. It consists of
exposing the patient to the cause of the belching benorilate
anxiety in stages: for example, the ther- The noisy return of air from the stom- A nonsteroidal anti-inflammatory drug
apist may accompany an agoraphobic ach through the mouth. Swallowing air (NSAID) that contains aspirin and para-
patient on a short journey. At the same is usually an unconscious habit, which cetamol. Benorilate is mainly used to
time, the patient is taught to cope with may result from eating or drinking too relieve joint pain and stiffness in osteo-
anxiety symptoms by using relaxation much and/or too quickly. Occasionally, arthritis and rheumatoid arthritis. Side
techniques.The intensity of the exposure belching may help to alleviate discom- effects of benorilate are not usually seri-
is increased, until eventually, he or she is fort caused by indigestion. ous, but the aspirin in the drug may
able to deal with the full situation. cause nausea, indigestion, or bleeding
Flooding In flooding, the patient is con- belladonna from the stomach lining.
fronted directly and for a lengthy period An extract of the deadly nightshade plant
with the anxiety-provoking stimulus. that has, since ancient times, been used benorylate
He or she is supported by the therapist medicinally. Belladonna contains alkaloids The former spelling of the nonsteroidal
until the fear is reduced. This technique (substances containing nitrogen), such anti-inflammatory drug benorilate.

94
 BERRY ANEURYSM

benzalkonium chloride months to prevent withdrawal symp- their chances of recovery, specialized
A preservative that is widely used in toms. Benzodiazepines are sometimes counselling or psychotherapy
is necessary.
eye-drops and products such as cosmet- abused for their sedative effects. (See also stillbirth.)
ics and mouth washes.
benzoyl peroxide beriberi B
benzocaine An antiseptic agent used in the treatment A nutritional disorder resulting from a
A local anaesthetic (see anaesthesia, of acne and fungal skin infections (see lack of thiamine (vitamin B1) in the diet.
local) commonly used as an ingredient fungal infections). In acne, benzoyl per- Thiamine, found in wholemeal cereals,
in over-the-counter preparations for oxide also works by removing the meat, green vegetables, potatoes, and
relieving the pain of conditions such as surface layer of skin, thereby unblock- nuts, is essential for the metabolism of
mouth ulcers and sore throat. ing sebaceous glands. carbohydrates. Without it, the brain, the
nerves, and the muscles (including the
benzodiazepine drugs benzylpenicillin heart muscle) are not able to function
COMMON DRUGS A type of penicillin drug that is given properly. In developed countries, the ill-
SLEEPING DRUGS • Flunitrazepam • Flurazepam by injection. ness is seen only in people who are
• Loprazolam • Lormetazepam • Nitrazepam starving or those who have an extremely
• Temazepam bereavement restricted diet, such as alcoholics.
SEDATIVES • Alprazolam • Chlordiazepoxide The emotional reaction following the SYMPTOMS AND SIGNS
• Clorazepate • Diazepam • Lorazepam death of a loved one. The expression of There are two forms of the illness:
• Oxazepam grief is individual to each person, but “dry” and “wet” beriberi. In dry beri-
there are recognized stages of bereave- beri, thiamine deficiency mainly affects
A group of sedative drugs given for ment, each of which is characterized by the nerves and skeletal muscles. The
short periods either as sleeping drugs for a particular attitude. symptoms include numbness, a burning
insomnia or to control the symptoms of STAGES OF BEREAVEMENT sensation in the legs, and muscle wast-
anxiety (see tranquillizer drugs). Common In the first stage of bereavement, which ing. In severe cases, the affected person
benzodiazepine drugs include diazepam, may last from three days to three becomes virtually paralysed, emaciated,
which is used as a tranquillizer, and months, there is often a feeling of and bedridden.
nitrazepam, which is used to relieve numbness and an unwillingness to rec- In wet beriberi, the main problem is
insomnia. Benzodiazepine drugs are also ognize the death. These emotions are heart failure (the inability of the heart to
used in the management of alcohol defence mechanisms against admitting, maintain efficient pumping of blood
withdrawal and in the short-term con- and therefore accepting, the loss and the around the body). This in turn causes
trol of an epileptic seizure. associated pain. Often, the reality of the oedema (swelling caused by fluid accu-
HOW THEY WORK death does not penetrate completely at mulation) in the legs and sometimes
Benzodiazepine drugs promote sleep this time, and many people continue to also in the trunk and face. Other symp-
and relieve anxiety by interfering behave as though the dead person were toms of wet beriberi include poor
with chemical activity in the brain and still alive. Hallucinations, in which the appetite, rapid pulse, and breathlessness.
nervous system. This reduces the com- deceased person is seen or sensed, are a Without treatment, heart failure wors-
munication between nerve cells and common experience among the rec- ens and can lead to death.
depresses brain activity. ently bereaved. This sensation can be TREATMENT
POSSIBLE ADVERSE EFFECTS quite comforting for some people, but Beriberi is treated with thiamine, given
Adverse effects of benzodiazepines in- others may find it disturbing. either orally or by injection, which usu-
clude excessive daytime drowsiness, Once the numbness wears off, the ally brings about a complete cure. A
dizziness, and forgetfulness. Unstead- person may be overwhelmed by feel- permanent improvement in diet is also
iness and slowed reactions may also ings of anxiety, anger, and despair that required to prevent recurrence.
occur. If taken with alcohol, benzo- can develop into a depressive illness
diazepines may increase the alcohol’s (see depression). Gastrointestinal distur- Bernard–Soulier syndrome
effect to a dangerous extent. bances, insomnia, malaise, agitation, A genetic disorder in which platelets (the
After as little as two weeks, users of a and tearfulness are also common. blood cells responsible for initiating
benzodiazepine drug may become psy- Gradually, but usually within two blood clotting) do not function prop-
chologically and physically dependent years, the bereaved person adjusts to the erly. The syndrome is characterized by
on the drug. For this reason, most doc- loss and begins to look more towards abnormal bleeding in the skin and
tors are now reluctant to prescribe the the future. This process can involve internal organs.
drugs unless they are absolutely neces- periods of pain and despair, alternating
sary, and then only for a maximum of with periods of enthusiasm and interest. berry aneurysm
three weeks. SUPPORT AND COUNSELLING An abnormal swelling that occurs at the
When benzodiazepine treatment is Family and friends can often provide junction of arteries supplying the brain.
stopped suddenly, withdrawal symp- the support a bereaved person needs. Berry aneurysms are usually due to a
toms, such as anxiety, restlessness, and Outside help is sometimes required and congenital (present at birth) weakness
nightmares may occur. People who have may be given by a social worker, health in the artery wall. They may occasionally
been taking benzodiazepine drugs long visitor, member of the clergy, or self- rupture, which results in a subarachnoid
term need to have them gradually with- help group. For some people, when haemorrhage. (See also aneurysm; intra-
drawn over the course of several depression, apathy, and lethargy impede cranial aneurysm.)

95
 BERYLLIOSIS

berylliosis
An occupational disease that is caused HOW BETA-BLOCKERS WORK
by the inhalation of dust or fumes con-
Beta-blockers block specific sites on to both types. Beta-blockers slow the
B taining beryllium, a metallic element
that is used in high-technology indus-
body tissues where neurotransmitters
(chemicals released from nerve
heart rate and reduce the force of
contraction of heart muscle. These
tries such as nuclear energy, electronics, endings) bind. These sites are called effects can be used to slow a fast heart
and aerospace. Short exposure to high beta receptors, and there are two rate and regulate abnormal rhythms.
concentrations of beryllium may lead to types: beta1 receptors, found in heart Beta-blockers prevent attacks of
an episode of severe pneumonitis (lung tissue, and beta2 receptors, found in angina pectoris by reducing the
inflammation). Exposure over a number the lungs, blood vessels, and other work performed by the heart muscle
of years to smaller concentrations may tissues. At these receptors, two and therefore the heart’s oxygen
lead to permanent damage to the lungs chemicals, adrenaline (epinephrine) requirement. High blood pressure is
and the liver. and noradrenaline (norepinephrine), reduced because the rate and force at
Treatment with corticosteroid drugs are released from nerve endings in the which the heart pumps blood into the
can reduce damage to the lungs. In sympathetic nervous system, the part circulation is lowered.
of the involuntary nervous system that The effect of blocking beta receptors
most cases, the introduction of safe
enables the body to deal with stress, on muscles elsewhere in the body is
working practices prevents exposure to anxiety, and exercise. These to reduce the muscle tremor of anxiety
dangerous levels of beryllium. neurotransmitters bind to beta and an overactive thyroid gland.
receptors to increase the force and Beta-blockers may help to reduce
Best’s disease speed of the heartbeat, to dilate the the frequency of migraine attacks by
A genetic disorder in which the macula airways to increase air flow to the preventing the dilation of blood vessels
(part of the light-sensitive retina at the lungs, and to dilate blood vessels. surrounding the brain, which is what
back of the eye) is abnormal. The disor- Cardioselective beta-blockers bind causes the headache. In glaucoma they
der is congenital (present from birth) predominantly to beta1 receptors; lower pressure in the eye by reducing
and results in progressive loss of vision. noncardioselective beta-blockers bind fluid production in the eyeball.

beta-blocker drugs Normal

Adrenaline (epinephrine) and
COMMON DRUGS B1 receptor Heart cell
noradrenaline (norepinephrine)
CARDIOSELECTIVE • Atenolol • Betaxolol can be released either from the
• Bisoprolol • Celiprolol • Metoprolol adrenal gland or from sympathetic
NONCARDIOSELECTIVE • Acebutolol • Carvedilol
nerve endings. They bind to beta1
and beta2 receptors in tissues
• Labetolol • Nadolol • Oxprenolol • Pindolol B2
around the body. receptor
• Propranolol • Sotalol • Timolol

A group of drugs, also known as beta-

adrenergic blocking agents, prescribed Adrenaline/ Lung/blood
noradrenaline vessel cell
principally to treat heart and circulatory
disorders such as angina pectoris (pain
Cardioselective beta-blockers
in the chest due to an insufficient sup- Cardioselective beta-blockers
B1 receptor
ply of blood to the heart muscle) and Heart cell
occupy predominantly B1 receptors,
hypertension (high blood pressure). The preventing adrenaline and
drugs block the effects of the sympathetic noradrenaline from binding to them.
This reduces the stimulating action Cardioselective
nervous system, which releases adrenaline beta blocker
of adrenaline and noradrenaline on
(epinephrine) and noradrenaline (nor- heart tissue. Cardioselective beta-
B2
receptor
epinephrine) at nerve endings known blockers do not block B2 receptors,
as beta receptors. thereby allowing adrenaline
There are two types of beta receptor: (epinephrine)/noradrenaline
(norepinephrine) to act on other
beta1 and beta2. Beta1 receptors are pre- tissues around the body. Adrenaline/ Lung/blood
sent mainly in the heart and beta2 are noradrenaline vessel cell
found in the lungs, blood vessels, and
elsewhere in the body. Certain beta- Noncardioselective beta-blockers B1
Noncardioselective beta-blockers receptor
blockers (such as atenolol, bisoprolol occupy both B1 and B2 receptors,
Heart cell
and metoprolol) are termed cardio- reducing the stimulating action of
selective and, because they act mostly adrenaline (epinephrine) and Adrenaline/
on beta1 receptors, are used principally noradrenaline (norepinephrine) noradrenaline
to treat heart disease such as angina, on tissues around the body.
B2
hypertension, and cardiac arrhythmia receptor
(abnormal heartbeat). These drugs are
sometimes given following a myocardial
infarction (heart attack) in order to Noncardioselective Lung/blood
beta-blocker vessel cell
reduce the likelihood of further damage
to the heart muscle.

96
 BIGUANIDES

Other types of beta-blocker, such as ox- and is taken by mouth to treat some muscle, located at the back of the thigh,
prenolol, propranolol, and timolol, may cases of asthma and arthritis. which bends the leg at the knee and
be given to prevent migraine attacks by Adverse effects of betamethasone are extends the thigh.
acting on blood vessels in the head. unlikely with short-term use. However,
They are also used to reduce the physi- prolonged topical use of the drug can bicornuate uterus B
cal symptoms of anxiety and to control cause thinning of the skin and may The term that is used to describe an
the symptoms of thyrotoxicosis (an over- aggravate any infection that has devel- abnormally shaped uterus (womb) that
active thyroid gland). Beta-blockers such oped. Taken orally over a prolonged divides into two halves in its upper
as timolol are sometimes given in the period or in high doses, betamethasone part. Bicornuate literally means “having
form of eye-drops to treat glaucoma; can cause adverse effects typical of other two horns”.
they work by lowering the fluid pres- corticosteroid drugs.
sure within the eyeball. (See also the bicuspid
illustrated box.) betel nut A term meaning to have two cusps
POSSIBLE ADVERSE EFFECTS The seed of the tropical palm ARECA CAT- (curved, pointed structures). Bicuspid
Beta-blocker drugs may reduce an ECHU , which, when chewed, acts as a describes certain heart valves and is used
individual’s capacity for strenuous exer- stimulant and digestant. Betel nut is as an alternative name for a premolar
cise. They may worsen the symptoms of commonly used throughout India and tooth (see teeth).
asthma, bronchitis, or other forms of Southeast Asia.
lung disease. They may also reduce the bifocal
flow of blood to the limbs, causing cold Betnovate A spectacle lens with two different focal
hands and feet. In addition, sleep dis- A brand name for the corticosteroid lengths. Glasses that have bifocal lenses
turbance and depression can be side drug betamethasone, which is used in make corrections both for close and for
effects of beta-blockers. Anyone taking topical preparations. distant vision. (See also myopia; hyper-
beta-blockers should not suddenly stop; metropia.)
a severe recurrence of previous symp- bezafibrate
toms and a significant rise in blood A lipid-lowering drug used to reduce biguanides
pressure may result. blood cholesterol levels. Oral hypoglycaemic drugs (see hypo-
glycaemics, oral) used in the treatment
betahistine bezoar of type 2 (non-insulin-dependent) dia-
A drug that is used in the treatment of A ball of food and mucus, vegetable betes mellitus. Metformin, which is the
the inner-ear disorder Ménière’s disease. fibre, hair, or other indigestible material only available type of biguanide drug,
Betahistine reduces the frequency and in the stomach. Trichobezoars, which reduces the production of glucose
severity of the characteristic attacks of are composed of hair, may form in the
nausea and vertigo. stomachs of children or emotionally
disturbed adults who nibble at, or pull LOCATION OF BICEPS
beta interferon out and swallow, their hair.
There are four biceps
A type of interferon (a protein produced Symptoms include loss of appetite,
muscles in the body:
naturally by body cells) sometimes used constipation, nausea and vomiting, and one in each upper arm
in the treatment of multiple sclerosis. abdominal pain. If trichobezoars pass and one on the back of
into the intestines, they may cause a each thigh.
beta-lactam antibiotics blockage (see intestine, obstruction of).
A group of antibiotic drugs that includes Bezoars can be removed by endoscopy (a
the penicillins and the cephalosporins. procedure in which a flexible viewing
Beta-lactam antibiotics work by altering tube is passed down the digestive tract)
chemical activity in bacteria, thereby or by conventional surgery.
killing them. Two heads of biceps
bi-
beta-lactamase A prefix meaning two or twice, as in
An enzyme, also known as lactamase, bilateral (two-sided).
Biceps muscle
that inactivates antibiotic drugs such as
penicillins. Bacteria that are able to pro- bicarbonate of soda
duce this enzyme are therefore resistant See sodium bicarbonate.
to treatment with these kinds of anti-
biotic drugs. biceps muscle
Humerus
The name that is given to any muscle
betamethasone that originates as two separate parts,
A corticosteroid drug that is used in the which then fuse. The term biceps mus-
treatment of inflammation. Betametha- cle is commonly used to refer to the
sone is applied to the skin as a cream biceps brachii muscle of the upper arm,
to treat contact dermatitis and eczema. which bends the arm at the elbow and
Ulna Radius
The drug is also prescribed as nasal rotates the forearm. Another example of
spray to treat allergic rhinitis (hay fever) a biceps muscle is the biceps femoris

97
 BILATERAL

(sugar) in the liver and also increases (bile pigment) in the blood. Prolonged sis. Secondary biliary cirrhosis occurs as
the uptake of glucose by the body’s obstruction of the bile duct can lead to a result of a longstanding blockage. In
cells. (See also antidiabetic drugs.) secondary biliary cirrhosis, which is a both types of the condition, liver func-
B bilateral
serious form of liver disease.
CAUSES
tion is impaired due to cholestasis
(accumulation of bile in the liver).
A term that means affecting both sides The most common cause of bile duct Primary biliary cirrhosis principally
of the body, or affecting both organs if obstruction is gallstones. Other causes affects middle-aged women and seems
they are paired (for example, both ears include a tumour affecting the pancreas to be linked with a malfunction of the
in bilateral deafness). (see pancreas, cancer of) and cancer that immune system. In this disorder, the bile
has spread from elsewhere in the body. ducts within the liver become inflamed
bile Cholangiocarcinoma (cancer of the bile and are destroyed. Symptoms include
A greenish-brown alkaline liquid that is ducts) is a rare cause of a blockage. Bile itching, jaundice (a yellowish discolor-
secreted by the liver. Bile carries away duct obstruction is known to be a rare ation of the skin and the whites of the
waste products formed in the liver and side effect of certain drugs. It may also eyes), an enlarged liver, and sometimes
also helps to break down fats in the be caused by cholangitis (inflammation abdominal pain, fatty diarrhoea, and
small intestine for digestion. of the bile ducts), trauma (such as xanthomatosis (deposits of fatty material
The waste products in bile include injury during surgery), and, rarely, by under the skin). Osteoporosis may also
the pigments bilirubin and biliverdin, flukes or worms. develop. Symptoms of liver cirrhosis
which give bile its greenish-brown col- SYMPTOMS and liver failure may occur after a few
our; bile salts, which aid in the Bile duct obstruction causes “obstruc- years. Drugs can be used to minimize
breakdown and absorption of fats; and tive” jaundice, which is characterized complications and to relieve symptoms
cholesterol. Bile passes out of the liver by pale-coloured faeces, dark urine, and such as itching, but a liver transplant is
through the bile ducts and is then con- a yellow skin colour. There may also be the only cure.
centrated and stored in the gallbladder. itching. Other symptoms of bile duct Secondary biliary cirrhosis results
After a meal, bile is expelled and enters obstruction depend on the cause of the from prolonged bile duct obstruction or
the duodenum (the first section of the blockage; for example, there may be biliary atresia (abnormal bile ducts).
small intestine) via the common bile abdominal pain (with gallstones) or Symptoms and signs include abdominal
duct. Most of the bile salts are later weight loss (with cancer). pain and tenderness, liver enlargement,
reabsorbed into the bloodstream to be TREATMENT fevers and chills, and sometimes blood
recycled by the liver into bile. Bile pig- Treatment depends on the cause, but abnormalities. Treatment is the same as
ments are excreted in the faeces. (See surgery is sometimes necessary. Gall- for bile duct obstruction.
also biliary system; colestyramine.) stones may be removed by means of
ERCP (an X-ray procedure that uses a biliary colic
bile duct viewing tube called an endoscope with A severe pain in the upper right quad-
Any of the ducts through which bile is instruments attached to it). rant of the abdomen that is usually
carried from the liver to the gallbladder caused by the gallbladder’s attempts to
and then on to the duodenum (the first bilharzia expel gallstones or by the movement of
section of the small intestine). Another name for the tropical parasitic a stone in the bile ducts. The pain may
The bile duct system forms a network disease schistosomiasis. be felt in the right shoulder (see referred
of tubular canals. Canaliculi (small pain) or may penetrate to the centre of
canals) surround the liver cells and col- biliary atresia the back. Episodes of biliary colic often
lect the bile. The canaliculi join together A rare congenital disorder in which last for several hours and may recur,
to form ducts of increasing size. The some or all of the bile ducts fail to particularly after meals.
ducts emerge from the liver as the two develop or develop abnormally. As a Injections of an analgesic drug and anti-
hepatic ducts, which join within or just result, bile is unable to drain from the spasmodic drug may be given to relieve
outside the liver to form the common liver (see cholestasis). Unless the atresia the colic. Tests such as cholecystography
hepatic duct. The cystic duct branches can be treated, secondary biliary cirrhosis or ultrasound scanning can confirm the
off to the gallbladder; from this point (a serious liver disorder) will develop presence of gallstones, in which case
the common hepatic duct becomes the and may prove fatal. Symptoms include cholecystectomy (surgical removal of the
common bile duct and leads into the jaundice, usually beginning a week after gallbladder) may be performed.
duodenum. (See also biliary system.) birth, and the passing of dark urine and
pale faeces. Treatment is by surgery to biliary system
bile duct cancer bypass the ducts. If this fails, or if The organs and ducts in which bile is
See cholangiocarcinoma. the jaundice recurs, a liver transplant formed, concentrated, and carried from
is required. the liver to the duodenum (the first part
bile duct obstruction of the small intestine). Bile is secreted
A blockage or constriction of a bile duct biliary cirrhosis by liver cells and collected by a network
(see biliary system). Obstruction of a bile An uncommon form of liver cirrhosis of bile ducts that carry the bile out of the
duct results in the accumulation of bile that results from problems with the bile liver via the hepatic duct. The cystic
in the liver (cholestasis) and jaundice ducts. There are two types of biliary cir- duct branches off the hepatic duct and
(yellowing of the skin and the whites of rhosis. One is an autoimmune disorder leads to the gallbladder, where the bile
the eyes) due to a buildup of bilirubin and is known as primary biliary cirrho- is concentrated and stored. Beyond this

98
 BILLROTH’S OPERATION

junction, the hepatic duct becomes the biliousness Billings’ method

common bile duct, which opens into A condition in which bile is brought up A technique (also known as the mucus
the duodenum at a controlled orifice to the mouth from the stomach. Bil- inspection method) in which a woman
known as the ampulla of Vater. The iousness is also used as a nonmedical notes changes in the characteristics of
presence of fat in the duodenum fol- term for nausea and vomiting. mucus produced by her cervix. The B
lowing a meal prompts the secretion technique is employed to predict ovula-
of a hormone that opens the ampulla of bilirubin tion for the purposes of contraception or
Vater. This causes contraction of the The main pigment in bile. Bilirubin is family planning.
gallbladder, which squeezes stored bile produced by the breakdown of haemo-
into the duodenum. globin, the pigment in red blood cells. Billroth’s operation
The main disorders affecting the bil- Very high levels of bilirubin cause the A type of partial gastrectomy in which
iary system are gallstones, congenital yellow pigmentation of jaundice. Prod- the lower part of the stomach is sur-
biliary atresia and bile duct obstruction. ucts formed from the breakdown of gically removed. Previously used in the
(See also gallbladder, disorders of.) bilirubin make faeces brown. treatment of peptic ulcers, the operation

FUNCTION OF THE BILIARY SYSTEM

The biliary system consists of the bile ducts leading from the liver and gallbladder,
the gallbladder itself, and associated structures. The system drains waste products
from the liver into the duodenum and aids the process of fat digestion through
controlled release of fat-emulsifying agents (contained in bile).

Liver Hepatic duct Oesophagus

FAT DIGESTION Bile is secreted by liver cells This carries bile
and collected in a system of out of the liver.
tubes (drainage channels).
Bile is carried out of the liver
via the hepatic ducts.

Cystic duct
This carries bile between
the gallbladder and the
common bile duct.

Food
Dietary fat passes from the stomach Common bile duct
1 to the duodenum in the form of large
droplets.
The hepatic duct
becomes the common
bile duct, which leads
to the intestine.

Gallbladder
Bile is concentrated
and stored here and
is released back into
the common bile duct
when this organ
contracts.

Duodenum

2intoBile released into the duodenum

contains salts that disperse the fat
smaller droplets.
When fat from a recent
meal arrives in the
duodenum, a hormone
is released that acts on
the gallbladder. The
gallbladder contracts,
causing bile to be
passed into the
duodenum to emulsify
the fat.

Ampulla of Vater
Bile enters the Ileum
duodenum here.
The fats are now more easily broken
3the pancreas,
down by lipase, an enzyme made by
and absorbed through the
Pancreas
In response to the presence of fat in the duodenum, the Stomach
intestinal lining. pancreas produces hormones that stimulate contraction Fat and other products of
of the gallbladder and cause the ampulla of Vater to digestion pass from the
open so that bile flows into the duodenum. stomach to the duodenum.

99
 BINET TEST

is now rarely performed due to the Other, more specific, chemical processes biological clock
introduction of newer, less invasive are confined to specialized cells that A popular term for the inherent timing
treatment, often using antibiotic drugs. make up the tissues of particular organs. mechanism that supposedly controls
B Binet test
For example, liver cells store and chem-
ically modify the digestion products of
physiological processes and cycles in
living organisms. (See also biorhythms.)
The first intelligence test that attempted food; kidney cells help to control the
to measure higher mental functions amounts of various substances (such as biology
rather than more primitive abilities. The certain minerals) in the blood, as well The scientific study of all living organ-
Binet test was devised in 1905. as regulating the total amount of fluid isms, including animals, plants, and
in the body. microorganisms (single-celled organ-
binge–purge syndrome A constant interchange of substances isms). Biology involves the study of the
An alternative term for the eating disor- occurs between the cell fluids and the structure and functions of living organ-
der bulimia. blood and urine. Biochemists can learn isms, their relationships with other
a great deal about the chemical changes organisms, and the ways in which they
bio- occurring inside the body’s cells by reg- interact with their environment. (See
A prefix describing a relationship to ularly taking, and comparing, precise also biochemistry; microbiology.)
life, as in biology, the science of life. measurements of the various minerals,
gases, enzymes, hormones, and proteins biomechanical engineering
bioavailability in the different fluids of the body. A discipline that applies engineering
The proportion of a drug that reaches Such biochemical tests may be used methods and principles to the body to
the target organs and tissues, usually to make, or to confirm, a diagnosis, as explain how it functions and to treat
expressed as a percentage of the dose well as to screen for a particular disease disorders. Applications include the design
administered. Intravenous administration and to monitor its progress. The most of artificial joints and heart valves, pace-
of a drug results in 100 per cent bio- commonly used biochemical tests are makers, and kidney dialysis machines.
availability because the drug is injected performed on blood; such tests include
directly into the bloodstream. Drugs liver function tests and kidney function tests. biopsy
taken orally have a much lower bio- Biochemical tests can also be performed A diagnostic test involving the removal
availability. Preparations that have equal on urine (see urinalysis) as well as on all of small amounts of tissue or cells from
bioavailabilities are described as bio- other body fluids. the body for microscopic examination.
equivalent. (See also drug.) A biopsy is an accurate method of diag-
bioengineering nosing many illnesses, including cancer.
biochemistry See biomechanical engineering. Microscopic examination of tissue (see
A science that studies the chemistry histology) or of cells (see cytology) usually
of living organisms, including human biofeedback training gives a correct diagnosis.
beings. The human body is made up of A technique in which a person uses HOW IT IS DONE
millions of cells that require nutrients information about a normally uncon- There are several types of biopsy. In
and energy, and which grow, multiply, scious body function, such as blood excisional biopsy, the whole abnormal
and die. The chemical processes that are pressure, to gain conscious control over area is removed for study. Incisional
involved in providing these cells with that function. This training may help to biopsy involves cutting away a small
energy, eliminating their wastes, repair- treat stress-related conditions, including sample of skin or muscle for analysis. In
ing damage, promoting cell growth, certain types of hypertension (high a needle biopsy, a needle is inserted
and causing both normal and abnormal blood pressure), anxiety, and migraine. through the skin and into the organ or
cell division are all studied by bio- HOW IT IS DONE tumour to be investigated. Aspiration
chemists, the specialists in the field. The doctor connects the patient to a biopsy uses a needle and syringe to
Life is maintained by a huge number recording instrument that can measure remove cells from a lump (see box).
of chemical reactions that are carried one of the unconscious body activities, Guided biopsy uses ultrasound scanning
out inside cells. These reactions link such as blood pressure, heart rate, mus- or CT scanning to locate the area of tissue
together in a complex way and together cle tension, the quantity of sweat on the to be biopsied and follow the progress
make up the metabolism of the body.The skin, brain waves, or stomach acidity. of the needle. In endoscopic biopsy, an
reactions that produce energy and break The patient receives information (feed- endoscope (viewing tube) is passed into
down food and body structures are back) on the changing levels of these the organ to be investigated and an
termed catabolism; those that build up activities from changes in the instru- attachment is used to take a sample
body structures and store food are ment’s signals, for example a flashing from the lining of accessible hollow
termed anabolism. Overall regulation of light or sound changing tone. structures such as the lungs, stomach,
these chemical processes is a principal After some experience with the tech- and bladder. In an open biopsy, a sur-
function of hormones which are secreted nique, the person starts to become aware geon opens a body cavity to reveal a
into the bloodstream by the endocrine of how he or she is feeling whenever diseased organ or tumour and removes
glands; regulation of individual reactions there is a change of signal. By using a sample. Prompt analysis, in some cases
is carried out by enzymes (substances relaxation techniques, the person learns to by frozen section (in which the tissue is
that promote biochemical reactions). change the signals by conscious control frozen and thinly sliced), can enable the
Certain vital chemical processes take of the function. Once acquired, control surgeon to decide whether to remove
place in every single cell in the body. can be exercised without the instrument. the entire diseased area immediately.

100
 BIRTH DEFECTS

biorhythms birth
ASPIRATION BIOPSY A term used to describe physiological See childbirth.
functions that vary in a rhythmic way
(for example, the menstrual cycle, which birth canal
repeats approximately every 28 days in The passage through the pelvis, running B
fertile women). from the cervix (the neck of the womb)
Most biorhythms are based on a daily, to the vaginal opening, through which
or circadian (24-hour), cycle. Our bod- the baby passes during childbirth.
ies are governed by an internal clock,
which is itself regulated by hormones birth control
(chemicals released into the circulation Limitation of the number of children
by endocrine glands). Periods of sleepi- born, either to an individual or within a
ness and wakefulness may be affected population. Family planning allows men
by the level of melatonin secreted by the and women to choose if and when to
pineal gland in the brain. Release of have children; contraception can prevent
melatonin is stimulated by darkness and unwanted pregnancies.
1are Ainserted
fine needle attached to a syringe is
into the lump, and fluid or cells
sucked out to be examined under a
suppressed by light. Cortisol, a hormone
that is secreted by the adrenal glands, birth defects
microscope. The syringe can be held in a also reflects sleeping and waking states, Abnormalities that are obvious at birth
device that withdraws the plunger. Usually being low in the evening and high in or detectable early in infancy. Also called
no anaesthetic is necessary, but local
anaesthetic may be sometimes be used.
the morning. congenital defects, they encompass both
When the normal regular division minor abnormalities, such as birthmarks,
between night and day is distorted by and serious disorders such as spina bifida
air travel to a distant time zone, the (failure of the spinal column to close
body’s internal clock is disrupted and properly). Birth defects may occur as the
the result is jet-lag. result of a variety of factors, but in most
cases no obvious cause can be found.
biosynthesis CHROMOSOME DEFECTS
The formation of chemical compounds Some children are born with more or
by a living organism. fewer than the normal 23 pairs of
chromosomes (threadlike structures in
biotechnology the cell nuclei that carry the genetic
Before examination any fluid may be
2 spun at high speed in a centrifuge and
a small amount placed on a slide.
The use of living organisms such as
bacteria in industry and science (for
information for normal development).
Down’s syndrome, a condition in which
example, in drug production). there is an extra copy of one of the
chromosomes, is one of the most com-
bioterrorism mon chromosomal abnormalities.
The use of disease-causing organisms as GENETIC OR HEREDITARY DEFECTS
Cells as
seen an act of violence and intimidation. These may be inherited from one or
through a Examples of such organisms are anthrax both parents (see gene; genetic disorders).
microscope spores and the smallpox virus. Genetic defects obvious at birth include
albinism (lack of normal pigmentation
biotin in the skin, hair, and eyes) and achon-
A vitamin of the B complex (see vitamin droplasia (abnormally short stature).
The cells are then fixed (preserved) and B complex)that is essential for the break- DRUGS AND OTHER HARMFUL AGENTS
3 finally stained for viewing. The cytologist
examines individual cells for abnormalities,
down of fats. Certain drugs and chemicals (known as
teratogens) can damage the fetus if the
paying particular attention to the size,
shape, and structure of the nucleus.
biphosphonate drugs mother takes or is exposed to them dur-
See bisphosphonate drugs. ing early pregnancy. Teratogenic drugs
include thalidomide (now rarely pre-
bipolar disorder scribed) and isotretinoin, which is used
OBTAINING RESULTS An illness, commonly known as manic– in the treatment of severe acne. Alcohol
Biopsy samples are analysed by staining; depressive illness,that is characterized can affect the development of the brain
dyes are used to show up structures or by swings in mood from severe depres- and face (see fetal alcohol syndrome).
identify constituents such as antibodies sion to overexcitability and vice versa. IRRADIATION
or enzymes. Tissue may be tested with Irradiation of the embryo at an early
specific antibodies in the investigation bird-fancier’s lung stage of development, for example, if a
of infection and inflammation. In some A form of allergic alveolitis (inflamma- woman is X-rayed before she is aware of
cases, a tissue culture (cultivation of tis- tion of the lungs) caused by inhalation her pregnancy, can cause abnormalities.
sue cells in a growing medium) may be of dust particles from bird droppings. INFECTIONS
required. (See also endometrial biopsy; The disease is also sometimes known as If a woman contracts certain infections
excision; kidney biopsy; liver biopsy.) pigeon-fancier’s lung. during pregnancy, there is a chance that

101
 BIRTHING CHAIR

they may cause birth defects. For exam- freckles, and other types of melanocytic bisacodyl
ple, rubella (German measles) in early naevi (a variety of flat, brown to blue- A type of stimulant laxative drug that
pregnancy can cause fetal abnormalities, grey skin patches), strawberry marks works by stimulating the intestinal wall
B including deafness, cataract (clouding
of the lens of the eye), and heart dis-
(bright red, usually protuberant areas),
and port-wine stains (purple-red, flat,
into contracting, increasing the speed at
which faecal matter passes through.
ease. Toxoplasmosis (infection with a often large areas). The latter two are
parasite found in cats’ faeces), can also types of haemangioma (malformation of bisexuality
be passed on to the fetus, causing dam- blood vessels). Strawberry marks often Sexual interest in members of both
age to the eyes, liver, and other organs. increase in size in the first year, but most sexes that may or may not involve sexual
OTHER COMMON DEFECTS disappear after the age of nine. Port- activity.
Abnormalities in the embryo’s develop- wine stains seldom fade, but some of
ment can damage the brain and spinal them can be reduced by laser treatment bismuth
cord, causing defects such as spina bif- during adulthood. A metal, salts of which are used in
ida and hydrocephalus (a buildup of tablets to treat peptic ulcer and in creams
fluid in the brain). In congenital heart and suppositories to treat haemorrhoids
disorders (see heart disease, congenital), (piles). Bismuth preparations taken by
there is a structural abnormality in the mouth may colour the faeces black. The
heart that may interfere with normal tongue may darken and, occasionally,
blood flow. Cleft lip and palate result nausea and vomiting may occur.
from a failure of the two sides of the
fetal face and palate to join completely. bisphosphonate drugs
DETECTION Drugs used to slow bone metabolism
Ultrasound scanning and blood tests dur- (for example, in Paget's disease) and to
ing pregnancy can identify women at reduce the high calcium levels in the
high risk of having a baby with a birth blood that are associated with destruc-
defect. Further tests such as chorionic vil- tion of bone by secondary cancerous
lus sampling, amniocentesis, or fetoscopy growths. Bisphosphonate drugs may
Birthmark
may then be carried out. Strawberry marks, a common type of birthmark also be used in the prevention or treat-
PREVENTION caused by malformation of blood vessels, are ment of osteoporosis.
Some birth defects can be prevented, or usually bright red, protuberant, and spongy.
the risks minimized; for example, by bite
rubella immunization before pregnancy birthpool See occlusion.
or avoiding teratogens during pregnancy. A pool of warm water in which a
woman can sit to help relieve pain dur- bites, animal
birthing chair ing labour (see childbirth). Any injury inflicted by the mouthparts
A specially designed chair to support a of an animal, which may range from
woman during childbirth. In the opinion birth, premature the puncture wounds of bloodsucking
of many doctors, sitting, as opposed to See prematurity. insects to the massive injuries caused by
lying down, can help to shorten labour. shark or crocodile attacks. Teeth, especi-
birth, preterm ally those of carnivores, can inflict
birth injury See preterm birth. widespread mechanical injury. Severe
Damage sustained by a baby during injuries and lacerations to major blood
childbirth. Minor injuries, such as bruis- birth rate vessels can lead to heavy blood loss and
ing and swelling of the scalp during a A measurement of the number of births physiological shock. Serious infection
vaginal delivery (see cephalhaematoma) in a particular year in relation to the size may occur as a result of bacteria in the
are common. More serious injury can of the population. animal’s mouth being transferred in the
occur, particularly if the baby is large bite, and tetanus is a particular hazard.
and has difficulty passing through the birthweight In countries where rabies is present, any
birth canal. A breech delivery may result A baby’s weight at birth, which usually mammal may potentially harbour the
in injury to nerves in the baby’s shoul- ranges from 2.5 to 4.5 kg. Birthweight rabies virus and transmit it via a bite.
der, causing temporary paralysis in the depends on a number of factors, includ- TREATMENT
arm. The face may be paralysed tempor- ing the size and ethnic origin of the Medical advice should be sought for all
arily if the facial nerve is traumatized by parents. Baby boys weigh, on average, but minor injuries, and in all cases if
forceps during delivery. Fractured bones slightly more than baby girls. Babies who there is a risk of rabies. The treatment
are another hazard of difficult deliveries, weigh less than 2.5 kg at birth are con- usually includes cleaning and examina-
but the bones usually heal easily. (See sidered to be of low birthweight. Causes tion of the wound. The wound will
also birth defects; brain damage.) include prematurity and undernourish- usually be left open and dressed, rather
ment in the uterus (because the mother than stitched, as closing it can encourage
birthmark had pre-eclampsia, for example). Abnor- the multiplication of bacteria. Preventive
An area of discoloured skin that is mally high birthweight may be due to antibiotic drug treatment and an anti-
present at birth, or appears very soon unrecognized or poorly controlled dia- tetanus injection may also be given.
afterwards. Birthmarks include moles, betes mellitus in the mother. Antirabies vaccine is given, together with

102
 BLADDER

immunoglobulin, if there is any possibility black death they are associated with increased seba-
that the animal could be infected with The medieval name for bubonic plague, ceous gland activity. They are one of the
the rabies virus. (See also bites, human; which in past epidemics killed 50 per features of most types of acne.
insect bites; snake bites; spider bites; ven- cent of its victims. One feature of the
omous bites and stings.) disease is bleeding under the skin, causing blackout B
bluish-black bruises, hence the name. A common term for loss of conscious-
bites, human ness (see fainting).
Wounds that are caused by one person black eye
biting another. Human bites rarely result A dark discoloration of the skin around black teeth
in serious tissue damage or blood loss; the eye, usually following an injury. The See discoloured teeth.
but infection from any microorganisms discoloration is due to blood collecting
in the mouth is likely, particularly if the under the skin (see bruise). Because the blackwater fever
bite is deep. For example, there is a risk skin around the eye is loose and thin, An occasional, life-threatening compli-
of tetanus infection, and transmission of bruising is darker than on other parts of cation of falciparum malaria (the most
hepatitis B, herpes simplex, and HIV through the body. A cold compress held over the dangerous form of malaria). Symptoms
a human bite is a theoretical hazard. eye can help to relieve the discomfort. include loss of consciousness, fever,
vomiting, and very dark urine (due to
Bitot’s spots blackhead pigment from destroyed red blood cells
Grey, foamy patches that appear on Also called a comedo, a semi-solid, being filtered into the urine).
the conjunctiva (the mucous membrane black-capped plug of keratin and sebum
covering the front of the eye). Bitot’s that blocks the outlet of a sebaceous bladder
spots, which are made up of keratinized (oil-forming) gland in the skin. Black- The hollow, muscular organ situated in
(horny) cells, are associated with vita- heads occur most commonly on the the lower abdomen that acts as a reser-
min A deficiency. face, chest, shoulders, and back, and voir for urine. The bladder lies within,

ANATOMY OF THE BLADDER

The bladder is a hollow organ that Ureter

holds urine. It is situated behind the
pubic bone and is protected by the
pelvis. The ureters carry urine to the
bladder from the kidneys. When the
sphincter at the lowest part of the
bladder is relaxed, urine is passed
into the urethra and out of the body. Intestine

Ureter
Pelvis
Opening
of ureter

Vaginal wall
Opening
of urethra

Muscle wall
of bladder

Spine Urethra

Ureter
Pelvis

Bladder

Pubic bone
Bladder
Urethra

Intravenous urography Vagina

This special X-ray technique shows clearly
the position of the bladder in the pelvis. Female Penis Male

103
 BLADDER CANCER

and is protected by, the pelvis. The aver- DIAGNOSIS AND TREATMENT Blalock shunt
age adult bladder can hold about 0.5 Bladder tumours are diagnosed using A surgical procedure in which a con-
litres of urine before the need to pass cystoscopy (passage of a viewing tube up nection is made between one of the
B urine is felt.
The bladder walls consist of muscle
the urethra into the bladder) and biopsy
(tissue sampling for microscopic analy-
two subclavian arteries (which normally
deliver oxygen-rich blood to the neck
and an inner lining. Two tubes called sis) of the abnormal area. and arms) and one of the pulmonary
ureters carry urine to the bladder from If they are small, the tumours can be arteries (which carry blood from the
the kidneys. At the lowest point of the treated by heat or removed surgically. right side of the heart to the lungs for
bladder is the opening into the urethra Tumours tend to recur within the blad- oxygenation). The shunt may be used
(outflow tube), known as the bladder der, so regular follow-up cystoscopy is as a temporary treatment for congenital
neck. This is normally kept closed by a usually necessary. Bladder tumours that heart disorders, such as tetralogy of
ring of muscle (the urethral sphincter). have spread through the bladder wall Fallot, in which oxygen-depleted blood
FUNCTION may be treated by radiotherapy or by the is diverted back to the heart before it
The bladder’s function is to collect and removal of part or all of the bladder. reaches the lungs. The shunt redirects the
store urine until it can be expelled from
the body. Full control over bladder func-
DISORDERS OF THE BLADDER
tion takes several years to develop. In
infants, emptying of the bladder is an
The most important causes of bladder retention. The most common cause is
entirely automatic, or reflex, reaction.
problems are infection, tumours, spinal-cord injury or tumours. Bladder
When the bladder fills with urine and is
calculi (stones), and impairment of control can be affected by nerve degen-
stretched beyond a certain point, nerve
the bladder’s nerve supply. eration in conditions such as diabetes
signals are sent to the spinal cord. Sig-
mellitus, multiple sclerosis, or dementia.
nals from the spinal cord then cause the
Infection
urethral sphincter to relax and the prin-
Bacterial infection of the bladder, which Other disorders
cipal bladder muscle to contract, thereby
causes inflammation of the bladder wall An unstable or irritable bladder is a
expelling urine via the urethra.
(see cystitis), is particularly common in common condition, particularly in
Children develop complete bladder
women. The short female urethra makes women, in whom the bladder wall is
control at varying ages. Most are dry at
it relatively easy for bacteria to enter from especially sensitive to being stretched.
night by the age of five years, but some
outside the body. In men, infection is Weakness of the muscles at the bladder
take longer (see enuresis, nocturnal).
usually associated with obstruction of neck, causing stress incontinence, is also
Defective bladder function, leading to
urine flow from the bladder by, for common in women, particularly after
problems such as incontinence (see
example an enlarged prostate gland (see childbirth. Tension or anxiety can cause
incontinence, urinary) and urinary reten-
prostate, enlarged) or bladder tumours. frequent urination.
tion, can have a variety of causes. (See
In children, delayed bladder control
also bladder disorders box.)
Tumours (see enuresis, nocturnal) is most often
bladder cancer Bladder tumours may be cancerous or due to delayed maturation of the
noncancerous and are more common in nervous system. Injury to the bladder
See bladder tumours.
men than in women. They are usually is rare but may occur if the pelvis is
bladder outflow obstruction painless in the early stages, the first fractured when the bladder is full.
symptoms being blood in the urine (see
See prostate, enlarged; urinary retention.
haematuria) or urinary retention, in which
INVESTIGATION
bladder tumours the bladder cannot be emptied. All
bladder tumours need careful follow-up
Growths originating in the inner lining Various methods are used to investigate
because, left untreated, noncancerous bladder disorders. Urinary tract
of the bladder. Papillomas (small wart-
bladder tumours may become cancerous. infection is diagnosed by tests on a
like growths) often recur and eventually
become cancerous. Other, more malig- sample of urine. The bladder can be
Calculi viewed directly by cystoscopy (insertion
nant, growths may extend not only into
Bladder stones (see calculus, urinary tract) of a viewing tube). Ultrasound scanning
the bladder cavity, but also through the
are mostly caused by the crystallization is often performed, particularly if
bladder wall to involve nearby organs, stones are suspected. X-ray procedures
of substances, such as calcium, in the
such as the colon, rectum, prostate include micturating cystourethrography,
urine. They mainly affect men and
gland, or uterus. Bladder cancer is more which normally shows only the
usually result from a longstanding
common in smokers and workers in the bladder and urethra, and intravenous
urinary tract infection and/or
dye and rubber industries. urography, which shows the whole
incomplete emptying of the bladder.
SYMPTOMS urinary tract except the urethra.
Haematuria (blood in the urine) is the Urodynamics, which may involve
Nerve impairment X-rays, are studies carried out to
main symptom of bladder cancer. A
Damage to the nerves controlling the investigate bladder control problems.
tumour may obstruct the point at which
bladder can prevent normal bladder Cystometry measures bladder capacity
a ureter enters the bladder, causing back
function and lead either to incontinence in relation to pressure.
pressure and pain in the kidney region,
(see incontinence, urinary) or to urinary
or the urethral exit, causing difficulty in
passing, or retaining, urine.

104
 BLEEDING DISORDERS

oxygen-depleted blood to the lungs. The concealed (internal). Rapid loss of more affected. Von Willebrand’s disease is an
improved blood oxygen levels allow the than 10 per cent of the blood volume inherited disorder in which there is a
child to survive and grow until correc- can cause symptoms of shock, with platelet and a factor VIII defect; it affects
tive surgery is possible. fainting, pallor, and sweating. both sexes about equally.
The speed with which blood flows Individuals with one of these dis- B
bland diet from a cut depends on the type of vessel orders may suffer from bruising,
An easily digested diet that is free from damaged: blood usually oozes from a internal bleeding, abnormally heavy
possible irritants to the digestive tract, capillary, flows from a vein, and spurts menstrual periods, and excessive bleed-
such as spicy foods and raw vegetable from an artery. If an injury does not ing from wounds. In severe cases, there
fibre. A bland diet is often advised break open the skin, the blood collects may be recurrent bleeding into joints,
following abdominal surgery or for around the damaged blood vessels just such as the knee.
people with gastrointestinal disorders. beneath the skin and forms a bruise. Acquired Acquired defects of blood
Any lost blood that mixes with other coagulation factors may develop at any
blast cell body fluids such as sputum (phlegm) age due to severe liver disease, digestive
An immature cell that later develops or urine will usually be noticed quite system disorders that prevent the ab-
into a specialized cell. For example, readily; bleeding from the lining of the sorption of vitamin K (which is needed to
white blood cells begin as blast cells in digestive tract may make vomit or faeces make certain coagulation factors), or
the bone marrow and eventually form appear darker than usual. Internal bleed- the use of anticoagulant drugs.
different types of mature white blood ing may not be discovered until severe Disseminated intravascular coagula-
cells that are then released into the anaemia develops. tion (DIC) is an acquired disorder that
bloodstream. The presence of certain is complex and serious. It may be the
blast cells may indicate illness. For bleeding disorders result of an underlying infection or of a
example, blast cells are found in the A group of conditions characterized by cancerous tumour. In this condition,
blood in acute leukaemia (see leukae- bleeding in the absence of injury or platelets accumulate and clots develop
mia, acute). (See also stem cell.) by abnormally prolonged and excessive within small blood vessels; coagulation
bleeding following injury. Bleeding dis- factors are used up faster than they are
blast injury orders are the result of defects in the able to be replaced, and severe bleeding
Tissue damage due to the effects of blast mechanisms by which bleeding is nor- may result.
waves generated by an explosion. The mally stopped: the coagulation of blood, Tests and treatment Coagulation disor-
eardrums and digestive tract are particu- the plugging of damaged blood vessels ders are investigated by blood-clotting
larly at risk; the air within the ear and by platelets (the smallest type of blood tests. If such a disorder is severe, it is
hollow parts of the gut transmits the cell), and the constriction of blood ves- treated by replacing the missing factor.
waves in all directions, often resulting sels (see blood clotting). Factors are extracted from fresh blood
in severe damage. Defects in the coagulation system or from fresh frozen plasma, or geneti-
tend to cause deep bleeding into the cally engineered factors may be used.
blastocyst gastrointestinal tract, muscles, and joint Paradoxically, anticoagulants are some-
A cell cluster that develops from a fertil- cavities. Defects of the platelets or blood times used to suppress excess clotting
ized ovum and grows into an embryo vessels usually cause superficial bleed- activity in DIC, which results in a
(see fertilization). ing into the skin, the gums, or the lining reduction in bleeding.
of the intestine or the urinary tract. PLATELET DEFECTS
blastomycosis COAGULATION DEFECTS Bleeding may occur if there are too few
A type of fungal infection that can affect These disorders are usually due to a platelets in the blood, a condition called
the lungs and other internal organs. deficiency of or abnormality in the thrombocytopenia. The main feature of
enzymes (coagulation factors) that are this disorder is surface bleeding into the
bleaching, dental involved in blood clotting. Clot forma- skin and gums, and there are multiple
A cosmetic procedure for lightening cer- tion is very slow and the clots are weak small bruises.
tain types of discoloured teeth, including and do not seal blood vessels securely. Occasionally, the platelets are present
nonvital “dead” teeth. The surface of the Coagulation defects may be congenital in normal numbers but function abnor-
affected tooth is painted with oxidizing (present at birth) or may be acquired mally, causing bleeding. Platelet defects
agents and then exposed to ultraviolet later in life. may be inherited, they may be associated
light. A home procedure, consisting of Congenital The main congenital coag- with the use of certain drugs (including
trays loaded with bleaching material, is ulation defects are haemophilia, Christmas aspirin), or arise as a complication of
also available but is slower. disease, and von Willebrand’s disease. In certain bone marrow disorders such as
all of these, one coagulation factor is leukaemia. Platelets can be destroyed by
bleb either absent from the blood or present autoimmune disorders that may have been
Another term for a blister. only in small amounts. Haemophilia triggered by an infection or by drug
and Christmas disease are similar disor- treatment.
bleeding ders, resulting from deficiencies of two Platelet defects are investigated by
Loss of blood from the circulatory system, different coagulation factors: factor VIII blood tests. Bleeding due to a lack of
which may be caused by damage to the and factor IX respectively. Inheritance of platelets may be treated with intravenous
blood vessels or by a bleeding disorder. these disorders is sex-linked (see genetic platelet transfusions. In some cases, oral
Bleeding may be visible (external) or disorders) and normally only males are corticosteroid drugs are prescribed.

105
 BLEEDING, DYSFUNCTIONAL UTERINE

BLOOD VESSEL DEFECTS Eyeball Normal vision depends on an

In rare cases, abnormal bleeding is the uninterrupted passage of light from the
result of a blood-vessel defect or scurvy front of the eye to the light-sensitive
B (a disorder that is caused by a defi-
ciency of vitamin C). Elderly people and
retina at the back. Anything that pre-
vents light from reaching the retina can
patients on long-term courses of cortico- cause blindness.
steroid drugs may suffer mild abnormal Various disorders can lead to the
bruising due to loss of skin support to clouding of the cornea at the front of
the smallest blood vessels. Treatment is the eye. These disorders include Sjögren’s
rarely required in these cases. syndrome (in which the eyes become
excessively dry), vitamin A deficiency,
bleeding, dysfunctional uterine chemical damage, infections, and injury.
Abnormal bleeding from the uterus Corneal ulcers, which most commonly
(womb) with no obvious cause. (See develop after severe infections, can
also menorrhagia). cause blindness due to scarring of the
cornea. Uveitis (inflammation of the
bleeding gums iris, ciliary body, or choroid), can also
See gingivitis. cause loss of vision.
Appearance before (top) and after (bottom)
Blepharoplasty involves the removal of a crescent- Cataract (cloudiness of the lens) is
bleeding, occult shaped section of skin and underlying fat from another common cause of blindness. It
Bleeding that is not obvious to the each eyelid. is usually the result of the lens becom-
naked eye (such as that which occurs ing less transparent in old age, but is
within the intestine) and that may be due to photophobia (abnormal sensitivity occasionally present from birth or
detected only by tests. (See also occult of the eyes to light), to damage to the develops in childhood.
blood, faecal). cornea (the transparent dome that forms Diabetes mellitus, hypertension (high
the front part of the eyeball), or to dys- blood pressure), or injury can all cause
bleeding time tonia (abnormal muscle rigidity), for bleeding into the cavity of the eyeball
An assessment of the functioning of which botulinum toxin (a muscle relaxant) and a subsequent loss of vision. Bleed-
platelets (the tiny cell fragments within treatment is highly effective. ing into the fluid in front of the lens
the blood that play a vital role in blood (see hyphaema) or behind the lens (see
clotting) by measuring the speed at blind loop syndrome vitreous haemorrhage) can also result in
which they form plugs to stem bleeding A condition in which a redundant area loss of vision.
from damaged blood vessels. Two small or dead end (blind loop) in the small Disorders of the retina that may result
cuts are made in the forearm and the intestine becomes colonized with bac- in blindness include age-related macular
time taken for the bleeding from these teria. The bacteria break down bile salts, degeneration (degeneration of the cen-
cuts to stop is recorded. which are necessary for the absorption tral area of the retina, which occurs in
of fat and certain vitamins. This results old age); retinopathy due to diabetes or
blepharitis in poor absorption of fats and abnormal to hypertension; retinal artery occlusion
Inflammation of the eyelids, with red- faeces. Blind loop syndrome may result or retinal vein occlusion (blockage of the
ness, irritation, and scaly skin at the lid from surgery or a stricture (narrowing) blood flow to and from the retina); reti-
margins. Blepharitis may cause burning in the intestine as a result of a disorder nal detachment; certain types of tumour,
and discomfort in the eyes and flakes or such as Crohn’s disease. It is charac- such as retinoblastoma and malignant
crusts on the lashes. The condition is terized by steatorrhoea (pale yellow, melanoma affecting the eye (see melan-
common, tends to recur, and is some- foul-smelling, fatty, bulky faeces that are oma, malignant); and retinal haemorrhage
times associated with dandruff of the difficult to flush away), tiredness, and (bleeding into the retina), caused by
scalp or eczema. Severe blepharitis may weight loss. Antibiotic drug treatment is diabetes, hypertension, vascular disease,
lead to corneal ulcers. In many cases, usually effective, but the condition may or injury.
treatment of associated dandruff with recur if the underlying abnormality In glaucoma, excessive fluid pressure
an antifungal shampoo will result in cannot be corrected. within the eyeball causes degeneration
improvement of the blepharitis. of nerve fibres at the front end of the
blindness optic nerve.
blepharoplasty Inability to see. Definitions of blindness Nerve pathways The light energy that is
A cosmetic operation to remove droop- and partial sight vary. In the UK, blind- received by the retina is transformed
ing, wrinkled skin from the upper ness is defined as a corrected visual acuity into nerve impulses that travel along the
and/or lower eyelids. Blepharoplasty is of 3/60 or less, or a visual field of no optic nerve and nerve pathways into the
usually performed under local anaes- more than 20 degrees, in the better eye. brain. Loss of vision may result if the
thetic (see anaesthesia, local). CAUSES conduction of these nerve impulses is
Loss of vision may result from injury impaired.
blepharospasm to, or disease or degeneration of, the Reasons for damage to nerve pathways
Prolonged, involuntary contraction of eyeball; the optic nerve or the nerve include pressure caused by a tumour in
one of the muscles controlling the eye- pathways that connect the eye to the the orbit (the bony cavity that contains
lids, causing them to close. It may be brain; or the brain itself. the eyeball); a reduced blood supply to

106
 BLOOD CELLS

the optic nerve, which may be caused (nerve endings responsive to light). The rest of the blood volume is made up of
by diabetes mellitus, hypertension, a blind spot can also be used to describe plasma, a watery, straw-coloured fluid
tumour, injury, or temporal arteritis the part of the visual field in which containing proteins, sugars, fats, salts,
(inflammation of arteries in the scalp); objects cannot be detected. and minerals.
optic neuritis (inflammation of the optic Nutrients are transported in the B
nerve that may occur in multiple sclero- blister bloodstream to the tissues after absorp-
sis); the toxic (poisonous) effects of A collection of fluid beneath the outer tion from the intestinal tract or after
certain chemicals; and certain nutritional layer of the skin that forms a raised release from storage depots such as the
deficiencies. area. The fluid is serum that has leaked liver. Waste products, including urea and
Brain Nerve impulses from the retina from blood vessels in underlying skin bilirubin, are carried in the plasma to the
eventually arrive in a region of the cere- layers after minor damage; it provides kidneys and liver respectively.
brum (the main mass of the brain) protection for the damaged tissue. Plasma proteins include fibrinogen,
called the visual cortex. Blindness can Common causes of blisters are burns which is involved in blood clotting;
result if there is pressure on the visual and friction. Blisters may also occur in immunoglobulins (also called antibodies)
cortex from a brain tumour or a brain some skin diseases, including eczema, and complement, which are part of the
haemorrhage, or if the blood supply to epidermolysis bullosa, impetigo, erythema immune system; and albumin. Hormones
the visual cortex has been reduced fol- multiforme, pemphigus, pemphigoid, and are also transported in the blood to
lowing a stroke. dermatitis herpetiformis, and in some their target organs.
DIAGNOSIS AND TREATMENT types of porphyria. Small blisters develop
It is frequently possible to detect the in chickenpox, herpes zoster (shingles), blood–brain barrier
cause of blindness by direct examina- and herpes simplex. Blisters are generally A system of tight, impermeable junc-
tion of the eye, using such techniques best left intact; large or unexplained tions between the cells that form the
as ophthalmoscopy, slit-lamp examination, blisters need medical attention. walls of the capillaries (tiny blood ves-
and tonometry. The conduction of nerve sels) within the central nervous system.
impulses can be measured by means of bloating The blood–brain barrier has a protec-
evoked responses. Distension of the abdomen, commonly tive function; it allows only certain
Treatment of blindness depends on due to wind in the stomach or intestine substances and drugs in the blood-
the underlying cause. If the loss of (see abdominal swelling). stream to gain access to the central
vision cannot be corrected, the patient nervous system, especially to the brain.
may then be registered as legally blind blocked nose
or partially sighted, and will become See nasal congestion; nasal obstruction. blood cells
eligible for certain benefits and services. Cells, also called blood corpuscles, that
(See also eye; vision, loss of.) blocking are present in blood for most or part of
The inability to express true feelings or their lifespan. They include red blood
blind spot thoughts, usually due to emotional cells (which make up about 45 per cent
The small, oval-shaped area on the retina or mental conflict. In Freudian-based of the volume of normal blood), white
of the eye where the optic nerve leaves psychotherapy, blocking is thought to blood cells, and platelets. All blood cells
the eyeball. The area is not sensitive to result from the repression of painful are made in the bone marrow by a
light because it has no light receptors emotions in early life. A very specific series of divisions from a single type of
form of thought blocking occurs in cell called a stem cell.
schizophrenia: trains of thought are per- RED BLOOD CELLS
LOCATION OF BLIND SPOT sistently interrupted involuntarily to be These cells are also known as RBCs, red
replaced by unrelated new ones. blood corpuscles, or erythrocytes. They
The blind spot is a minute area on transport oxygen from the lungs to the
the retina that lacks light receptors blood tissues (see respiration).
and is therefore not light-sensitive.
The red fluid that circulates in the Formation Red blood cells are formed
Blind Retina body’s veins, arteries, and capillaries. from stem cells in the bone marrow by
spot Blood is pumped by the heart via the a process called erythropoiesis, which
arteries to the lungs and all other tissues takes about five days. Their formation
and is then returned to the heart in requires an adequate supply of nutri-
veins (see circulatory system). Blood is ents, including iron, amino acids, and
the body’s transport system and also the vitamins B12 and folic acid. The rate
plays an important role in the defence at which RBCs are formed is influenced
against infection. An average adult has by a hormone called erythropoietin,
about 5 litres of blood. which is produced by the kidneys.
Almost half the blood’s volume con- Immature red blood cells that have
sists of blood cells, including red blood just been released into the bloodstream
cells (erythrocytes), which carry oxygen from the bone marrow are called retic-
to the tissues; white blood cells (leuko- ulocytes; within two to four days, these
cytes), which defend the body against develop into mature cells.
Optic nerve Light-rays
infection; and platelets (thrombocytes), Structure and function In l ml of blood
which are involved in blood clotting. The there are approximately 5 million red

107
 BLOOD CELLS

CONSTITUENTS OF BLOOD

Blood is pumped around the body in Normal blood smear

B veins and arteries, transporting oxygen
from the lungs to the tissues and
Red blood cell This is the appearance of
normal blood under a
carbon dioxide from the tissues to microscope. The dominant
the lungs. Blood also carries nutrients feature is the abundance of
Platelet red blood cells, which make
such as sugars, fats, and proteins that
up almost half of the volume
have been absorbed from the intestine of blood. One white blood cell
White blood cell
and hormones produced by a variety (a lymphocyte) can be clearly
of glands. Waste products that are seen; the platelets are the
released from cells are carried in the tiny dark particles.
blood to be broken down in the liver
or excreted from the kidneys.

White blood cells Plasma Plasma

These cells protect the body against The fluid part of the blood that
infection and fight it when it occurs. consists mostly of water. It carries
They are bigger than red blood cells substances such as proteins, fats,
but fewer in number. Each of the glucose, and salts.
three main types (granulocytes, Monocyte
monocytes, and lymphocytes)
plays a different role in
Red Red blood cells
dealing with infection. blood These disc-shaped
cells cells are formed in the
bone marrow and carry
Granulocyte Lymphocyte oxygen from the lungs
to the rest of the body.
They have a large
Layer containing
white blood cells surface area and a
Platelets flexible shape.
and platelets
The smallest type of blood cell
produced in the bone marrow.
They play an important role in
blood clotting.
Platelets Red blood cells

blood cells, each of which is disc- reactions), minerals, and sugars that the body against infection and fight
shaped, about 0.0075 mm in diameter, provide energy for the cell’s metabolism infection when it occurs. White blood
and thicker around the edge than at the (chemical processes) and maintain its cells are bigger than red blood cells (up
centre. This shape gives each cell a rela- shape, structure, and elasticity. to 0.015 mm in diameter) but are far
tively large surface area, which helps it Aging and destruction The normal lifes- less numerous (about 7,500 per ml of
absorb and release oxygen molecules, pan of RBCs in the circulation is about blood). They generally spend a shorter
and allows it to distort as it squeezes 120 days. As they age, their internal part of their lifespan than red blood
through narrow blood vessels. The sur- chemical machinery wears out, they cells in the blood itself. The three main
face structure of red blood cells varies lose elasticity, and they become trapped types of WBC are granulocytes (also
slightly among individuals, and this in small blood vessels in the spleen and called polymorphonuclear leukocytes),
provides the basis for classifying blood other organs; they are then destroyed by monocytes, and lymphocytes.
into groups (see blood groups). a type of white blood cell called a Granulocytes Granulocytes are further
RBCs are packed with large quantities macrophage. Most of the components classified as neutrophils, eosinophils, or
of haemoglobin, a pigmented protein of haemoglobin molecules are reused, basophils, each type having a specific
that contains iron. Haemoglobin binds but some are broken down to form the role. The most important are neutro-
(combines chemically) with oxygen to waste product bilirubin. phils, which isolate and destroy invading
form oxyhaemoglobin, which carries Disorders Abnormalities can occur in bacteria. Neutrophils remain in the
oxygen to body tissues. Oxyhaemoglo- the rate at which RBCs are produced or blood for only about six to nine hours
bin is responsible for the bright red destroyed; in their numbers; and in their before moving through blood-vessel
coloration of oxygenated blood, which shape, size, and haemoglobin content, walls into tissues. Eosinophils play a
flows mainly through the arteries. Most all of which may cause forms of part in allergic reactions and increase in
venous blood is darker because it con- anaemia and polycythaemia (see blood numbers in response to certain parasitic
tains the unbound (deoxygenated) form disorders box). infections. Basophils are involved in
of haemoglobin. WHITE BLOOD CELLS inflammatory and allergic reactions.
Every RBC also contains enzymes These are also called WBCs, white blood Monocytes These cells also play an
(substances that promote biochemical corpuscles, or leukocytes. They protect important role in the immune system.

108
 BLOOD CELLS

DISORDERS OF THE BLOOD

Abnormalities can occur in any of the Nutritional disorders in the gene that controls production
components of blood: in red blood Heavy or persistent blood loss, most of a clotting factor (see factor V, for B
cells, white blood cells, platelets, and commonly as a result of menstruation, example) or use of oral contraceptives.
the numerous constituents of plasma. may mean that iron (an essential People with Hughes’ syndrome are also at
There are various types of anaemia component of the red cell pigment increased risk of thrombosis.
(a reduced level of the oxygen-carrying haemoglobin) is lost faster than it can
pigment haemoglobin in the blood), be replaced in the diet (see anaemia, iron- Other disorders
which is by far the most common deficiency). Deficiencies of the vitamins Blood poisoning may be caused by the
blood disorder. Some abnormalities of B12 or folic acid interfere with the multiplication of bacteria in the blood
the blood are inherited; others may be production of red blood cells in bone (see septicaemia) or by the toxins
the result of various diseases, such as marrow and give rise to abnormally released by bacteria (see toxaemia).
cancer, or be caused by poisoning by large, deformed red blood cells (see blood, Poisoning can also be caused by toxins
infective organisms, toxins, or drugs. anaemia, megaloblastic). such as carbon monoxide and lead.
Some drugs can cause blood
Genetic disorders Cancer abnormalities. For example,
Some blood disorders are inherited There are various types of bone marrow thiazide diuretic drugs may depress
(genetic) and are present from birth cancer, all of which affect the blood. the production of white blood cells
(congenital). Such disorders include Leukaemia causes an overgrowth of and/or platelets; methotrexate may
sickle cell anaemia and thalassaemia, abnormal white blood cells and destroys interfere with red cell production;
in which the red blood cells are healthy bone marrow. In polycythaemia, and too high a dose of anticoagulant
abnormally fragile, and haemophilia, too many red blood cells are produced. drugs can cause abnormal bleeding.
in which there is a deficiency of one Another bone marrow cancer, multiple Albumin, which is an important
of the blood clotting factors. myeloma, can cause an excess of certain protein in blood plasma, may become
proteins in the blood plasma. Secondary deficient as a result of either liver or
deposits that have spread from cancers kidney disease.
elsewhere in the body may also involve
the bone marrow.
INVESTIGATION
Clotting disorders
Blood disorders are investigated
Defects in the blood platelets and in blood
principally by various blood tests,
clotting mechanisms may lead to bleeding such as blood count, blood film, and
disorders, such as haemophilia and blood-clotting tests. Levels of vitamins
disseminated intravascular coagulation (DIC). and minerals, such as iron, may
Sickle-cell anaemia
Liver disease may cause deficiencies of also be measured. In some cases, a
This electron micrograph shows a red blood cell some clotting factors. Unwanted clot bone marrow biopsy may also
deformed by sickle-cell anaemia (left). On the formation (see thrombosis) may have any be required.
right is another red cell that has started to sickle. of a variety of causes, such as a mutation

They circulate in the bloodstream for cells. T-lymphocytes can be classified There are about 250,000 of them per
about one to three days. according to their surface marker pro- cubic mm of blood. Like other blood
Lymphocytes Lymphocytes are usually teins. For example, T-lymphocytes with cells, they originate in the bone mar-
formed in the lymph nodes, rather than CD4 surface marker proteins are partic- row. Platelets survive in the blood for
in the bone marrow. They play an ularly important in monitoring HIV about nine days.
important role in the immune system, infection. In addition, T-lymphocytes Function Platelets circulate in the blood
roving throughout the body between the moderate the activity of B-lymphocytes, in an inactive state until brought into
bloodstream, the lymph nodes, and the which form the antibodies that can act action by certain circumstances, when
channels between lymph nodes. Lym- to prevent a second attack of certain they begin to stick to blood-vessel walls
phocyte cells may survive for anywhere infectious diseases. and to each other. These activities play
between three months and ten years. Disorders The leukaemias are blood disor- an important part in blood clotting,
There are two principal types of ders in which there is uncontrolled which helps wounds to heal. However,
lymphocyte: T-lymphocytes (or T-cells) overproduction of white blood cells in the accumulation of platelets can, occa-
and B-lymphocytes (or B-cells). T- the bone marrow. Other disorders arise sionally, lead to the formation of clots
lymphocytes are responsible for delayed when white blood cells are not pro- in blood vessels (see thrombosis).
hypersensitivity reactions (see allergy) duced in sufficient numbers. BLOOD CELLS IN DIAGNOSIS
and are also involved in protection PLATELETS The numbers, shapes, and appearance
against cancer. T-lymphocytes manufac- Platelets, which are also called thrombo- of the various types of blood cell are of
ture chemicals, called lymphokines, cytes, are the smallest type of blood cell great value in the diagnosis of disease
which affect the functioning of other (0.002 mm to 0.003 mm in diameter). (see blood count; blood film).

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 BLOOD CLOT

HOW BLOOD CLOTS

Clotting describes the solidification of Red blood cells enmeshed

B blood anywhere in the body. Clotting
occurs almost immediately at the site
in fibrin filaments
Fibrin is formed by a chemical
change from a soluble protein,
of a cut and helps to limit blood loss fibrinogen, which is present
by sealing damaged blood vessels. in the blood. The fibrin
However, if abnormal clotting occurs molecules aggregate to form
in major blood vessels, a heart attack, long filaments, which enmesh
stroke, or other disorder may occur. blood cells (see left) to form a
The clotting process has two main solid clot. The conversion of
parts – platelet activation and the fibrinogen to fibrin is the last
step of the “coagulation
formation of fibrin filaments. cascade”, a series of reactions
in the blood that are triggered
by injury to the tissues and
activation of platelets.
Platelet Fibrin Clot

Epidermis

Dermis

White blood
cell

Red blood
cell

Platelets are activated by Chemicals released by

1damaged
coming into contact with
blood vessel walls,
2damaged
the platelets and
tissues stimulate
3alongThe fibrin filaments
enmesh the platelets
with red and white
4fibrin,Once the cut blood vessel
is plugged by the mass of
platelets, and red and
where they become sticky and coagulation factors within blood cells. white blood cells, the fibrin
then clump at the site of the blood to form filaments filaments contract to form a
injury and adhere to the of fibrin at the site of injury. solid clot.
damaged blood-vessel wall.

blood clot ANTICLOTTING MECHANISMS abnormalities of blood coagulation fac-

See thrombus. There are several anticlotting mechanisms tors or of platelets (see blood clotting).
that prevent the formation of unwanted The tests are also used to monitor treat-
blood clotting blood clots. These mechanisms include ment with anticoagulant drugs; excessive
The process of blood solidification. prostacyclin (a prostaglandin), which doses of these drugs could cause bleed-
Blood clotting is important in stemming prevents platelet aggregation (the first ing. (See also international normalized ratio.)
bleeding from damaged blood vessels. stage of blood clotting), and plasmin,
However, blood clots can also form which breaks down fibrin (see fibrinoly- blood count
inside major blood vessels, leading to a sis). Blood flow washes away active A test, also called full blood count, that
myocardial infarction (heart attack) or to coagulation factors; and the liver deacti- measures the haemoglobin concentration
a stroke (see thrombosis). vates excess coagulation factors. and the numbers of red blood cells,
CLOTTING MECHANISM CLOTTING DEFECTS white blood cells, and platelets in 1 cu.
When a blood vessel is damaged, it Defects in blood clotting may result in mm of blood.The proportion of various
constricts immediately to reduce blood bleeding disorders. Excessive clotting, or white blood cells is measured and the
flow to the area. The damage sets off a thrombosis, may be due to an inherited size and shape of the red and white cells
series of chemical reactions, leading to increase or defect in a coagulation factor is also noted.
the formation of a clot to seal the injury. (see factor V); the use of oral contracep- A blood count is the most commonly
First, platelets around the injury site are tives; a decrease in the level of enzymes performed blood test and is important
activated, becoming sticky and adhering that inhibit coagulation; or sluggish for diagnosing anaemia or confirming
to the blood-vessel wall. The activated blood flow through a particular area. the presence of an infection to which
platelets then release chemicals that, in Treatment is usually with anticoagulant cells in the blood have responded. It is
turn, activate coagulation factors. These drugs such as heparin or warfarin. also used to diagnose disorders such as
factors, together with vitamin K, act on leukaemia and thrombocytopenia (abnor-
fibrinogen, a substance found in blood, blood-clotting tests mally low platelet levels).
converting it to fibrin. Strands of fibrin Laboratory tests used to screen for and About 1 to 2 ml of blood is required
form a kind of meshwork, which traps diagnose bleeding disorders. Such disor- for a blood count, which is usually per-
red blood cells to form a clot. ders usually result from deficiencies or formed by an automatic analyser.

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 BLOOD PRESSURE

blood culture Blood oxygen can also be monitored surface of the red blood cells determines
A laboratory test performed on a sample continuously without the need to take a person’s blood group. People with the
of blood to determine the presence of blood samples by using an oximeter. A antigen (blood group A) have anti-B
microorganisms such as bacteria. (See antibodies; people with the B antigen
also culture.) blood glucose (blood group B) have anti-A antibodies; B
The level of glucose in the blood. Abnor- those with both antigens (blood group
blood donation mally high blood glucose (sometimes AB) have neither type of antibody; and
The process of giving blood for use in called blood sugar) levels may be an those with neither antigen (blood group
blood transfusion. Blood donors give up indication of diabetes mellitus. (See also O) have both types of antibody.
to 500 ml of blood (about one-tenth of hyperglycaemia; hypoglycaemia.) RHESUS FACTORS
total blood volume), usually about twice The rhesus system involves several anti-
a year. Donated blood is routinely tested blood glucose monitoring gens, the most important of which is
for a range of infectious agents, such as A method of analysing a person’s blood called factor D. People with this factor
hepatitis B and hepatitis C, and antibodies glucose (sugar) levels that requires only are Rh-positive; those without it are Rh-
to HIV. After being classified into blood a drop of blood taken from a pinprick negative. The importance of the Rh
groups, the blood is stored in a blood on the fingertip. The blood is applied to group relates mainly to pregnancy in
bank, either whole or separated into its a test strip, which has an area impreg- Rh-negative women because, if the baby
components (see blood products). nated with a chemical that reacts with is Rh-positive, the mother may form
Apheresis is a specific type of blood the glucose in the blood sample. The antibodies against the baby’s blood (see
donation in which only a particular glucose level is shown either by a visi- rhesus incompatibility).
component of blood (such as plasma, ble colour change on the strip or by USES
platelets, or white blood cells) is with- placing the strip in a digital meter. Peo- Blood group typing is essential for safe
drawn from the donor. ple with diabetes mellitus must perform blood transfusion. The ABO and rhesus
regular blood glucose monitoring tests groups are used to categorize blood
blood film to monitor their blood glucose control. stored in blood banks, so that donor
A test that involves smearing a drop of (See also hyperglycaemia; hypoglycaemia.) blood that is compatible with that of
blood on to a glass slide for examin- the patient can be selected before trans-
ation under a microscope. The blood blood groups fusion takes place.
film is stained with dyes to make the Systems of classifying blood according Because a person’s blood group is
blood cells show up clearly. to the different antigens (marker pro- inherited, identification of blood group
The test allows the shape and appear- teins) on the surface of red blood cells may be used in paternity testing. Gen-
ance of blood cells to be checked for (RBCs) and the antibodies in the blood etic analysis allows identification of the
any abnormality, for example the sickle- plasma. The antigens affect the ability of blood of a criminal suspect with virtual
shaped red blood cells characteristic of the RBCs to provoke an immune response. certainty (see genetic fingerprinting).
sickle cell anaemia. The relative propor- The two principal blood grouping sys-
tions of the different types of white tems used are the ABO system and the blood level
blood cells can also be counted. This rhesus system. The concentration of a given substance
examination, known as a differential ABO GROUPS in the blood plasma or serum that may
white cell count, may be helpful in In this system, the presence or absence be measured by blood tests.
diagnosing infection or leukaemia. Blood of two types of antigen (A and B) on the
films are also used in diagnosing infec- blood loss
tions in which the parasites can be seen See bleeding.
inside the red blood cells; an example of BLOOD GROUP
COMPATIBILITY blood poisoning
such an infection is malaria.
Blood film tests are usually carried Group A is compatible with A and O,
A common name for septicaemia with
out together with a full blood count. and group B with B and O. Group AB toxaemia, a life-threatening illness that is
is compatible with all groups, but O caused by multiplication of bacteria and
blood gases is compatible with no other group. formation of toxins in the bloodstream.
Measurement of the concentrations of Septicaemia may occur as a compli-
oxygen and carbon dioxide in the Donor blood group cation of an infection in an organ or
blood. The acidity–alkalinity (pH) and tissue. In some infective conditions, sep-
bicarbonate levels are also measured. A B AB O tic shock may be caused by toxins that
The test is carried out on a sample of A are released by bacteria. Treatment for
blood that has been taken from an blood poisoning is with antibiotic drugs
artery, usually at the wrist or the groin. Recipient B and intensive therapy for shock. (See
It is useful in diagnosing and moni- blood also bacteraemia.)
toring respiratory failure. Bicarbonate and group AB
acidity reflect the acid–base balance of blood pressure
the body, which may be disturbed in O The pressure exerted by the flow of
conditions such as diabetic ketoacido- blood through the main arteries. The
Key Compatible Incompatible
sis, aspirin poisoning, hyperventilation pressure at two different phases is mea-
(overbreathing), or repeated vomiting. sured. Systolic, the higher pressure, is

111
 BLOOD PRODUCTS

TYPES
MEASURING BLOOD PRESSURE Important haematological blood tests
are blood count and blood group tests if a
Blood pressure measurement is a
B routine part of a physical examination.
A sphygmomanometer measures blood
blood transfusion is needed. Biochemi-
cal tests measure chemicals in the blood
pressure as systolic (the top figure), (see acid–base balance; kidney function
when the heart contracts, and tests; and liver function tests). Microbiol-
diastolic, when the heart relaxes. ogical tests (see immunoassay) look for
An inflatable cuff attached to the microorganisms that are in the blood,
sphygmomanometer is wrapped such as in septicaemia. Immunological
around the upper arm and deflated tests also look for antibodies in the
while a doctor listens to the blood flow blood, which may confirm immunity
through an artery, using a stethoscope. to an infection.
Sphygmomanometer blood transfusion
The infusion of large volumes of blood
or of blood products directly into the
created by the contraction of the ventri- used to correct many types of bleeding bloodstream to remedy severe blood
cles of the heart. Diastolic, the lower disorder because plasma contains all loss or to correct chronic anaemia. In an
pressure, is recorded during relaxation the clotting factors. Plasma substitutes exchange blood transfusion, nearly all
of the ventricles between heartbeats; it may be used to treat shock that has of the recipient’s blood is replaced by
reflects the resistance of all the small occurred as a result of severe blood loss, donor blood.
arteries in the body and the load against until sufficient compatible whole blood HOW IT IS DONE
which the heart must work. The pres- becomes available. Purified albumin Before a transfusion, a sample of the
sure wave that is transmitted along the preparations are used for people who recipient’s blood is taken to identify
arteries with each heartbeat is easily felt have nephrotic syndrome and chronic his or her blood group, which is then
as the pulse. liver disease. matched with suitable donor blood. The
Blood pressure is measured using a Concentrates of blood clotting factors donor blood is transfused into an arm
sphygmomanometer and is expressed as VIII and IX are used in the treatment vein through a plastic cannula (a tube
millimetres of mercury (mmHg). Blood of the conditions haemophilia and Christ- with a smooth tip). Usually, each unit
pressure varies with age, between indi- mas disease. Immunoglobulins (also called (about 500 ml) of blood is given over
viduals, and at different times in the antibodies), which are extracted from one to four hours; in an emergency,
same individual. A healthy young adult blood plasma, can be given by injection 500 ml may be given within a couple of
usually has a blood pressure reading, at (see immunoglobulin injection) to protect minutes. The blood pressure, body tem-
rest, of about 120/80 (120 mmHg sys- those people who are unable to produce perature, and pulse of the patient are
tolic and 80 mmHg diastolic pressure). their own antibodies or have already monitored during the procedure.
A sustained level of high blood pressure been exposed to an infectious agent. COMPLICATIONS
is called hypertension; abnormally low Immunoglobulins may also be given to If mismatched blood is accidentally
pressure is termed hypotension. provide short-term protection against introduced into the circulation, anti-
hepatitis A. Immunoglobulins are given bodies in the recipient’s blood may
blood products in large doses to treat certain autoim- cause the donor cells to burst, leading
Donated blood (see blood donation) that mune disorders. to shock or kidney failure. Less severe
is separated into its components: red reactions can produce fever, chills, or a
cells, white cells, platelets, and plasma. blood smear rash. Reactions can also occur as the
Each blood product has a specific life- See blood film. result of an allergy to a particular com-
span and use in blood transfusion. Packed ponent of the transfused blood.
red cells (blood that has most of the blood sugar The risk of infection is extremely
plasma removed) are used to treat indi- See blood glucose. small. All blood used for transfusion is
viduals with some forms of chronic carefully screened for a number of infec-
anaemia and babies with haemolytic dis- blood test, haematological tious agents, including HIV (the AIDS
ease of the newborn. Washed red cells Analysis of a sample of blood to provide virus) and hepatitis B and hepatitis C.
(with white blood cells and/or plasma information about its cells and proteins In elderly or in severely anaemic
proteins removed) are used when a per- and the chemicals, gases, antigens, and patients, blood transfusion can overload
son requires repeated transfusions since antibodies it contains. Haematological the circulation, leading to heart failure.
there is less risk of an allergy to any of blood tests are used to check respiratory In patients with chronic anaemia who
the blood components developing. function, the immune system, the need regular transfusions over the course
Platelets may be given through trans- metabolism, hormonal balance, and of many years, excess iron may accumu-
fusions for those people who have the health of the major organs. The tests late (a condition called haemosiderosis)
blood-clotting disorders. Patients who look at the numbers, appearance, shape, and damage organs such as the heart,
have life-threatening infections may be and size, of blood cells and assess liver, and pancreas. Treatment with the
treated with granulocytes, a type of the function of clotting factors in drug desferrioxamine to remove excess
white blood cell. Fresh frozen plasma is the blood. iron may be needed in this case.

112
 BOIL

blood transfusion, autologous blue naevus body contour surgery

The use of a person’s own blood, which A type of naevus (skin blemish) with a Surgery that is performed to remove
had been donated at an earlier time, for dark blue or black coloration and a excess fat, skin, or both, from various
blood transfusion. Autologous transfusion clearly defined border. Blue naevi are parts of the body, especially from the
eliminates the slight but serious risk of noncancerous and they are made up of abdomen, the thighs, and the buttocks. B
contracting an infectious illness from a collection of pigment-producing cells One of the most commonly used opera-
contaminated blood. Another advantage called melanocytes. tions is abdominal wall reduction, also
is that there is no risk of a reaction called abdominoplasty, which involves
occurring as a result of incompatibility blurred vision removing excess skin and fat from the
between donor and recipient blood. Indistinct, or fuzzy, visual images. abdominal area.
Up to 2.5 litres of a person’s blood Blurred vision, which should not be To miminize scarring, a less invasive
can be removed and stored in several confused with double vision (diplopia), procedure, such as suction lipectomy
sessions up to three days before planned can occur in one eye or both, for epi- (liposuction), may be performed. In
surgery. There must be at least four days sodes of varying lengths of time, and this operation, a rigid hollow tube is
between each session. Blood may also can develop gradually or suddenly. The inserted through a small incision in the
be taken during surgery. The blood is fil- usual cause of longstanding blurred skin and is used to break up large areas
tered and returned to the body. vision is a refractive error such as astig- of fat. The fat can then be sucked out
matism (unequal curvature of the front through the instrument.
blood transfusion, incompatible of the eye), hypermetropia (longsighted- All body contour surgery carries a
A blood transfusion in which the recipi- ness), or myopia (shortsightedness), all risk of complications, including wound
ent’s blood and the donor’s blood are of which can be corrected by glasses or infection. Minor irregularities and some
mismatched. As a result, antibodies that contact lenses. After the age of 40, pres- dimpling of the skin commonly occur
are present in the recipient’s circulation byopia (reduced ability to focus on near following liposuction.
lead to destruction of the transfused red objects) becomes more common.
blood cells. This can have serious conse- Vision may also be blurred or im- body dysmorphic disorder
quences, including kidney failure and paired as a result of damage, disease, or A psychiatric disorder in which a person
occasionally even death. Careful cross- abnormalities of parts of the eye or its suffers intense anxiety about an imag-
matching of blood in the laboratory connections to the brain. Blurred vision ined defect in part of his or her body.
make incompatible transfusions rare. as a result of disease is most commonly
caused by cataract or retinopathy. body image
blood vessels A person’s perception of the different
A general term for arteries, veins, and blushing parts of his or her own body.
capillaries (see circulatory system). Brief reddening of the face, and some-
times the neck, caused by widening of body mass index (BMI)
Bloom’s syndrome the blood vessels close to the skin’s sur- An indicator of healthy body weight.
A genetic disorder that is most commonly face. Blushing is often an involuntary BMI is calculated by dividing weight
found among people of East European reaction to embarrassment. In some in kilograms by the square of height in
Jewish descent. Physical characteristics women, blushing is a feature of the hot metres. The normal range is 20 to 25.
of the syndrome include short stature, a flushes that occur during the menopause.
butterfly-shaped red rash on the face, Flushing of the face also occurs in asso- body odour
and photosensitivity (an abnormal reaction ciation with carcinoid syndrome. The smell caused by the action of bac-
to sunlight). Individuals with Bloom’s teria on sweat. It is most noticeable in
syndrome may also be at increased risk B-lymphocyte the armpits and around the genital area,
of certain cancers, such as leukaemia. A type of white blood cell, also referred to where the apocrine glands contain pro-
as a B-cell. B-lymphocytes play a vital teins and fatty materials favourable to
blue baby part in the immune system, the body’s bacterial growth.
An infant with a cyanotic (bluish) com- natural defence mechanism, by produc-
plexion, especially visible on the lips ing antibodies (special proteins) to find body temperature
and tongue, caused by a relative lack of and destroy harmful microorganisms. See temperature.
oxygen in the blood. This is usually due
to a structural defect of the heart or the BMI boil
major arteries leaving the heart. Such The abbreviation for body mass index. An inflamed, pus-filled area of skin,
defects may need to be corrected surgi- usually an infected hair follicle. A more
cally (see heart disease, congenital). BMR severe and extensive form of boil invol-
The abbreviation for basal metabolic rate. ving several hair follicles is known as a
blue bloater carbuncle. The usual cause of a boil is
An outdated term to describe a person BM-test 1–44 infection with the bacterium STAPHYLO-
with bluish lips and tongue and oedema A brand-named blood glucose monitoring COCCUS AUREUS . Recurrent boils may occur
(a buildup of fluid in the tissues). The test strip for analysing the blood glu- in people with known or unrecognized
cause is long-term lung damage that has cose level in diabetes mellitus.The strip is diabetes mellitus or in those with other
led to heart failure (see pulmonary dis- sensitive to blood glucose levels ranging conditions in which general resistance
ease, chronic obstructive). from 1 mmol to 44 mmol. to infection is impaired.

113
 BOLUS

Treatment sometimes involves antibiotic bonding may be delayed if a baby is the form of cartilage. This cartilage
drugs. However, a boil that is opened premature or ill and has to be separated begins to be replaced by hard bone, in a
surgically to release the pus usually from his or her parents immediately process known as ossification, at around
B heals rapidly without the need for
drug treatment.
after birth (for example, by being placed
in an incubator).
the seventh or eighth week of pregnancy;
this process is not complete until early
adult life. At birth, many bones consist
bonding, dental mainly of cartilage, which ossifies later
Techniques that use plastic resins and in life. The epiphyses (the growing ends
Raised surface acrylic or porcelain veneers to repair, of the long bones) are separated from
of boil restore, or cosmetically improve the the bone shaft (diaphysis) by the epiphy-
teeth. Dental bonding may sometimes be seal plate. Some bones in the body, such
Pus-filled cavity used as an alternative to crowning (see as certain skull bones, do not develop
crown, dental) and can also be used to from cartilage, and these are known as
protect the teeth. membranous bones.
Sweat gland
bone bone abscess
Blocked hair
follicle The structural material of the skeleton A localized collection of pus in a bone
that provides a rigid framework for the (see osteomyelitis).
Nerve
muscles and protects certain organs of
the body. In combination with the bone age
joints and the muscles, the bones form A measure of skeletal maturity used to
the locomotor system. assess physical development in children.
STRUCTURE X-rays, which show how much bones
Bone consists of several layers. The sur- have grown in a particular body area,
Cross-section of a boil
Following bacterial infection of the hair follicle,
face has a thin covering known as the are used to determine bone age. (See
there is a buildup of pus, and a raised tender periosteum, a membrane that contains a also age.)
lump appears on the surface of the skin. network of blood vessels and nerves.
Beneath the periosteum is an inner shell bone cancer
bolus of hard (also called compact or cortical) Malignant growth in bone. Bone cancer
A soft mass of chewed food that is pro- bone composed of columns of bone may originate in the bone itself (primary
duced by the action of the tongue, the cells (osteoclasts and osteoblasts). Each bone cancer) or, more commonly, may
teeth, and the saliva to facilitate swal- column has a central hollow (haversian occur as a result of cancer spreading
lowing of the food. The term bolus is canal) that is important for the nutri- from elsewhere in the body (secondary,
also used to describe a single dose of a tion, growth, and repair of the bone. or metastatic, bone cancer).
drug that is rapidly injected into a vein. The direction of the haversian canals PRIMARY BONE CANCER
corresponds with the mechanical forces Cancers that originate in the bone are
bonding acting on the bone. rare; the type of primary bone cancer
The reciprocal process by which a Inside the hard shell, bone has a cen- that occurs most often is osteosarcoma.
strong tie, both psychological and emo- tral meshlike structure (which is known Other types include chondrosarcoma and
tional, is established between a parent as spongy, cancellous, or trabecular fibrosarcoma. Cancers can also start in the
and a newborn child. The process of bone). The cavity in the centre of cer- bone marrow, but these are not usually
tain bones, and the spaces in spongy considered to be bone cancers (see mul-
bone, contain bone marrow, in which tiple myeloma and leukaemia). The
the red blood cells, platelets, and most treatment of primary bone cancer will
of the white blood cells are formed. depend on the extent to which the dis-
GROWTH ease has spread. If it remains confined
Bone is continuously reabsorbed by to bone, it may be possible to remove
osteoclasts and replaced by osteoblasts. the cancer and fill the defect with a bone
The osteoblasts encourage deposition of graft. In other cases, amputation may be
calcium phosphate on the protein recommended. Radiotherapy or chemo-
framework of the bone; the osteoclasts therapy, or both, may also be needed.
remove it. The actions of these cells are SECONDARY BONE CANCERS
controlled by growth hormone, secreted The cancers that spread most readily to
by the pituitary gland, the sex hormones form secondary bone cancer are those
oestrogen and testosterone, the adrenal of the breast, lung, prostate, thyroid,
hormones, the thyroid hormone thyro- and kidney.These bone metastases occur
calcitonin, and parathyroid hormone. commonly in the spine, pelvis, ribs, and
These hormones also work to maintain skull. Pain is usually the main symptom.
the level of calcium in the blood. Affected bones are abnormally fragile
The bonding process
Most bones begin to develop in the and may fracture easily. Bone cancer that
By the maintenance of close physical contact, embryo during the fifth or sixth week affects the spine may cause collapse or
bonding gradually becomes established. of pregnancy, at which time they take crushing of vertebrae, damaging the

114
 BONE MARROW

STRUCTURE OF BONE

Bone consists of several

layers: a thin, membranous
surface and an inner, dense
B
Bone marrow
shell surrounding spongy
material in which the bone Nutrient Marrow Compact Spongy
marrow lies. Nutrient artery cavity bone bone
artery

Soft, spongy bone

Periosteum

Hard, compact bone

Microscopic image of bone Haversian canals contain X-ray of hand

blood vessels, lymph, Bone is virtually opaque to X-rays,
A Haversian canal is clearly and nerves
visible in the centre of this which are therefore an ideal means
micrograph of compact bone. of imaging the skeleton.

spinal cord and causing weakness or cyst and fill the cavity with bone chips bone imaging
paralysis of one or more limbs. usually cures the condition; many small Techniques for providing pictures that
Secondary bone cancers from the cysts do not actually require treatment. show the structure or function of bones.
breast and prostate gland may respond X-ray images are commonly used for
to treatment with hormone antagonists. bone density diagnosing fractures and injuries. More
In other cases, local treatment with The compactness of bone tissue in rela- detailed information is provided by
radiotherapy is often effective in reliev- tion to its volume. A decrease in bone tomography, CT scanning, or MRI, which
ing pain caused by the tumour. density is a normal part of aging. can show tumours, infections, and the
However, excessive loss of bone density effects of diseased bone on the sur-
bone conduction (see osteoporosis) can lead to fractures. rounding tissues. Radionuclide scanning
A method of transmitting sound that is An increase in bone density (see osteo- detects areas in the skeleton in which
tested during investigation into the sclerosis) occurs in some disorders, such there is high bone-cell activity.This type
cause of impaired hearing. as osteopetrosis and Paget’s disease. Bone of scanning is used mainly to determine
A vibrating tuning fork is held next density is measured by densitometry, a whether cancer has spread to the bones.
to the ear. The base of the fork is then technique that uses low-dose X-rays.
placed against the bone behind the bone marrow
ear. If the deafness is the result of an bone graft The soft fatty tissue found in bone cavi-
outer- or middle-ear problem (conduc- A surgical operation in which small ties; it may be red or yellow. Red bone
tive deafness), the sound will be heard pieces of bone are taken from one part marrow is present in all bones at birth
better when the tuning fork is held of the body in order to repair or replace and is the factory for most blood cells.
behind the ear. The bone transmits abnormal or missing bone elsewhere. During the teens, red bone marrow is
sound directly to the inner ear, bypass- The bone graft eventually dies, but it gradually replaced in some bones by
ing the outer and middle ear. (See also acts as a scaffold upon which strong less active yellow marrow. In adults, red
deafness; hearing tests.) new bone grows. marrow is confined principally to the
Bone is most commonly taken from spine, sternum, (breastbone), pelvis (hip
bone cyst the iliac crests (upper parts of the hip- bones), ribs, scapulae (shoulderblades),
An abnormal cavity in a bone. Bone bones). They contain a large amount of clavicles (collarbones), and skull bones.
cysts typically develop at one end of a inner, spongy bone, which is very useful Stem cells within the red marrow are
long bone and may be discovered only for getting grafts to “take”. Other com- stimulated to form blood cells by the
by chance after a fracture at the site of mon sources are the ribs (for curved hormone erythropoietin. Yellow mar-
the cyst. Minor surgery to scrape out the bone) and the ulna in the forearm. row is composed mainly of connective

115
 BONE MARROW BIOPSY

the circulation from where cells find

DISORDERS OF BONE their way to the bone marrow cavities
Bone is affected by the same types of
and start to grow.
and other organs, leading to gigantism.
B disorders as other body tissues, but its Excess parathyroid hormone may lead
In autologous BMT, the patient’s bone
marrow is stored by cryopreservation
hard, rigid structure makes for extra to bone cysts. Osteoporosis (loss of
(freezing). Before being frozen, the
complications. If a bone receives a direct bone density) is common in women
marrow is usually treated to eliminate
blow or suffers from repeated stress, it following the menopause, when
any undetected cancerous cells. If the
may fracture. If it becomes infected (due oestrogen levels fall.
patient’s disease recurs, the stored bone
to osteomyelitis or a bone abscess, for
marrow can then be reinfused.
example), the resulting inflammation Tumours
COMPLICATIONS
may interfere with the blood supply, Several different types of cancerous and
The major risks with BMT are infection
leading to death of part of the bone. noncancerous growth can arise from
during the recovery period and rejec-
bone (see bone cancer and bone tumour).
tion (known as graft-versus-host disease,
Genetic disorders In addition, the bones are a common
or GVHD). Immunosuppressant drugs are
Several inherited conditions may affect site for secondary tumours (metastases)
used to prevent and treat rejection. The
bone growth; these include achondro- that have spread from cancerous
risk of GVHD may be reduced by
plasia and osteogenesis imperfecta. Such tumours elsewhere in the body.
removing the T-cells (see T-lymphocyte)
disorders often result in short stature. from the marrow using monoclonal anti-
Other disorders
bodies (see antibody, monoclonal) before
Nutritional disorders Paget’s disease involves thickening of
it is reinfused. GVHD does not occur
Lack of calcium and vitamin D in the some areas of the bones, while other
with autologous BMT or with stem-cell
diet may result in rickets in children areas become spongy.
transplantation.
and osteomalacia in adults; in both
conditions the bones become soft and
INVESTIGATION bone metastases
lose their shape. Cancerous tumours in bone, also known
Bone disorders are investigated using as secondary bone cancers, that have
Hormonal disorders imaging techniques such as X-rays, CT spread from a cancer in another part of
If the pituitary gland produces excess scanning, radionuclide scanning, and the body (see bone cancer).The bones of
growth hormone before puberty, this densitometry; by biopsy; and blood tests. the ribs, pelvis, skull, and spine are par-
results in excessive growth of the bones ticularly affected.
bone pain
tissue and fat. If the body needs to bone marrow transplant An unpleasant sensation (see pain) felt
increase its rate of blood formation, The technique of using normal red bone in a part of the skeleton (see musculo-
some of the yellow marrow will be marrow to replace cancerous, defective, skeletal pain). Bone pain is frequently
replaced by red. Sometimes marrow or diseased bone marrow in a patient. described as constant and gnawing, and
fails to produce sufficient numbers of In allogeneic bone marrow transplan- it may disturb sleep. There are many
normal blood cells, as occurs in aplastic tation (BMT), healthy marrow is taken possible causes of bone pain, including
anaemia (see anaemia, aplastic) or when from a donor with a very similar tissue- trauma of the bone (see fracture), infec-
marrow has been displaced by tumour type to the recipient’s (often a brother or tion (see osteomyelitis), disorders of the
cells. In other cases, marrow may over- sister). In autologous BMT, the patient’s bone itself (such as Paget’s disease), and
produce certain blood cells, as occurs in own healthy bone marrow is harvested bone tumours. (See also osteoid osteoma;
polycythaemia and leukaemia. while his or her disease is in remission osteomalacia; sickle cell anaemia.)
and is reinfused at a later time. Generally,
bone marrow biopsy BMT is used only in the treatment of bone resorption
A procedure to obtain a sample of cells serious, potentially life-threatening blood Loss of bone tissue. Bone resorption and
from the bone marrow (an aspiration and immune system disorders, including the laying down of new bone tissue are
biopsy) or a small core of bone with aplastic anaemia (see anaemia, aplastic), continuous processes. With increasing
marrow inside (a trephine biopsy). The sickle cell anaemia, and leukaemia. age, resorption exceeds new bone for-
sample is usually taken, under local An alternative treatment is stem-cell mation, and the bone tissue gradually
anaesthesia, from the sternum (breast- transplantation, in which cells from the becomes thinner. However, in certain
bone) or iliac crests (upper part of the umbilical cord of a newborn baby or disorders (for example, osteoporosis),
hip-bones). Microscopic examination the bloodstream of an adult are trans- resorption takes place more rapidly and
gives information on the development planted instead of bone marrow. to a greater extent, causing weakening
of the blood components and on the HOW IT IS DONE of bone and increased risk of fractures.
presence of cells foreign to the marrow. Before transplantation, all of the recipi-
It is useful in the diagnosis of many ent’s bone marrow is destroyed with bone tumour
blood disorders, including leukaemia cytotoxic drugs or radiation in order to A bone swelling that may be cancerous
and anaemia. It can also show whether prevent rejection of the donated cells (see bone cancer) or noncancerous. The
bone marrow has been invaded by lym- and to kill any cancer cells present. The most common type of noncancerous
phoma or cells from other tumours. donor bone marrow is transfused into bone tumour is an osteochondroma.

116
 BONE TUMOUR

PERFORMING A BONE MARROW TRANSPLANT

Normal bone marrow is used to replace

malignant or defective marrow. In the
allogeneic procedure, healthy marrow
SITES OF BONE MARROW B
is taken from a donor. In the autologous Red or yellow in colour, bone marrow is a soft, fatty tissue
procedure, the patient’s own healthy found in the cavities of bones. In newborn babies, red bone
marrow is used. marrow is present in all bones; during the teen years, most
is replaced by yellow marrow. The marrow used for
transplants is red.
With one sibling
there is a 25% Soft, spongy Hard,
chance of finding a bone compact bone
compatible donor.

With three siblings

there are three
opportunities for
a 25% chance of
finding a donor.

Finding a donor
The more siblings one has, the greater the
chance of finding a donor. With three or more Bone Bone marrow seen
siblings, the chances are good. marrow under the microscope

1withBefore transplantation, all the recipient’s

bone marrow is destroyed by treatment
drugs or radiation. Destroying the
Surgeon
Assistant

marrow kills any cancer cells.

2and/orUsing general anaesthesia, bone marrow

is aspirated from the donor’s iliac crests
sternum. Up to one litre is removed.
The transplanted marrow grows quickly to
occupy the bone spaces. Anaesthetist

After aspiration,
3is transfused
the bone marrow

intravenously into
the patient. The bone
marrow cells find their
way through the
circulation into the
patient’s marrow
cavities, where they
start to grow.

DONOR ASPIRATION

With the donor lying face down, a The stylet is then removed. Bone
hollow aspiration needle, which has a marrow is sucked out through the
stylet (a thin, sharp lance) within it, is cortex into a syringe connected
introduced into the bone (iliac crests). to the needle.
Iliac crest

Aspiration needle
Stylet

Syringe
Aspiration needle

117
 BOOSTER

Other types of bone tumour are osteoma tions than breast-fed babies and may be ment. It may also be used to stretch a
and chondroma (see chondromatosis). more likely to develop allergic disor- narrowed area. There are various types
Treatment is needed only if the tumour ders. (See also feeding, infant.) of bougie; they can be either hollow or
B becomes large or causes symptoms by
pressing on other structures. In such Botox
solid, and most are slightly flexible.

cases, it can be removed by surgery. A brand name for the drug botulinum bovine spongiform
Osteoclastoma (also called a giant cell toxin, which is used to treat muscle encephalopathy (BSE)
tumour), which usually occurs in the spasm in conditions such as cerebral A neurological disorder in cattle that
arm or leg of a young adult, is tender palsy. Botox is also used for cosmetic can be transmitted to humans through
and painful and has to be removed. reasons to reduce the appearance of the consumption of infected meat, caus-
wrinkles in the skin. ing Creutzfeldt–Jakob disease. (See also
booster encephalopathy.)
A follow-up dose of vaccine, given to botulinum toxin
reinforce or prolong immunity after an A potentially lethal toxin produced by bowel
initial course of immunization. the bacterium CLOSTRIDIUM BOTULINUM A common name for the large and/or
(see botulism). In tiny doses, botulinum small intestines.
borborygmi toxin is used as a muscle-relaxant drug to
The medical name for bowel sounds that control muscle spasms in some disor- bowel disorders
are audible without a stethoscope. ders (see blepharospasm; facial spasm). It Any disorder that affects the intestine.
is also increasingly used for cosmetic Common bowel disorders are inflam-
borderline personality disorder purposes; when injected into facial matory bowel disease and irritable bowel
A personality disorder that falls between muscles, botulinum toxin temporarily syndrome (IBS). (See also intestine disor-
neurotic and psychotic levels. Mood reduces wrinkles. ders box; intestine, cancer of; intestine,
changes are often rapid and inappro- obstruction of; intestine, tumours of.)
priate. Angry outbursts are common, as botulism
are impulsive, self-damaging acts such A rare but serious form of poisoning bowel movements, abnormal
as gambling or suicide attempts. caused by eating improperly canned or See faeces, abnormal.
preserved food contaminated with a
Bordetella pertussis toxin produced by the bacterium CLOS- bowel sounds
A species of bacteria that may infect the TRIDIUM BOTULINUM . The toxin causes Sounds made by the passage of air and
human respiratory tract and is responsi- progressive muscular paralysis as well as fluid through the intestine. Absent or
ble for causing whooping cough. other disturbances of the central and abnormal bowel sounds may indicate a
peripheral nervous system. CLOSTRIDIUM disorder. Those that are audible without
Bornholm disease BOTULINUM produces spores that resist a stethoscope are known as borborygmi
One of the various names for epidemic boiling, salting, smoking, and some and are a normal part of the digestive
pleurodynia, an infectious viral disease forms of pickling. These spores, which process, but they may be exaggerated by
that is characterized by severe chest multiply only in the absence of air, anxiety and some intestinal disorders.
pains and fever. thrive in canned or poorly preserved
food. Ingestion of even minute amounts Bowen’s disease
Borrelia of toxin can lead to severe poisoning. A rare skin disorder that is characterized
A genus of spiral-shaped bacteria trans- SYMPTOMS by the formation of a flat patch of red,
mitted through tick bites (see ticks and The symptoms of botulism first occur scaly skin, most commonly on the face
disease). B ORRELIA species cause relapsing within 8 to 36 hours of ingesting con- or the hands. Bowen’s disease may
fever (an infectious disease characterized taminated food. They include difficulty become cancerous.
by recurrent bouts of fever) and also in swallowing and speaking; nausea and Treatment involves surgical removal
Lyme disease. vomiting; and double vision. Prompt of the diseased skin, or its destruction
treatment is vital. by freezing or cauterization.
bottle-feeding In infants, the toxin can form within
Infant feeding using a milk preparation the body after the ingestion of foods bowleg
usually based on modified cow’s milk. contaminated with the bacterium, such An outward curving of bones in the
This formula milk contains similar pro- as honey. (See also food poisoning.) legs that results in wide separation of
portions of protein, fat, lactose (milk the knees when the feet are together.
sugar), and minerals to those in human Bouchard’s node Bowlegs are common in very young
milk, but it lacks the protective antibod- A bony swelling that forms on the joint children, and they are a normal part of
ies that are present in breast milk. in the middle of the finger in a person development. In most cases, the curve
Vitamins are added. suffering from osteoarthritis. (See also straightens as the child grows. If the
In some cases, medical problems in Heberden’s node.) bowing is severe, is on one side only, or
the mother or child may make breast- persists beyond the age of three, a doc-
feeding impossible or undesirable, in bougie tor should be consulted. Surgery may be
which case bottle-feeding is recom- A rod-shaped instrument used for inser- needed. Rarely, leg deformity is a result
mended. However, bottle-fed babies are tion into tubular organs, such as the of bone disease, particularly rickets (a
at higher risk of gastrointestinal infec- urethra, during investigations or treat- vitamin D deficiency) in children.

118
 BRAIN ABSCESS

Bowman’s capsule brachytherapy ing of grey matter, which is rich in

A cup-shaped membrane within the A type of radiotherapy. nerve-cell bodies and is the main region
kidney’s nephron containing a glomeru- in the brain for conscious thought, sen-
lus (a cluster of tiny blood vessels called bradycardia sation, and movement. Beneath the
capillaries). Here, blood is filtered into An abnormally slow heart rate. Most cortex are tracts of nerve fibres called B
the kidney tubule. people have a heart rate of between 60 white matter, and, deeper within the
and 100 beats per minute. Many ath- hemispheres, are the basal ganglia (paired
BP letes and healthy people who exercise nerve cell clusters). The surface of each
The abbreviation for blood pressure. regularly and vigorously have slower of the hemispheres is divided by fissures
rates. In others, bradycardia may indi- (sulci) and folds (gyri) into distinct
brace, dental cate an underlying disorder such as lobes (occipital, frontal, parietal, and
See orthodontic appliances. hypothyroidism or heart block. Bradycar- temporal lobes), named after the skull
dia may also occur as a result of taking bones that overlie them. A thick band of
brace, orthopaedic beta-blocker drugs. Profound or sudden nerve fibres called the corpus callosum
An appliance worn to support part of bradycardia may cause a drop in blood connects the hemispheres.
the body or hold it in a fixed position. A pressure that results in fainting (see The cerebrum encloses a central
brace may be used to correct or halt the vasovagal attack). group of structures including the thalami
development of a deformity, to aid and the hypothalamus, which has close
mobility, or to relieve pain. (See also bradykinin connections with the pituitary gland.
caliper splint; corset; splint.) A polypeptide (protein molecule) that Encircling the thalami is a complex of
forms naturally in the blood as part of nerve centres called the limbic system.
brachial artery the inflammatory process. Bradykinin is These structures act as links between
The artery that runs down the inner side a powerful vasodilator (it causes the parts of the cerebrum and the brain-
of the upper arm, between the armpit widening of blood vessels). Bradykinin stem lying beneath the thalami.
and the elbow. also allows fluid to leak from the blood BRAINSTEM AND CEREBELLUM
vessels; stimulates pain receptors; and The brainstem is concerned mainly
brachialgia causes contraction of the smooth mus- with the control of vital functions such
Pain or stiffness in the arm that is often cle in internal organs such as the lungs as breathing and blood pressure. The
accompanied by pain, tingling and/or or intestines. cerebellum at the back of the brain con-
numbness of the hands or fingers, and trols balance, posture, and muscular
weak hand grip. It may be a symptom Braille coordination. Both of these regions op-
of underlying disorders such as frozen A system of embossed dots, now erate at a subconscious level.
shoulder or nerve compression from cer- accepted for all written languages, that MENINGES AND CEREBROSPINAL FLUID
vical osteoarthritis. enables blind people to read and write. The brain and spinal cord are encased
The system is based on six raised dots, in three layers of membranes known as
brachial plexus which can be combined in different meninges. Cerebrospinal fluid circulates
A group of large nerve trunks formed ways to form symbols. between these membrane layers and
from nerve roots of the lower part of There are two types of Braille. In within the four main brain cavities,
the cervical spine (in the neck) and grade I, each symbol represents an indi- which are known as ventricles. This fluid
upper part of the thoracic spine (in the vidual letter or punctuation mark. In helps to nourish and cushion the brain.
chest). These nerve trunks divide into grade II, which is the more widely BLOOD SUPPLY
the musculocutaneous, axillary, median, used, symbols represent common letter The brain as a whole has an extensive
ulnar, and radial nerves, which control combinations or words. blood supply. Blood comes from a circle
muscles in and receive sensation from of arteries fed by the internal carotid
the arm and the hand. Injuries to the brain arteries (which run up each side of the
brachial plexus can cause loss of move- The major organ of the nervous system, front of the neck to enter the base of
ment and sensation in the arm. located in the cranium (skull). The brain the skull) and from two vertebral arter-
In severe injuries, there may be dam- receives, sorts, and interprets sensations ies that run parallel to the spinal cord.
age to both the upper and the lower from the nerves that extend from the The brain receives about 20 per cent of
nerve roots of the brachial plexus, pro- central nervous system (brain and spinal the blood from the heart’s output.
ducing complete paralysis of the arm. cord) to the rest of the body; it initiates
The paralysis may be temporary if the and coordinates nerve signals involved brain abscess
stretching was not severe enough to in activities such as speech, movement, A collection of pus, surrounded by
tear nerve fibres. It may be possible to thought, and emotion. inflamed tissues, within the brain or on
repair nerve roots that have been torn An adult brain weighs about 1.4 kg its surface. The most common sites are
by nerve grafting, which is a micro- and has three main structures: the brain- the frontal and temporal lobes of the
surgery procedure, but if a nerve root stem; the cerebellum; and the largest part, cerebrum in the forebrain.
has become separated from the spinal the cerebrum, which consists of left and Brain abscesses may occur after a
cord, surgical repair will not be success- right hemispheres. head injury, but most cases result from
ful. Apart from injuries, the brachial CEREBRUM the spread of infection from elsewhere
plexus may be compressed by the pres- Each hemisphere in the cerebrum has in the body, such as the middle ear or
ence of a cervical rib (extra rib). an outer layer called the cortex, consist- the sinuses. Another cause of a brain

119
 BRAIN ABSCESS

STRUCTURE OF THE BRAIN

The brain has three main parts: Meninges Skull Right cerebral
B the brainstem (an extension of the
spinal cord), the cerebellum, and
hemisphere

Left cerebral
the cerebrum, much of which hemisphere Corpus
consists of the two large cerebral callosum
hemispheres. Each hemisphere
consists of an outer layer, or cortex,
which is rich in nerve cells and called White matter
grey matter, and inner areas rich in Grey matter Sulcus
nerve fibres, called white matter.
The surface of each hemisphere
is thrown into folds called gyri, Gyrus
separated by fissures called sulci. Thalamus
The two hemispheres are linked by a
thick band of nerve fibres, the corpus
Basal
callosum. Deep within the forebrain ganglia
are various central structures, which
include the thalamus, hypothalamus,
basal ganglia, and pituitary gland. Cerebellum
The brain has the consistency of Hypothalamus
jelly and, in adults, weighs about
1.4 kg. It is protected by membranous Pituitary gland
coverings (known as meninges) Spinal cord
within the skull. Brainstem

Muscle Abstract thought

Postcentral Precentral Frontal lobe contraction Creativity
Conscience
Special areas
gyrus gyrus Some areas of the brain
Touch Personality
Pressure are associated with
specific functions – for
Parietal
lobe example, the occipital
lobe with vision and the
Vision cerebellum with balance
and coordination. Touch
Lobes Hearing and pressure sensation
These are broad Smell is perceived within the
surface regions of Taste postcentral gyrus.
Occipital each hemisphere that Muscle movements
lobe are named after the Coordination are controlled from the
overlying bones of Balance precentral gyrus;
the skull. The four main Posture speech is controlled
Cerebellum
regions are the frontal, from an area in the
parietal, temporal, and Breathing frontal lobe of the
occipital lobes. Blood dominant hemisphere.
Temporal lobe pressure

IMAGING THE BRAIN

CT scanning Angiography Magnetic resonance imaging

CT scans produce images as “slices” through This technique makes blood vessels clearly MRI produces three-dimensional or cross-
the head. The scan above shows bleeding into visible. The angiogram above shows the carotid sectional images. This MRI shows a tumour (the
the brain tissue (a cerebral haemorrhage). artery and its branches. white area to the right of centre) in the cerebellum.

120
 BRAIN HAEMORRHAGE

abscess is an infection following a pene- DIFFUSE DAMAGE deep within the brain. This leads to a
trating brain injury. Multiple brain One of the most common causes of condition called kernicterus. Brain dam-
abscesses may occur as a result of diffuse brain damage is prolonged age that occurs before, during, or after
blood-borne infection, most commonly cerebral hypoxia (an insufficient supply birth may result in cerebral palsy.
in patients with a heart-valve infection of oxygen to the brain), which may OUTCOME
B
(see endocarditis). occur in a baby during a difficult birth. Diffuse damage to the brain may result
Symptoms of a brain abscess include Other causes of diffuse damage to the in learning difficulties and severe physical
headache, drowsiness, vomiting, visual brain tissue include cardiac arrest (cessa- disability. Localized brain damage may
disturbances, fever, and seizures. There tion of the heartbeat), respiratory arrest cause specific deficits in brain function,
may also be other symptoms, such as (cessation of breathing), drowning, cer- such as disturbances of movement or
speech disturbances, that are due to tain types of poisoning, and status speech (see speech disorders). Nerve cells
local pressure. Treatment is with anti- epilepticus (prolonged seizures). Diffuse and tracts in the brain and spinal cord
biotic drugs and surgery. A craniotomy damage may also occur gradually as a cannot repair themselves once they have
may be needed to open and drain the result of exposure to environmental been damaged, but some return of func-
abscess. Untreated, brain abscesses can pollutants, such as lead or mercury tion may be possible with training, as
cause permanent damage and can be compounds (see Minamata disease), or patients learn to use other parts of the
fatal. Despite treatment, scarring can if nerve-cell poisons build up in the brain. (See also Structure of the brain box.)
cause epilepsy in some cases. brain, as occurs in untreated phenylketo-
nuria. Other possible causes of diffuse brain death
brain contusion brain damage include brain infections The irreversible cessation of all func-
Bruising of the brain accompanied by such as encephalitis. tions of the brain, including those of
loss of consciousness, which occurs as LOCALIZED DAMAGE the brainstem. (See also death.)
the result of an injury. (See also brain Localized brain damage may occur as
damage; concussion.) the result of a head injury, stroke (dam- brain failure
age to part of the brain caused by an See brain syndrome, organic.
brain damage interruption to its blood supply), brain
Degeneration or death of nerve cells tumour, or brain abscess. At birth, a brain haemorrhage
and tracts within the brain that may be raised blood level of bilirubin (see Bleeding within or around the brain
localized to a particular area of the haemolytic disease of the newborn) can caused either by injury or by the spon-
brain or may be diffuse. cause local damage to the basal ganglia taneous rupture of a blood vessel. There

DISORDERS OF THE BRAIN

Defects and disorders of the brain have (water on the brain) and anencephaly Degenerative disorders
numerous causes, including infection, (congenital absence of the brain). Multiple sclerosis is a progressive disease
injury, brain tumour, or a lack of blood of the brain and spinal cord. Degenera-
or oxygen (see hypoxia). Brain cells Impaired blood and oxygen supply tive brain diseases include Alzheimer’s
destroyed by injury or disease cannot Brain cells can survive only a few minutes disease and Parkinson’s disease.
be replaced, so any resulting loss in without oxygen. A reduced supply may
function can be difficult to reverse. occur at birth, causing cerebral palsy. Later Other disorders
Because the brain is encased within in life, choking or arrest of breathing and Emotional or behavioural disorders are
the skull, any space-occupying tumour, heartbeat can cause hypoxia (oxygen lack). often called psychiatric illnesses, but the
brain abscess, or haematoma (large blood From middle age onwards, cerebro- distinction between these and
clot) creates raised pressure, which can vascular disease, which impairs the blood neurological disorders is unclear. In
impair the function of the whole brain. supply to one or more regions of the many illnesses, such as depression and
Brain disorders that are localized brain, is the most important cause of brain schizophrenia, there may be an under-
in a small region may affect a specific disorders. If an artery within the brain lying disturbance of brain chemistry.
function, such as speech (see aphasia). becomes blocked or ruptures, leading to
However, more often, damage is more haemorrhage, the result is a stroke.
diffuse and the symptoms can be varied
and numerous. Infection INVESTIGATION
The brain may also be damaged by a Encephalitis (infection within the brain)
Procedures used to investigate brain
blow to the head (see head injury). may be due to a virus. Meningitis (infection disorders and function include tests
of the membranes surrounding the brain) of reflexes and of mental and physical
Congenital defects is generally due to bacterial infection. abilities. Electrical activity may be
Some brain disorders are congenital Creutzfeldt–Jakob disease is a rare, fatal measured with an EEG. Physical
(present from birth) due to genetic or brain disease associated with an infective abnormalities can be found using
chromosomal disorders, as in Down’s agent called a prion, which, in some cases, brain imaging techniques such as
syndrome. Structural defects during fetal has been linked with bovine spongiform angiography, CT scanning, or MRI.
development include hydrocephalus encephalopathy (BSE), a disease in cattle.

121
 BRAIN IMAGING

are four possible types of brain haemor-

rhage: subdural, extradural, subarachnoid, SITES OF BRAIN HAEMORRHAGE
and intracerebral (see the illustrated box).
Haemorrhages within the skull fall into four main categories – extradural, subdural,
B Extradural and subdural haemorrhages
are usually caused by a blow to the head
subarachnoid, and intracerebral – according to the site of the bleeding in relation
to the brain and its protective coverings (the meninges). The causes and effects of
(see head injury). Subarachnoid and intra- the bleeding and the outlook for the patient vary depending on which category the
cerebral haemorrhages tend to occur haemorrhage falls into.
spontaneously due to rupture of aneur- Haemorrhage
ysms or small blood vessels in the brain. Scalp

brain imaging Subcutaneous

layer
Techniques that can provide pictures of
the brain. Brain imaging techniques are Skull
used to detect injury or disease of the Dura mater
brain and include X-rays, angiography, CT
scanning, MRI (magnetic resonance imag- Arachnoid
ing), PET (positron emission tomography) Pia mater
scanning, and SPECT (single photon
emission CT). Brain
INVESTIGATION OF BRAIN STRUCTURE
CT scanning gives images of the brain Subarachnoid Intracerebral haemorrhage
substance; it provides clear pictures of This CT scan shows bleeding in the
Extradural Subdural Intracerebral brain tissue (cerebral haemorrhage).
the ventricles (fluid-filled cavities) and
can reveal tumours, blood clots, strokes,
aneurysms, and abscesses.
MRI (magnetic resonance imaging) between other parts of the brain and move the jaw, adjust facial expressions,
produces very detailed images of the spinal cord. It also connects with 10 of and produce some eye movements.
brain’s structure. This technique is also the 12 pairs of cranial nerves (which Medulla The medulla resembles a thick
used to detect patches of abnormal emerge directly from the underside of extension of the spinal cord. It contains
brain tissue, as seen in multiple sclerosis. the brain) and controls basic functions the nuclei of the ninth to 12th cranial
Angiography involves the injection of such as breathing, vomiting, and eye nerves. by which it receives and relays
a contrast medium that shows up the reflexes. Brainstem activities are below taste sensations from the tongue and
blood vessels in the brain on X-ray. It is the level of consciousness, and they
used to investigate aneurysms and other operate mainly on an automatic basis.
circulatory disorders. STRUCTURE LOCATION OF THE BRAINSTEM
INVESTIGATION OF BRAIN FUNCTION The brainstem is composed of three
PET and SPECT scanning are specialized main parts: the midbrain, pons, and The brainstem is a 7.5
forms of radionuclide scanning that use medulla. Attached to the back of the cm-long stalk of nerve
small amounts of radioactive material to brainstem is a separate part of the brain, cells and fibres that joins
the upper spinal cord to
provide information about brain func- the cerebellum, which is concerned with the rest of the brain.
tion as well as structure. They enable balance and coordinated movement.
blood flow and metabolic activity in the Running longitudinally through the Midbrain Cerebrum
brain to be measured. middle of the brainstem is a canal; this
Functional magnetic resonance imag- widens in the pons and medulla to
ing (fMRI) can be used to determine form the fourth ventricle (cavity) of the
which parts of the brain are activated by brain, which contains the circulating
different sensations or activities, such as cerebrospinal fluid.
sight or movement of the fingers. This Midbrain The midbrain is the smallest
technique is used to assess how the section of the brainstem. This part con-
brain is working. tains the nuclei (nerve-cell centres) of
Ultrasound scanning, through the fon- the third and fourth cranial nerves,
tanelles (holes where the skull bones which control eye movements and the
have yet to fuse), can detect bleeding in size and reactions of the pupil. It also
the brain only in premature or very contains cell groups, such as the sub-
Pons
young babies; ultrasound waves cannot stantia nigra, involved in smooth
penetrate the bones of a mature skull. coordination of limb movements. Medulla
Pons The pons contains thick bundles of
brainstem nerve fibres that connect with the cere-
A stalk of nerve tissue that forms the bellum. It also houses the nuclei for the
lowest part of the brain and links with fifth to eighth cranial nerves, and relays Spinal cord Cerebellum
the spinal cord.The brainstem acts partly sensory information from the ear, face,
as a highway for messages travelling and teeth, as well as the signals that

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 BREAKTHROUGH BLEEDING

relays signals to muscles involved in within the rigid skull may also result in For primary and secondary tumours,
speech and in tongue and neck move- damage to the normal tissue that sur- radiotherapy or anticancer drugs may also
ments. The medulla also contains the rounds the tumour. be given. Corticosteroid drugs are often
“vital centres” (groups of nerve cells prescribed temporarily to reduce the
that regulate the heartbeat, breathing,
TYPES
Brain tumours may be primary growths size of a tumour and any associated B
blood pressure, and digestion (informa- arising directly from tissues within the swelling of brain tissues.
tion on which is relayed via the 10th skull or metastases (secondary growths)
cranial nerve (see vagus nerve). that have spread via the bloodstream bran
Reticular formation Throughout the from cancerous tumours elsewhere in The fibrous outer covering of grain that
brainstem are numerous nerve-cell the body, particularly from those in the cannot be digested. The fibre is used as
groups known collectively as the reticu- lung or breast. a bulk-forming laxative to prevent con-
lar formation. This network alerts the The cause of primary brain tumours stipation (see fibre, dietary).
higher brain centres to sensory stimuli is not known. About 60 per cent are
that may require a conscious response. gliomas (which are frequently cancer- branchial disorders
Our sleep/wake cycle is controlled by ous), and arise from the brain tissue. Disorders due to abnormal develop-
the reticular formation. Other primary tumours include mening- ment, in an embryo, of the branchial
DISORDERS iomas, which arise from the meningeal arches (paired segmented ridges of tis-
The brainstem is susceptible to the membranes covering the brain; acoustic sue in each side of the throat). Such
same disorders that afflict the rest of the neuromas, which arise from the acoustic disorders include branchial cyst and
central nervous system (see brain, dis- nerve; and pituitary tumours, which arise branchial fistula.
orders of). Damage to the medulla’s vital from the tissue of the pituitary gland. A branchial cyst is a soft swelling,
centres is rapidly fatal; damage to the Most of these tumours are noncancer- containing fluid that may be either clear
reticular formation may cause coma. ous, but their relatively large size can or puslike, that appears on the side of
Damage to specific cranial nerve nuclei cause local tissue damage. the neck in early adulthood. Treatment
can sometimes lead to specific effects. Some types of primary brain tumour of a branchial cyst is usually with surgi-
For example, damage to the seventh cra- affect mainly children.These include two cal removal.
nial nerve (the facial nerve) leads to types of glioma called medulloblastoma A branchial fistula occurs between
facial palsy. Degeneration of the sub- and cerebellar astrocytoma. Primary brain the back of the throat and the external
stantia nigra in the midbrain is thought tumours virtually never spread (metasta- surface of the neck, where it appears as
to be a cause of Parkinson’s disease. size) outside the central nervous system. a small hole, usually noted at birth. A
Secondary growths (metastases) are hole in the neck that does not extend to
brain syndrome, organic always cancerous and may be found in the back of the throat is a branchial cleft
Disorder of consciousness, intellect, or more than one organ. sinus. A branchial fistula or cleft sinus
mental functioning that is of organic SYMPTOMS may discharge mucus or pus and may
(physical), as opposed to psychiatric, Compression of brain tissue or nerve be removed surgically.
origin. Possible causes include degener- tracts near the tumour may cause mus-
ative diseases, most notably Alzheimer’s cle weakness, loss of vision, or other brash, water
disease; infections; certain drugs; or the sensory disturbances, speech difficul- See waterbrash.
effects of injury, stroke, or tumour. ties, and epileptic seizures.
SYMPTOMS The presence of a growing tumour Braxton Hicks’ contractions
Symptoms of acute organic brain syn- can increase pressure within the skull, Short relatively painless contractions of
drome range from mild confusion to causing headache, visual disturbances, the uterus during pregnancy. They may
stupor or coma. They may also include vomiting, and impaired mental func- be felt in late pregnancy and are some-
disorientation, memory loss, hallucin- tioning. Hydrocephalus (excess fluid in times mistaken for labour pains.
ations, and delusions (see delirium). In the brain) may occur if the circulation
the chronic form, there is a progressive of cerebrospinal fluid is obstructed by BRCA 1 and BRCA 2
decline in intellect, memory, and be- the tumour. Two of the abnormal genes that are
haviour (see dementia). Treatment is DIAGNOSIS AND TREATMENT thought to be responsible for inherited
more likely to be successful with the Many different brain imaging techniques breast cancer. Women with these genes
acute form. In chronic cases, irrever- may be used to locate the site of a brain may also have an increased risk of ovari-
sible brain damage may already have tumour and to establish its size and the an cancer (see ovary, cancer of).
occurred. (See also psychosis.) extent of its spread.
In some cases, complete removal of a breakbone fever
brain tumour brain tumour may be possible using A tropical viral illness, which is also
An abnormal growth in or on the brain. guidance from MRI scanning during called dengue, that is spread by mosqui-
Although they are not always cancer- surgery. In such cases, the patient may toes. The symptoms include high fever
ous, all brain tumours are serious due be cured. However, many cancerous and severe joint and muscle pain.
to the buildup of pressure they cause growths are inaccessible or too exten-
within the brain and the compression sive for removal. In cases where a breakthrough bleeding
of adjoining brain areas, both of which tumour cannot be completely removed, Bleeding or staining (“spotting”) from
may occur as the tumour grows and as much as possible of it will be cut the vagina between menstrual periods
expands. Expansion of a brain tumour away to relieve pressure. in women taking an oral contraceptive.

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 BREAST

The bleeding is most common during antibiotic drugs and repeated aspiration rarely develop in men.The advancement
the first few months of taking the pill (withdrawal by suction) of the pus of techniques for early diagnosis and
and is caused by incomplete suppres- using a needle and syringe. In rare treatment of breast cancer has improved
B sion of the monthly buildup of the
endometrium (lining of the uterus). (See
cases, surgical drainage may be needed. overall survival rates.
CAUSES
also vaginal bleeding.) breast awareness Current theories regarding the causes of
A woman’s familiarity with the appear- breast cancer are focused on hormonal
breast ance and feel of her breasts, which and genetic influences. However, the
Either of the two mammary glands, allows her to recognize both normal principal risk factor is age, with a
which, in women, provide milk to and abnormal changes. Doctors recom- woman’s chances of developing the dis-
nourish a baby and are secondary sexual mend that women develop “awareness” ease doubling every ten years of her life.
characteristics. The male breast is an in order to improve the chances of The incidence of breast cancer is
immature version of the female breast. detecting breast cancer at an early stage. known to be raised in women whose
DEVELOPMENT AND STRUCTURE (See also breast self-examination.) menstrual periods began at an early age
At puberty, a girl’s breasts begin to and in those whose menopause was late
develop: the areola (the circular area of breastbone to commence. The risk is also higher in
pigmented skin around the nipple) The common name for the sternum, the women who did not have children or
swells and the nipple enlarges. This is front part of the thorax (chest). those who had their first child late in
followed by an increase in glandular tis- life. Women whose mothers or sisters
sue and fat. breast cancer have had breast cancer are also at an
The adult female breast consists of A cancerous tumour of the breast. increased risk. Diet may also play a part;
between 15 and 20 lobes of milk-secret- Breast cancer is the most common type breast cancer is more common in coun-
ing glands embedded in fatty tissue. The of cancer in nonsmoking women and tries in which the typical diet contains a
ducts of these glands have their outlet the second most common type, after lot of fat. Studies have shown that hor-
in the nipple. The areolar skin contains lung cancer, in women who smoke. mone replacement therapy (HRT) slightly
sweat glands, sebaceous glands, and hair One woman in every 12 who live to old increases the chances of developing
follicles. Bands of fine ligaments deter- age will develop breast cancer at some breast cancer; the risk increases with the
mine the breast’s height and shape. point in her life. Breast cancer can also length of time that HRT has been taken.
The size, shape, and general appear-
ance of a woman’s breasts may vary
throughout the menstrual cycle, during THE FEMALE BREAST
pregnancy and lactation, and following
the menopause. The breast is made up of lobes of glands set
BREAST FUNCTION in fatty tissue, the ducts of which have their
During pregnancy, the hormones oestro- outlet at the nipple. The areola contains
sweat glands, sebaceous glands,
gen and progesterone, which are secreted
and hair follicles.
by the ovaries and placenta, cause the
milk-producing glands in the breasts to Fat
develop and to become active. These
two hormones also cause the nipples
Skin
to enlarge.
Just before and immediately after
childbirth, the glands in the breast pro- Areola
duce a watery fluid known as colostrum.
The production of this fluid is replaced Nipple
by milk production a few days later.
Milk production and release are stimu- Milk duct
lated by the hormone prolactin.
breast abscess
A collection of pus in the mammary
gland, usually in a woman who is lactat-
ing (producing milk). Breast abscesses
develop if acute mastitis (inflammation
of the breast) is not treated promptly
and occur most commonly during the Lobules
month after a woman’s first delivery.
The initial symptoms of a breast A mammogram Fatty tissue
abscess are the same as those of acute An X-ray of a healthy breast.
mastitis. The abscess develops in one The dense white areas are fibrous Pectoral
tissues that support the fat nodules. muscle
area, which becomes very firm, red, and
extremely painful. Treatment involves

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 BREAST IMPLANT

develop years after apparently successful

DISORDERS OF THE BREAST treatment, are treated with anticancer
breast development) may occur as a
drugs and hormones.
Disorders of the breast are mostly minor
and respond to treatment. Problems are result of hormonal disturbance or OUTLOOK
A complete cure or years of good health B
most commonly caused by infection, treatment with certain drugs.
can usually be expected after treatment
hormonal changes, and tumours.
for early breast cancer. Regular check-
Tumours
ups are required to detect recurrence or
Infection The majority of breast lumps are non-
the development of a new cancer in the
Mastitis(bacterial infection of breast cancerous tumours, such as cysts (fluid-
other breast. Mammograms should be
tissue) often occurs with breast-feeding, filled sacs) and fibroadenomas (thickened
performed periodically for this reason.
usually due to a blocked milk duct. areas of milk-producing tissue). More
If the cancer recurs, it can be con-
Untreated, it may lead to a breast abscess. rarely, breast cancer may occur.
trolled, sometimes for years, by drugs
and/or radiotherapy. (See also breast
Hormonal changes
INVESTIGATION self-examination.)
Breast pain and tenderness is common
just before menstruation or when a
Disorders of the breast may be breast cyst
woman is taking hormones. Before discovered during breast self- A fluid-filled lump that forms within
menstruation, breasts may increase in examination or physical examination the milk-producing tissue of the breast.
size and become lumpy. Such lumps by a doctor. Special investigations for Breast cysts most commonly affect
shrink when menstruation is over. the breast include biopsy (removal of women in their 30s and 40s, especially
Hormonal disorders may, rarely, cause a small sample of tissue for analysis)
in the years leading up to the meno-
galactorrhoea (abnormal production of and mammography.
pause. A lump can be diagnosed as a cyst
milk). In men, gynaecomastia (abnormal
by ultrasound scanning, a mammography,
or by withdrawing fluid from it with a
syringe and needle (see aspiration),
Breast cancer in women under the age breast is removed surgically, along with which usually results in the lump disap-
of 50 may be linked to genetic factors a surrounding margin of normal tissue. pearing. About half of all women with a
and various genes, including BRCA 1 and Lymph nodes in the armpit are usually breast cyst will develop future cysts. Any
BRCA 2, have been identified. These removed at the same time. Larger can- new breast lump should be seen by a
genes seem to account for some of the cers may require mastectomy (surgical doctor to confirm the diagnosis.
breast cancers that occur within fami- removal of the whole breast). Surgery
lies. Women with one or more relatives can be combined with or followed by breast enlargement surgery
who have developed the disease in their mammoplasty (breast reconstruction) to A type of mammoplasty.
30s or 40s may wish to seek specialist help reduce the psychosexual impact of
genetic advice. the disease. breast-feeding
SYMPTOMS AND SIGNS Any further treatment depends on the The natural method of infant feeding
The first sign of breast cancer is often a size of the tumour; whether or not during the period between birth and
painless lump. However, it is important there is evidence of spread to the lymph weaning. Human milk contains the
to note that nine out of ten breast nodes; and the sensitivity of the tumour ideal balance of nutrients for a baby and
lumps are not cancerous. Other symp- cells to hormones, which is assessed provides valuable antibodies (proteins
toms of breast cancer may include a in the laboratory using a technique made by the immune system) against
dark discharge from the nipple, retrac- known as oestrogen receptor testing. infections. For the first few days after
tion (indentation) of the nipple, and an The woman’s age and whether or not birth, the breasts produce a watery fluid
area of dimpled, creased skin over the she has gone through the menopause known as colostrum. Milk flow is stimu-
lump. In the majority of cases, only one are also significant factors in determin- lated by the baby’s sucking and is
breast is affected. ing appropriate treatment. usually established in three to four days.
An abnormality may sometimes be After surgery, most women have a Breast-feeding problems may occur
detected during a routine mammography, course of radiotherapy to any remaining as a result of engorged breasts and
which is offered every three years to all breast tissue and to the armpit, and/or cracked nipples or if the baby has prob-
women between the ages of 50 and 65. chemotherapy (treatment with anticancer lems sucking; a breast-feeding advisor
INVESTIGATION AND TREATMENT drugs). Tamoxifen, an oral anti-oestrogen may be able to help with these difficul-
If a lump is detected in the breast, an drug, is commonly prescribed for five ties. Breast-feeding can sometimes cause
imaging procedure, such as mammog- years following surgery for breast can- an infection (see mastitis) that leads to a
raphy or ultrasound scanning, will be cer to reduce the risk of recurrence. breast abscess. In such cases, treatment
carried out. Cells will then be collected Women who are approaching the meno- with antibiotic drugs may mean that it is
from the lump by needle aspiration pause may be offered treatment to bring possible to continue breast-feeding.
(withdrawal by suction) or biopsy (sur- on an early menopause if the tumour is
gical removal of a small sample of tissue oestrogen-sensitive. breast implant
for analysis). Secondary tumours in other parts of An artificial structure surgically intro-
A small cancerous tumour that is not the body, which may be present at the duced into the breast to increase its size
thought to have spread outside the time of the initial diagnosis or may (see mammoplasty).

125
 BREAST LUMP

breast lump breast tenderness Cyclical tenderness may be relieved by

Any mass, swelling, or cyst that can be Soreness or tenderness of the breasts, reduced caffeine intake, relaxation exer-
felt in the breast tissue. At least 90 per frequently accompanied by a feeling of cises for stress, a well-fitting bra, or
B cent of lumps are noncancerous; the
rest are cancerous (see breast cancer).
fullness. Breast tenderness is extremely
common. In most women it is cyclical,
weight loss to reduce breast size. If
these measures do not work, hormonal
Many women have generally lumpy varying in severity in response to the treatment may be recommended.
breasts, with the lumps more obvious hormonal changes of the menstrual
before a period. Once known as fibro- cycle. The breasts are usually most ten- breath-holding attacks
cystic disease or fibroadenosis, this is now der before a period (see premenstrual Periods during which a toddler holds
considered to be a variation of normal. syndrome). The condition tends to affect his or her breath, usually as an expres-
Lumpy breasts do not increase the risk both breasts and may be aggravated by sion of pain, frustration, or anger. The
of breast cancer, but any new or distinct stress or caffeine. Breast tenderness may child usually becomes red or even blue
lump should be medically assessed. In a also be noncyclical, caused by muscle in the face after a few seconds, and may
young woman, a single lump is likely to strain or mastitis. During lactation, it may faint. Breathing quickly resumes as a
be a noncancerous fibroadenoma. This be due to engorgement of the breasts natural reflex, ending the attack. Breath-
growth is usually round, firm, and rub- with milk. Rarely, tenderness may be holding does not cause damage and is
bery, causes no pain, and can be moved due to a breast cyst or to breast cancer. usually outgrown.
about beneath the skin. In an older Examination by a doctor will exclude
woman, a lump is more likely to be a any underlying problems. breathing
noncancerous, fluid-filled breast cyst. Women with large breasts are more The process by which air passes into
Breast awareness and regular breast likely to suffer from both cyclical and and out of the lungs to allow the blood
self-examination may help to detect any noncyclical breast tenderness. to take up oxygen and dispose of carbon
changes. Treatment depends on the
cause and type of lump. Cysts can be
BREAST SELF-EXAMINATION
drained in a simple outpatient proce-
dure. Other lumps may need to be
removed surgically.
breast pump
A device that is used to draw milk from
overfull breasts during lactation (see
breast-feeding). A breast pump may also
be used to express milk for future use or
to feed a baby who is unable to suckle.
breast reconstruction
See mammoplasty.
On a regular basis, examine your breasts
breast reduction 1general
in a mirror and become familiar with their
appearance. With your arms by your
2fromRaise each arm in turn above your head,
looking for changes in appearance. Turn
side to side, looking at the outline of the
See mammoplasty.
side, look at your breasts and be alert to any breasts for any changes. Examine the skin
changes to the nipples or to the shape and surface for peculiarities. Orange-peel texture
breast self-examination size of the breasts. could indicate the presence of a lump.
A visual and manual examination car-
ried out by a woman to detect lumps
and other changes in her breasts that
might be a sign of early breast cancer.
To carry out self-examination, the
breasts should be checked in a mirror
for any dimpling of the skin, changes
in the appearance of the nipples, or
changes in breast size and shape. Then,
placing one arm behind the head, and
using small, circular movements, the
breast should be gently but firmly
pressed. The entire breast, armpit area,
and nipple should be examined.
By performing regular self-examin-
ation, a woman is able to familiarize 3side.Lieshoulders
on your back with a pillow under your
and head, and one arm by your
Using the flat of your other hand, and the
Raise your arm above your head on one
4including
side and feel around the entire breast,
the nipple. Feel also along the top
herself with the appearance and feel of
pads of your fingers, work around the breast in of the collarbone and into the armpit. Repeat
her breasts (see breast awareness); any firm, small circular movements. the process for the other breast.
abnormal changes should be reported
to a doctor without delay.

126
 BREATHING STOPPAGE

dioxide. Breathing is controlled by the

respiratory centre in the brainstem. On BREATHING
inhalation, the diaphragm contracts and
In an adult, inhalation and exhalation occur between 13 and 17 times a minute at
flattens.The intercostal muscles (between
the ribs) contract and pull the ribcage
rest and up to 80 times a minute during vigorous exertion. A normal, resting
inhalation takes in about 400 ml of air; a deep breath, up to 4 litres.
B
up and out. The resulting increase in
volume in the chest cavity causes the
lungs to expand, and the reduced pres-
sure draws air into the lungs. On
exhalation, the chest muscles and dia-
phragm relax, causing the ribcage to Air inhaled Air exhaled
sink and the lungs to contract, squeez-
ing air out.
In normal, quiet breathing, less than
a tenth of the air in the lungs passes out
to be replaced by the same amount of
fresh air (the tidal volume). This new Ribcage Ribcage
air mixes with the stale air (the residual rises as falls as
intercostal intercostal
volume) already held in the lungs. The muscles muscles
normal breathing rate for an adult at contract relax
rest is 13 to 17 breaths per minute. (See
also respiration.)
breathing difficulty
Laboured or distressed breathing that
Diaphragm Diaphragm
includes a change in the rate and depth contracts relaxes
of breathing or a feeling of breathless-
ness. Some degree of breathlessness is
normal after exercise, particularly in
unfit or overweight people. Breathless- Inhalation Exhalation
ness at rest is always abnormal and is Air is drawn into the lungs as the intercostal Air is expelled from the lungs as the intercostal
usually due to disorders that affect the muscles (between the ribs) contract, causing the muscles relax, causing the ribcage to fall, and
airways (see asthma), lungs (see pul- ribcage to rise, and the diaphragm the diaphragm relaxes and resumes its
contracts and flattens. domed shape.
monary disease, chronic obstructive), or
cardiovascular system (see heart failure).
Severe anxiety can result in breathless-
ness, even when the lungs are normal bronchitis, asthma, an allergic reaction, breathing exercises
(see hyperventilation). Damage to the or lung cancer. Breathing difficulty may Techniques for learning to control the
breathing centre in the brainstem due also be due to inefficient transfer of rate and depth of breathing. They aim to
to a stroke or head injury can affect oxygen from the lungs into the blood- teach people to inhale through the nose,
breathing. This may also happen as a stream. Temporary damage to the lung while expanding the chest, and then to
side effect of certain drugs. Ventilator tissue may be due to pneumonia, pneu- exhale fully through the mouth, while
assistance is sometimes needed. mothorax (collapsed lung), pulmonary contracting the abdominal muscles. The
At high altitudes, the lungs have to oedema (fluid in the lung), or pleural exercises are used after chest surgery
work harder in order to provide the effusion (fluid around the lung). Per- and for people with chronic obstructive
body with sufficient oxygen (see moun- manent lung damage may be due to pulmonary disease (see pulmonary dis-
tain sickness). Breathlessness may occur emphysema, a condition in which the ease, chronic obstructive), who often tend
in severe anaemia because abnormal or small air sacs in the lungs are destroyed. to have difficulty breathing effectively.
low levels of the oxygen-carrying pig- Chest pain (for example, due to a Breathing exercises can also help people
ment haemoglobin means that the lungs broken rib) that is made worse by chest with anxiety disorders and may also help
need to work harder to supply the body or lung movement can make normal to relieve the symptoms of asthma.
with oxygen. Breathing difficulty that breathing difficult and painful, as can In yoga, deep, rhythmic breathing is
intensifies on exertion may be caused pleurisy (inflammation of the membrane used to achieve a state of relaxation.
by reduced circulation of blood through that lines the lungs and chest cavity). During childbirth, breathing exercises can
the lungs. This may be due to heart fail- Pleurisy is associated with pain in the relax the mother and may also help to
ure (reduced pumping efficiency of the lower chest and often in the shoulder control the contractions of the uterus
heart), pulmonary embolism (blockage of tip on the affected side. and reduce pain. (See also physiotherapy.)
blood vessels in the lungs by clots), or Abnormalities of the skeletal struc-
pulmonary hypertension (increased pres- ture of the thorax (chest), such as severe breathing stoppage
sure in the arteries in the lungs). scoliosis or kyphosis, may cause difficulty The cessation of breathing (see apnoea).
Breathing difficulty due to air-flow in breathing by impairing the normal Breathing may be stopped by an airway
obstruction may be caused by chronic movements of the ribcage. obstruction, by damage to the brainstem

127
 BREATHLESSNESS

(for example, following a stroke), by brittle bones broken leg

Cheyne–Stokes respiration, and, in chil- Bones with an increased tendency to See femur, fracture of; fibula; tibia.
dren, by breath-holding attacks. fracture. They are a feature of osteoporo-
broken nose
B breathlessness
sis and may occur in people who are
taking corticosteroid drugs, are immobile, Fracture of the nasal bones or disloca-
A feeling of laboured breathing. Breath- or have certain hormonal disorders. In tion of the cartilage that forms the
lessness is a normal response to exercise osteomalacia, the bones are soft and bridge of the nose (see nose, broken).
or exertion, but may also be caused by tend both to become deformed and to
some underlying disorders (see breath- fracture. The inherited disorder osteoge- broken tooth
ing difficulty). nesis imperfecta is a rare cause of brittle See fracture, dental.
bones and frequent fractures and is usu-
breath test ally detected in infancy. broken veins
A procedure used to check for infection A term that is commonly used to refer
of the digestive tract by HELICOBACTER brittle diabetes to telangiectasia, in which small blood
PYLORI , the bacterium associated with A former term for type 1 (insulin- vessels under the surface of the skin
peptic ulcers. The test involves drinking a dependent) diabetes mellitus in which it enlarge and give the impression of
substance that can be broken down by is difficult to maintain blood sugar being “broken”.
the bacterium. The breakdown process levels within an acceptable range.
produces a chemical that passes into the bromides
bloodstream and is then breathed out. A Broca’s area Substances formerly used as sedative
machine detects the substance’s pres- An area of the cerebral cortex (the outer drugs or as anticonvulsant drugs in the
ence in the breath, confirming infection layer of the brain) that is responsible for treatment of epilepsy. Bromides are no
with the bacterium. speech origination. Damage to Broca’s longer used due to their side effects,
area may result in aphasia (complete loss which include serious disturbance of
breech delivery of previously acquired language skills). brain function that may lead to coma.
A birth in which the fetus presents but-
tocks first. Many fetuses lie in a breech Brodmann areas bromocriptine
position before week 32 of pregnancy, Areas of the cerebral cortex (outer layer A drug used to suppress production of
but most of them turn by week 36. The of the brain), that are numbered one to prolactin (a hormone) to treat conditions
three per cent that do not turn may be 47. Each area contains nerve cells that such as noncancerous pituitary tumours
in one of three types of breech presen- correspond to specific functions, such (see prolactinomas; acromegaly). Bromo-
tation: in a complete breech, the fetus is as sight, hearing, and movement. criptine may also be used to suppress
curled up; in a frank breech, the fetus’s
legs are extended and the feet are close
to the face; in a footling breech, one or FITTING A BRIDGE
both feet are positioned over the cervix.
The most common type of bridge consists of one or more false teeth attached to a
In many twin pregnancies, one twin is in crown on each side of a gap. The natural teeth are shaped to receive the crowns,
a breech position. which are then cemented into place.
A mother whose fetus is in a breech
presentation may be offered a proce-
dure to turn the fetus around after week
36 of pregnancy, because this usually
makes birth easier. In some breech
deliveries, a caesarean section may be
recommended.
bridge, dental
Two complete teeth are missing. A bridge
False teeth attached to natural teeth on
either side of a gap left by one or more
1be attached.
of two false teeth and two crowns can 2of theThe two healthy teeth are shaped so that
they can receive the crowns on either side
gap.
missing teeth (see the illustrated box).
Adhesive bridges, which are attached
to, but do not damage, the teeth on
either side of the gap are now available
in certain situations. (See also denture.)
Bright’s disease
An alternative name for the kidney dis-
order glomerulonephritis.
Briquet’s syndrome 3on toThe bridge, which is mounted on a cast-
metal subframe (not shown), is cemented
the healthy teeth on either side of the gap.
4 The finished bridge is in position, showing
the new porcelain teeth; the metal base to
which they are cemented is concealed.
An alternative name for somatization dis-
order, a psychiatric illness.

128
 BRONCHOSPASM

milk production after childbirth and to acute or chronic. Both types are more as salbutamol) are used primarily for the
treat Parkinson’s disease. Side effects in- common in smokers and in areas with rapid relief of breathing difficulty. Anti-
clude nausea and vomiting; high doses high atmospheric pollution. (See also cholinergics (such as ipratropium) and
may cause drowsiness and confusion. bronchitis, acute; bronchitis, chronic.) xanthines (such as aminophylline) are
more frequently used for the long-term B
bronchial asthma bronchitis, acute prevention of attacks of breathing diffi-
See asthma. A form of bronchitis, usually due to a culty. Bronchodilators can be given by
viral infection, that develops suddenly inhaler, in tablet form, or, in severe
bronchiectasis but often clears up within a few days. cases, by nebulizer or injection.
A lung disorder in which one or more Bacterial infection of the airways may SIDE EFFECTS
bronchi (air passages leading from the be a complication. Smokers, babies, the The main side effects of sympathomim-
trachea) are abnormally widened and elderly, and people with lung disease etics are palpitations and trembling.
distorted, with damaged linings. Bron- are particularly susceptible. Symptoms Anticholinergics may cause dry mouth,
chiectasis commonly develops during include wheezing, shortness of breath, blurred vision, and, rarely, difficulty in
childhood and was once associated with and a cough producing yellow or green passing urine. Xanthines may cause
infections such as measles and pertussis sputum. There may also be pain behind headaches, nausea, and palpitations.
(whooping cough). The condition may the sternum (breastbone) and fever.
also be a complication of cystic fibrosis. Symptoms may be relieved by drink- bronchography
Bronchiectasis results in pockets of ing plenty of fluids and inhaling steam An X-ray procedure used for examining
long-term infection within the airways or using a humidifier. Most cases clear the bronchi, which are the two main air
and the continuous production of large up without further treatment, but acute passages of the lungs. Once used to
volumes of green or yellow sputum bronchitis may be serious in people diagnose bronchiectasis (widening and
(phlegm). Extensive bronchiectasis may who already have lung damage. distortion of the bronchi), this method
cause shortness of breath. has now been largely replaced by other
Symptoms are usually controlled with bronchitis, chronic imaging techniques, especially CT scan-
antibiotic drugs and postural drainage, a Smoking-induced inflammation of the ning, and by bronchoscopy.
technique that clears secretions from the airways associated with emphysema, in
lungs. If the condition is confined to which the air sacs in the lungs are bronchopneumonia
one area of lung, surgical removal of the destroyed. The combination of chronic The most common form of pneumonia.
damaged area may be recommended. bronchitis and emphysema is known as In bronchopneumonia, inflammation is
chronic obstructive pulmonary disease spread throughout the lungs in small
bronchiole (see pulmonary disease, chronic obstruc- patches around the airways; in lobar
One of many small airways of the lungs. tive). Symptoms include a productive pneumonia, it is confined to one lobe.
Bronchioles branch from larger airways cough and progressive breathlessness.
(bronchi) and subdivide into progres- bronchoscopy
sively smaller tubes before reaching the bronchoconstrictor Examination of the bronchi, the main
alveoli (see alveolus, pulmonary), where A substance that causes narrowing of airways of the lungs (see bronchus), by
gases are exchanged. the airways. Bronchoconstrictors, such means of an endoscope (viewing tube)
as histamine, are released during an known as a bronchoscope. Broncho-
bronchiolitis allergic reaction (see allergy) and may scopes may be rigid or flexible.
An acute viral infection of the lungs, provoke an asthma attack. The effect can WHY IT IS DONE
mainly affecting babies and young chil- be reversed by a bronchodilator drug. Bronchoscopy is performed to inspect
dren, in which the bronchioles (the the bronchi for abnormalities, such as
airways branching off the bronchi) bronchodilator drugs lung cancer and tuberculosis; to collect
become inflamed. A common cause is COMMON DRUGS samples of mucus; to obtain cells; and
the respiratory syncytial virus (RSV). SYMPATHOMIMETICS • Bambuterol • Eformoterol to take biopsy samples from the airways
Symptoms of bronchiolitis include • Ephedrine • Epinephrine • Fenoterol or lungs. A bronchoscope with special
rapid breathing, a cough, and fever. No • Salbutamol • Salmeterol • Terbutaline attachments is used to carry out treat-
treatment may be necessary but, in ANTICHOLINERGICS • Ipratropium bromide ments such as removing inhaled foreign
severe cases, hospital admission is nec- • Oxitropium bodies, destroying abnormal growths,
essary so that oxygen therapy can be XANTHINES • Aminophylline • Theophylline and sealing off damaged blood vessels.
given. If treatment is prompt, recovery (See also Bronchoscopy box, overleaf.)
is usually within a few days. Antibiotic Drugs that widen the bronchioles (small
drugs may be given to prevent a sec- airways in the lungs) to improve air flow bronchospasm
ondary bacterial infection. and breathing. They are especially used Temporary narrowing of the bronchi
to treat asthma and chronic obstructive (the air passages to the lungs). Bron-
bronchitis pulmonary disease (see pulmonary dis- chospasm is caused by contraction of
A disorder in which the bronchi, the ease, chronic obstructive), in which the the muscles in the walls of the bronchi,
large air passages to the lungs, are lungs are inflamed and damaged. by inflammation of the lining of the
inflamed. Bronchitis results in a cough TYPES bronchi, or by a combination of both.
that may produce considerable quanti- There are three main types of broncho- Contraction may be triggered by the
ties of sputum (phlegm) and may be dilator drug. Sympathomimetics (such release of substances during an allergic

129
 BRONCHUS

HOW BRONCHODILATORS WORK

When bronchioles become narrow Normal bronchioles

B following contraction of the muscle
layer and swelling of the mucous
The muscle surrounding
the bronchioles is
lining, the passage of air is impeded. relaxed, leaving the
airway open.
Bronchodilator drugs relax the
muscles surrounding bronchioles by
acting on the nerve signals that govern
muscle activity.
Sympathomimetic and anticholin- during an
ergic drugs interfere with nerve signals asthma attack
The muscle contracts
passed to the muscles through the and the lining swells,
autonomic nervous system. Sym- narrowing the airway.
pathomimetics enhance the action of
neurotransmitters that encourage
muscle relaxation. Anticholinergics
block the neurotransmitters that
trigger muscle contraction. Xanthine After drug treatment
drugs relax muscle in the bronchioles The muscles relax,
by a direct effect on the muscle fibres; opening the airway,
Bronchiole but the mucous lining
however, their precise action is not
remains swollen.
fully understood.
Alveoli

bronchus
BRONCHOSCOPY A large air passage in a lung. Each lung
There are two kinds of bronchoscope.
has one main bronchus, originating at
The rigid type is a hollow tube that the end of the trachea (windpipe). This
is passed into the bronchi via the Bronchoscope main bronchus divides into smaller
mouth and requires a general branches known as segmental bronchi,
anaesthetic. The flexible, fibre-optic which further divide into bronchioles.
bronchoscope (a narrower tube
formed from light-transmitting fibres) bronchus, cancer of
can be inserted through either the Trachea See lung cancer.
mouth or nose. It is used after giving
only a mild sedative and/or local Lung
bronze diabetes
anaesthetic and it reaches farther An outdated term for haemochromatosis,
into the lungs. Both types of
a rare genetic disorder in which excess
bronchoscope can be fitted with
forceps for taking tissue samples and
amounts of iron are deposited in tissues.
the instrument also has attachments
for performing laser therapy and
brown fat
cryosurgery. (See also endoscopy.) A special type of fat found in infants and
View through some animals. Located mainly between
bronchoscope
and around the shoulderblades, brown
THE BRONCHOSCOPE fat provides energy and helps infants to
Control lever
maintain a constant body temperature.
Brown–Sequard syndrome
Insertion tube A combination of symptoms associated
Forceps – various forceps can with damage to a part of the spinal cord.
be attached; this one has a basket
Eyepiece for removing small, hard objects There is loss of pain and temperature
sensation on the opposite side of the
body below the damage, and weakness
and stiffness of muscles below the dam-
reaction (see allergy). When the airways obstructive pulmonary disease (see pul- age on the same side of the body.
are narrowed, the air is reduced, caus- monary disease, chronic obstructive), in
ing wheezing or coughing. which the lungs are inflamed and dam- brow presentation
Asthma is the most common cause of aged, anaphylactic shock (a potentially A rare form of malpresentation in which
bronchospasm. Other possible causes life-threatening hypersensitivity reac- the head of the fetus is bent slightly
include respiratory infection, chronic tion), or allergic reaction to chemicals. backwards and its brow lies against the

130
 BULLA

mother’s cervix. Vaginal delivery is not bubo causing gangrene (tissue death). Buer-
possible if this presentation persists An inflamed and swollen lymph node, ger’s disease is most common in men
throughout labour, and a caesarean sec- usually in the groin or armpit. Buboes under the age of 45 who smoke heavily.
tion is then required. usually occur as the result of a bacterial
infection such as plague or a sexually buffalo hump B
brucellosis transmitted infection. A lump of fat under the skin on the
A rare bacterial infection, caused by var- back of the neck. A buffalo hump may
ious strains of BRUCELLA, which may be bubonic plague develop following long-term treatment
transmitted to humans from affected The most common form of plague, with high doses of corticosteroid drugs
cattle, goats, and pigs.The infection may characterized by the development of a or as a result of Cushing’s syndrome.
also be transmitted in unpasteurized bubo (a swollen lymph node) in the
dairy products. groin or armpit. building-related illnesses
Brucellosis causes high fever, sweat- Another term for the group of symp-
ing, poor appetite, joint aches, headache, buccal toms known as sick building syndrome.
backache, weakness, and depression. A term that refers to the cheek or mouth.
Rarely, severe untreated cases lead to Buccal preparations of some drugs are bulbar palsy
pneumonia or meningitis (inflammation available. Placed between the cheek and Weakness of the muscles involved in
of the membranes surrounding the gum, they dissolve and are absorbed talking and swallowing, causing slurred
brain and spinal cord). In long-term directly into the blood circulation. speech, hoarseness, difficulty in swal-
brucellosis, bouts of the illness recur lowing, and choking on food and drink.
over months or years, and the depres- buck teeth Bulbar palsy may be caused by damage
sion can be severe. The disease is treated Prominent upper incisors (front teeth) to the muscles’ nerve supply, as in motor
with antibiotic drugs. that protrude from the mouth. Ortho- neuron disease, or disease of the muscles
dontic treatment of buck teeth involves themselves, as in muscular dystrophy.
bruise repositioning the teeth with a remov-
A discoloured area under the skin able brace (see brace, dental) or a fixed bulimia
caused by leakage of blood from dam- orthodontic appliance. A psychiatric illness that is character-
aged capillaries (tiny blood vessels). The ized by bouts of overeating, usually
blood initially appears blue or black; as Budd–Chiari syndrome followed by self-induced vomiting or
the haemoglobin (the red pigment in A rare disorder in which the veins excessive use of laxatives. Most people
blood) breaks down, the bruise turns a draining blood from the liver become suffering from bulimia are girls or
yellowish colour. blocked or narrowed. Blood accum- women between the ages of 15 and 30.
A bruise that does not fade after ulates in the liver, which swells. Liver In some cases, the symptoms coexist
about week, that appears for no appar- failure and portal hypertension (raised with those of anorexia nervosa.
ent reason, or that is severe after only pressure in the vein carrying blood to Repeated vomiting can lead to dehy-
minor injury, may indicate a bleeding the liver) result. dration and loss of potassium, causing
disorder. (See also black eye; purpura.) Treatment is aimed at removing the weakness and cramps, and also causes
cause of the obstruction, which may be tooth damage due to the gastric acid in
bruits a blood clot, pressure on the veins from vomit. Treatment of bulimia includes
The sounds that are made in the heart, a liver tumour, or a congenital (present supervision and regulation of the per-
arteries, or veins when the blood circu- from birth) abnormality of the veins. In son’s eating habits, psychotherapy, and,
lation becomes turbulent or when it most cases, treatment has only a limited in some cases, antidepressant drugs (see
flows abnormally fast. This may happen effect and, unless a liver transplant can be selective serotonin reuptake inhibitors).
when blood vessels widen (as in an carried out, the disease is generally fatal
aneurysm), when they become narrowed within two years. bulk-forming agent
by disease (as in arteriosclerosis), or A type of antidiarrhoeal drug that absorbs
when heart valves are narrowed or dam- budesonide water, making stools less liquid. Bulk-
aged (as in endocarditis). Bruits can be A corticosteroid drug used in the pre- forming agents are also used as laxatives,
heard by a doctor through a stethoscope. vention of bronchial asthma attacks. stimulating bowel movement by soften-
(See also carotid bruit.) Budesonide is administered using an ing faeces and increasing their bulk.
inhaler. Adverse effects, which include
bruxism hoarseness, throat irritation and, rarely, bulla
Rhythmic grinding or clenching of the fungal infections, can be reduced by A large air- or fluid-filled bubble that is
teeth that usually occurs during sleep. rinsing the mouth after administration. usually found in the lungs or skin. Lung
The main causes are emotional stress bullae in young adults are usually con-
and minor discomfort when the teeth Buerger’s disease genital (present from birth). In later life,
are brought together. Continued brux- A rare disorder, also known as thrombo- lung bullae develop in patients with
ism may wear away the teeth. angiitis obliterans, in which the nerves, emphysema, a disorder in which the
arteries, and veins in the legs, and air sacs in the lungs are gradually
BSE sometimes the arms, become severely destroyed. Skin bullae are large, fluid-
The abbreviation for bovine spongiform inflamed. The blood supply to the toes filled blisters with a variety of causes,
encephalopathy. and fingers becomes cut off, eventually including the bullous disease pemphigus.

131
 BULL-NECK

bull-neck an abnormal outward projection of the THIRD-DEGREE BURNS

Swelling of the neck caused by severely big toe called a hallux valgus. Small buni- A third-degree burn destroys the full
swollen lymph glands, often related to ons can usually be remedied by wearing skin thickness and may extend to the
B infections in the tonsils and throat. (See
also diphtheria.)
well-fitting shoes and a special toe pad
to straighten the big toe. Large bunions
muscle layer beneath the skin. The
affected area will look white or charred;
may require surgery to realign the joint if the burn is very deep, muscles and
bullous pemphigoid and relieve the pressure. bones may be exposed. Even if very
An alternative term for pemphigoid, a localized, third-degree burns will need
skin disease in which large, tense blis- buphthalmos specialist treatment and possibly skin
ters develop. A large, prominent eyeball in an infant grafts to prevent scarring.
due to congenital glaucoma (increased ELECTRICAL BURNS
bumetanide pressure inside the eyeball). The condi- Electrical burns can cause extensive tis-
A powerful, short-acting loop diuretic tion is usually treated with surgery sue damage with minimal external skin
drug used to treat oedema (accumula- to reduce the pressure; otherwise, the damage. The electric current may cause
tion of fluid in tissues) resulting from child’s sight is progressively damaged. heart damage.
heart failure, nephrotic syndrome (damage EFFECTS AND COMPLICATIONS
to the kidney’s filtering units), or cirrho- bupivacaine Extensive first-degree burns (such as
sis. It may be given by injection for the A long-acting local anaesthetic (see sunburn) cause pain, restlessness, fever,
emergency treatment of pulmonary oed- anaesthesia, local) often used as a nerve and headache, but are not life-threaten-
ema (fluid in the lungs). Side effects block during childbirth and in epidural ing. A second- or third-degree burn that
may include rash and muscle pain. anaesthesia and spinal anaesthesia. Side affects more than ten per cent of the
effects are uncommon, but high doses body surface causes shock, with lowered
bundle may cause blood pressure to fall. blood pressure and a rapid pulse, due to
Also known as a fascicle, a cluster of massive fluid loss from the burned area.
nerve or muscle fibres. bupropion Shock may be fatal if this fluid is not
Another name for amfebutamone, a drug replaced intravenously.
bundle branch block used as an aid to stopping smoking. When the skin is burned it can no
See heart block. longer protect the body from con-
Burkitt’s lymphoma tamination by airborne bacteria. The
bunion A cancer of lymph tissues (see lymphatic infection of extensive burns may cause
A thickened pad of tissue or a fluid- system) characterized by tumours within fatal complications if effective treatment
filled bursa (sac) overlying a deformed the jaw and/or the abdomen. The con- with antibiotic drugs is not available.
big-toe joint. The underlying cause is dition almost exclusively affects children Victims who have inhaled smoke may
living in the low-lying, moist, tropical develop inflammation of the lungs and
regions of Africa and New Guinea. Anti- may need specialist care for burns of the
HOW BUNIONS FORM
cancer drugs or radiotherapy give a partial eyes and respiratory passages.
A bunion results from the rubbing of or complete cure in about 80 per cent TREATMENT
a shoe against an abnormal outward of cases. (See also lymphoma.) A burn is covered with a non-stick
projection of the joint at the base of dressing to keep the area moist. Anal-
the big toe (a hallux valgus), leading burns gesic drugs are given if necessary and
to irritation and inflammation. The Tissue damage caused by contact with antibiotics are prescribed if there is any
joint abnormality is often due to heat, electricity, chemicals, or radiation. infection. For extensive second-degree
wearing narrow, pointed shoes with Burns are classified, according to the burns, which may be slow to heal or
high heels, although it can also severity of skin damage, as first-, sec- carry a high risk of infection, a topical
result from an inherited weakness ond-, or third-degree (or superficial, antibacterial agent, such as silver sul-
in the joint. partial thickness, or full thickness). phadiazine, is used. Third-degree burns
FIRST-DEGREE BURNS always require skin grafts, which are
A first-degree burn causes reddening of used early to minimize scarring. Exten-
the skin and affects only the epidermis, sive burns may require plastic surgery.
(topmost layer of skin). These type of
burns usually heal quickly, but the dam- burping
aged skin may peel away after a day or Another term for belching.
two. Sunburn is a common example of a
first-degree burn. burr hole
SECOND-DEGREE BURNS A hole made in the skull by a special
A second-degree burn extends into, drill with a rounded tip (burr). The hole
and damages, the dermis (deep layer of relieves pressure on the brain that often
skin), sometimes causing the formation results from bleeding inside the skull,
Bunion of blisters. Because some of the dermis usually due to a head injury. Burr holes
Valgus deformity of the joint between the first is left to recover, these type of burns may be part of a craniotomy (in which a
metatarsal bone and the adjoining phalanx.
usually heal without leaving scars, section of skull is removed for access to
unless they are very deep. the brain) and may be life-saving.

132
 BYSSINOSIS

bypass operations
BURNS Surgical procedures that are used to
bypass blockages or narrowing. The
Superficial burns cause the skin to redden and peel
term bypass usually refers to operations
but, unless extensive, need no treatment. Burns
that blister usually heal well but can be fatal if they 9% on arteries, although blockages in the B
affect a large area of the body. Burns that extend digestive system can also be treated
beyond the skin layers may damage fat, nerves, and with bypass operations.
muscle; and healing is slow because they are likely The most common type of bypass
to require skin grafting. Front operation is coronary artery bypass, which
2 x 9%
9% 9% is used to treat coronary artery disease,
The skin Back (a condition in which the arteries have
2 x 9% become blocked or narrowed by athero-
Epidermis 1% sclerosis). Obstructions can be bypassed
1st by using sections of healthy artery or
degree vein from elsewhere in the body or
Front Back using tubing made from a synthetic
2 x 9% 2 x 9%
Dermis material such as dacron.
2nd
Intestinal bypass operations are most
degree often performed to treat cancer patients
in whom the tumour is too extensive to
Sweat gland
be removed surgically. The blocked area
Hair follicle is bypassed by joining the sections of
Subcutaneous 3rd
bowel above and below the blockage.
fat degree
byssinosis
Nerve
A lung disease caused by the dust that is
Degrees of burns Skin surface area
Burns are divided into three categories. First-degree (or For assessment of burns, the body produced during the processing of flax,
superficial) burns affect the epidermis and the skin may is divided roughly into nine per cotton, hemp, or sisal. Byssinosis causes
peel; second-degree (or partial thickness) burns cause cent areas. This varies slightly In a feeling of tightness in the chest and
blisters; third-degree (or full thickness) burns destroy the young children because the head shortness of breath that may become
whole of the skin’s thickness and require special treatment. is larger in relation to the body.
chronic (of long duration) if exposure
to the agent continues. Bronchodilator
drugs and other drugs used to treat
bursa (also known as housemaid’s knee), for asthma can relieve the symptoms; good
A fluid-filled sac that acts as a cushion at example, is the result of prolonged ventilation and equipment such as
a pressure point, often where a tendon or kneeling on a hard surface. Treatment masks reduce the risk.
muscle crosses bone or other muscles. is by avoiding further pressure and by
The important bursae are found around taking nonsteroidal anti-inflammatory
the knee, elbow, and shoulder joints. drugs. Antibiotic drugs may be necessary
if the bursa is infected.
bursitis
Inflammation of a bursa (a fluid-filled buserelin
sac) causing pain and swelling. Bursitis A synthetic form of the hormone
may result from pressure, friction, or gonadorelin that is used to treat endo-
injury to the membrane surrounding a metriosis (a disease of the lining of the
joint, or to infection. Prepatellar bursitis uterus), infertility, and cancer of
the prostate.
Coronary artery
butterfly rash
A skin eruption, also called a butterfly
patch, that is characteristic of systemic
lupus erythematosus (see rash).

buzzer and pad system

A device used to treat bedwetting (see
Iliofemoral artery
enuresis, nocturnal). A pad that detects
moisture is placed in the bed and is
attached to a buzzer that sounds when
the pad becomes wet with urine. The
Pre-patellar bursitis
This condition, which is caused by inflammation of
person is woken up as soon as he or she Common bypass locations
a bursa, produces a fluid-filled swelling in front of starts to pass urine and gradually learns The coronary artery and the iliofemoral vessels are
the kneecap. to wake up before starting to pass urine. the most common locations for bypasses.

133
 CACHEXIA

After the operation, the mother is given calamine

C
analgesic drugs (painkillers) as required. A preparation of zinc oxide and iron
If there are no complications, she and oxide that is applied to the skin as an
the baby can usually leave hospital ointment, lotion, or dusting powder to
about a week after the operation. relieve irritation and itching. Calamine
has a protective, cooling, and drying
C café au lait spots effect. It may be combined with a local
Coffee-coloured patches on the skin anaesthetic (see anaesthesia, local), cor-
that may occur on any part of the body. ticosteroid drug, or antihistamine drug.
Café au lait spots are usually oval in
shape and may measure several centi- calcaneal bursitis
cachexia metres across. Generally, the presence Inflammation of the bursa (fluid-filled
A condition of severe weight loss and of a few of these spots is not signifi- pad) that cushions the calcaneus and
decline in health caused by a serious cant. However, larger numbers of them prevents friction at the back of the heel
underlying disease, such as cancer or may be a sign of neurofibromatosis, a (see bursitis). The condition causes pain
tuberculosis, or by starvation. hereditary disorder of the sheaths that and swelling but usually clears up with
surround nerve fibres. rest and anti-inflammatory drugs.
cadaver
A dead human body used as a source of caffeine calcaneus
transplant organs or for anatomical A stimulant drug that is found in coffee, The heel bone. The calcaneus is one of
study and dissection. tea, cocoa, and cola drinks. Caffeine the tarsal bones and is the largest bone
reduces fatigue, improves concentra- in the foot. The Achilles tendon runs
cadmium poisoning tion, makes the heart pump blood between the back of the calcaneus and
The toxic effects of cadmium, a tinlike faster, and has a diuretic effect. the calf muscles; it controls upward
metal. Poisoning as a result of inhala- and downward movements of the foot.
tion of cadmium fumes is an industrial DISORDERS
hazard, the effects of which depend on CAFFEINE LEVELS The calcaneus may be fractured by a fall
the duration and severity of exposure. from a height on to the heel. Minor
The strength and preparation method
Eating vegetables grown in cadmium- fractures do not usually cause problems
determine exact amounts of caffeine
rich soil, or the consumption of food present (in mg per cup). and can be treated by placing the
or drink stored in cadmium-lined con- affected foot and leg in a cast. A more
tainers, can also cause poisoning. Drink Caffeine serious fracture, with compression of
Short-term exposure to cadmium Tea, weak 50mg the bone, may cause permanent dam-
may lead to pneumonitis (inflammation Tea, strong 80mg
age to the joints involved in turning the
of the lungs). Exposure over a long foot in and out, leading to pain and
Coffee, weak 80mg
period can lead to urinary tract calculi stiffness that are aggravated by walking.
(stones), kidney failure, or emphysema (a Coffee, strong 200mg The point at which the Achilles ten-
form of permanent lung damage). Cocoa 10–17mg don joins the calcaneus may become
Cola 43–75mg strained by excessive or prolonged
caecum stress from the pull of the tendon (in
The first section of the large intestine, some running injuries, for example). In
joining the ileum (the end of the small Large quantities of caffeine may pro- children, this area may be inflamed and
intestine) to the ascending colon. The duce side effects such as agitation and painful (see osteochondrosis) because the
appendix projects from the caecum. (See tremors. A regular high intake may lead bone is still growing.
also digestive system). to increased tolerance, so that people
need to increase their caffeine intake to
caesarean section obtain the equivalent stimulant effect. LOCATION OF THE CALCANEUS
An operation to deliver a baby from the In people who consume large amounts
mother’s uterus through a horizontal of caffeine, withdrawal symptoms (see The calcaneus is the largest of the
or, less commonly, a vertical incision in withdrawal syndrome), such as headaches
tarsal bones. It projects backwards
beyond the leg bones.
the abdomen. A caesarean section is and tiredness, may occur after a few
performed if vaginal delivery would be hours without caffeine.
difficult or dangerous for the mother Caffeine may be used in some drug
or the baby. Increasingly, women who preparations, particularly in combina- Talus
do not want to go through labour are tion with analgesic drugs (painkillers)
Metatarsals
also opting to have the operation. and with ergotamine in preventive treat-
A caesarean section may be perfor- ments for migraine.
med using either an epidural anaesthesia
or general anaesthesia (see anaesthesia, caisson disease
general). The procedure for performing An alternative term for decompression
a caesarean section is shown in the sickness. It
usually occurs when a person Calcaneus
illustrated box (see opposite page). surfaces too quickly after a deep dive.

134
 CALCANEUS

PROCEDURE FOR A CAESAREAN SECTION

A caesarean section allows delivery of a baby through a

horizontal or vertical cut in the abdominal and uterine walls. WHY IT IS DONE
The mother is given epidural anaesthesia, so that she remains
conscious during the procedure, or general anaesthesia. A caesarean can be elective
(planned) in cases of breech C
HOW IT IS DONE presentation; placenta
praevia (where the placenta
Vertebra
is lying close to or across
Spinal cord the cervix ); the mother’s ill
health; or, most commonly,
Epidural space if there were problems in
previous caesareans that still
exist (such as the mother
having a small pelvis). Breech presentation
Elective caesarean is
sometimes requested by the
First, epidural anaesthesia is carried
1by deadening
out to temporarily numb the abdomen
the nerves leading to it.
parents for social reasons.
An emergency caesarean
A needle is introduced into the epidural is needed in cases of fetal
space and a catheter is threaded through Skin Catheter distress (lack of oxygen);
it. A local anaesthetic is injected down unsuccessful induction of
the catheter. A catheter is also inserted labour; or bleeding (such
into the bladder to empty it. Horizontal incision as in placental abruption
(premature separation) or
The abdomen is then opened, placenta praevia). Placenta praevia
2incision
usually through a horizontal
made just above the pubic
bone. This type of cut heals most
effectively. The resulting scar is
hardly noticeable and comes 3uterus.The amniotic fluid is drained off by suction. The baby is
delivered through an incision in the lower part of the
The umbilical cord is cut and the afterbirth removed.
below the “bikini line”.
The incisions in the uterus and abdomen are then sewn up.
The mother is given an injection of ergometrine and oxytocin
to make the uterus contract and stop any bleeding.
Nurse Surgical nurse Obstetrician Intravenous drip
Anaesthetist
Instruments Baby resuscitation unit

Nurse

Birth partner

135
 CALCIFEROL

The tendons of the sole of the foot are WHY IT IS USED mally low levels (hypocalcaemia) may
fixed under the calcaneus, and the asso- A synthetic form of calcitonin used seriously disrupt cell function, particu-
ciated muscles are important in in the treatment of Paget’s disease, in larly in muscles and nerves. (See also
supporting the arches of the foot. which the bones grow abnormally and mineral supplements.)
Inflammation around these tendons (as become deformed, causing pain and an
occurs in plantar fasciitis) causes pain increased risk of fracture. Injections of calcium carbonate
C and tenderness under the heel when calcitonin can generally halt abnormal A calcium salt used in some antacid
standing or walking. A calcaneal spur (a bone formation in about a week and drugs, which can be taken for the treat-
bony protrusion) occurs in some peo- can relieve pain within a few months. ment of indigestion.
ple with plantar fasciitis and also, Calcitonin is also used in the treat-
occasionally, in those with healthy feet. ment of hypercalcaemia (abnormally calcium channel blockers
high levels of calcium in the blood), COMMON DRUGS
calciferol which may be caused by overactivity of •Amlodipine •Diltiazem •Felodipine
A former name for vitamin D2. This vit- the parathyroid glands or by bone cancer. •Isradipine •Lacidipine •Lercanidipine
amin is now more commonly known It helps to relieve the nausea and vom- •Nicardipine •Nifedipine •Verapamil
as ergocalciferol (see vitamin D). iting that result from hypercalcaemia
by rapidly reducing the level of calcium Drugs used in the treatment of angina
calcification circulating in the blood. pectoris (chest pain due to impaired
The deposition of calcium salts in body SIDE EFFECTS blood supply to the heart muscle),
tissues. Calcification is part of the nor- Calcitonin causes minimal side effects. hypertension (high blood pressure), and
mal processes of bone and teeth Gastrointestinal reactions, such as nau- certain types of cardiac arrhythmia
formation and the healing of fractures. sea, vomiting, and diarrhoea, usually (irregular heartbeat).
It also occurs in injured muscles, in diminish with continued use. HOW THEY WORK
arteries affected by atherosclerosis, and Calcium channel blockers work by
when blood calcium levels are raised by calcium interfering with the movement of cal-
disorders of the parathyroid glands. The body’s most abundant mineral, cal- cium across the membranes of muscle
cium is essential for cell function, cells in blood vessels and in the heart
calcification, dental muscle contraction, the transmission of muscle itself. This action decreases the
The deposition of calcium salts in devel- nerve impulses from nerve endings to work of the heart in pumping blood,
oping teeth. Primary teeth (see eruption muscle fibres, and for blood clotting. reduces the pressure of blood flow
of teeth) begin to calcify in a fetus at Calcium phosphate is the hard, basic through the body, and improves blood
between three and six months gesta- constituent of teeth and bones. Dietary circulation through the heart muscle.
tion. Calcification of permanent teeth sources of calcium include dairy prod- The drugs also slow the passage of
(other than the wisdom teeth) begins ucts, eggs, and green, leafy vegetables. nerve impulses through the heart’s in-
between birth and four years. CONTROL OF CALCIUM LEVELS ternal conduction system, which helps
Certain tooth conditions can cause Vitamin D and certain hormones help to to correct certain types of arrhythmia.
abnormal calcification. In amelogenesis control the overall amount of calcium SIDE EFFECTS
imperfecta, an enamel disorder (see in the body. They act by regulating the The side effects of calcium channel
hypoplasia, enamel), teeth have a thin, amount of calcium that is absorbed blockers are mainly related to their
grooved covering due to incomplete from food and the amount filtered out action of increasing the blood flow
calcification. Another cause is absorp- from the blood by the kidneys and through tissues. These effects include
tion of high levels of fluoride (see excreted in the urine. headaches, swollen ankles, flushing,
fluorosis) and drugs, such as tetracycline, The levels of calcium in the blood are and dizziness. Adverse effects tend to
that are taken in pregnancy. controlled by the actions of two hor- diminish with continued treatment.
mones: parathyroid hormone, which is
calcinosis produced by the parathyroid glands, and calculus
The abnormal deposition of calcium salts calcitonin, which is produced by the A hard deposit in the body. Calculus
in the skin, muscles, or connective tissues, thyroid gland. When the level of cal- may form on the surface of the teeth
forming nodules. Calcinosis occurs in cium in the blood falls to a low level, (see calculus, dental). Alternatively, it
connective tissue disorders such as scle- the parathyroid glands release more may be a small, hard, crystalline mass
roderma. (See also calcification.) parathyroid hormone, which raises the that forms in a body cavity from certain
blood calcium level by helping to substances in fluids such as bile, urine,
calcipotriol release calcium from the enormous or saliva. Such calculi (also called
A derivative of vitamin D that is used in reservoir in the bones. When the blood stones) can occur in the gallbladder
topical treatments for the skin condi- calcium level rises significantly, the thy- and bile ducts (see gallstones), kidneys,
tion psoriasis. roid gland releases more calcitonin. ureters, bladder (see calculus, urinary
This hormone counteracts the effects of tract), or in the salivary ducts.
calcitonin parathyroid hormone, thereby lower- Although some calculi do not cause
A hormone produced by the thyroid ing the level of calcium in the blood. any symptoms, some can cause severe
gland that helps to control blood cal- DISORDERS OF CALCIUM METABOLISM pain, in which case they may need to
cium levels by slowing the rate at which Abnormally high levels of calcium in be dissolved, shattered, or surgically
calcium is lost from the bones. the blood (hypercalcaemia) or abnor- removed from the body cavity.

136
 CALENDAR METHOD

calculus, dental bladder and/or a longstanding urinary can usually be confirmed by intraven-
A hard, crust-like deposit, also called tract infection. The composition of the ous urography. Some stones, particularly
tartar, found on the crowns and roots stones is related to the acidity or alka- those containing calcium, are visible on
of the teeth. Calculus forms when min- linity of the urine. a plain abdominal X-ray.
eral salts in saliva are deposited in SYMPTOMS Renal colic is treated with bed rest
existing plaque, a coating of mucus and The most common symptom of a stone and an analgesic drug (painkiller). With
debris that forms on the teeth. in the kidney or ureter is renal colic, an adequate fluid intake, small stones C
TYPES a severe pain in the back, under the are usually passed in the urine without
There are two types of dental calculus. ribs, that often spreads into the groin. causing problems.The first line of treat-
Supragingival calculus is a yellowish or This pain may be accompanied by nau- ment for larger stones in the urinary
white deposit that forms above the sea and vomiting. There may also be tract is often lithotripsy, a procedure that
gum margin, on the crowns of teeth in haematuria (blood in the urine). A blad- uses ultrasonic waves or shock waves to
areas close to the openings of salivary der stone usually causes difficulty in disintegrate the stones. Alternatively,
gland ducts. Subgingival calculus forms passing urine. cystoscopy can be used to crush and
below the gum margin, is more evenly DIAGNOSIS AND TREATMENT remove stones in the bladder and lower
distributed around all the teeth, and is Investigation of a suspected calculus ureter. In some cases, surgery may be
brown or black. usually starts with microscopic exami- needed to remove the stones.
Both types of calculus are hard and nation of the urine, which may reveal
are therefore difficult to remove; the red blood cells and the presence of calendar method
subgingival variety may be more diffi- crystals. The degree of acidity or alka- A method of contraception, also called
cult to remove because of its location linity of the urine may reflect the type the rhythm method, based on abstain-
and degree of calcification. of stone involved. The site of a stone ing from sexual intercourse around the
EFFECTS AND TREATMENT
The toxins present in calculus can lead
to gum inflammation (see gingivitis), URINARY TRACT CALCULI
which may progress to destruction of
Calculi form in the urinary tract when lodge in a ureter, causing renal colic (a
the supporting tissues (see periodontitis).
certain substances in the urine become sudden, severe pain in the small of the
Calculus should be removed on a regu- overly concentrated. The substances back that moves towards the groin) and
lar basis by professional scaling. Careful form crystals, which grow into stones. haematuria (blood in the urine). In the
attention to oral hygiene may reduce the Some stones may be associated with bladder, stones may settle over the
recurrence of dental calculus. recurrent episodes of urinary tract outlet, which can cause difficulty in
infection. Symptoms vary according to passing urine, a poor flow rate, and
calculus, urinary tract the site of the stone. Small stones may dribbling. Any obstruction to urine flow
A stone in the kidneys, ureters, or blad- be passed in the urine and cause no may result in rapid kidney damage and
der that is formed from crystallized symptoms. Some stones, however, may acute, severe infection (pyelonephritis).
substances in the urine.
Ureter Kidney
TYPES AND CAUSES
Kidney and ureteral stones Most stones
that form in the kidneys and ureters are
composed of calcium oxalate or other
salts crystallized from the urine. These
stones may be associated with a diet
that is rich in oxalates (which are
found, for example, in leafy vegetables
and tea); high levels of calcium in the
blood due to hyperparathyroidism (over- Bladder
activity of the parathyroid glands); or
Smaller
chronic dehydration. kidney
Other types of kidney or ureteral stone
stone are associated with gout and cer- Spine
tain cancers. Stones that develop in
Calyces
these locations due to chronic urinary
tract infection are termed “infective”. Staghorn
Kidney stones that fill the entire net- Bladder calculus
stone
work of urine-collecting ducts at the
Pelvis of
top of the ureter are called “staghorn” Pelvis kidney
calculi, due to their shape. Staghorn calculus
Bladder stones In developing countries, X-ray of a bladder stone Here, a staghorn calculus has filled the entire
bladder stones usually occur as a result A large bladder stone, such as the one that pelvis and calyces of the kidney, producing a
of dietary deficiencies. In developed can be clearly seen in this X-ray, can make the cast of them. A smaller stone has formed in
passing of urine both difficult and painful. the medulla (central area).
countries, they are usually caused by an
obstruction to urine flow from the

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 CALF MUSCLES

time of ovulation (the release of an egg immobile for a long time – for exam- is either absent or reduced. The pres-
from a woman’s ovary). This time is ple, after surgery or during a long ence and duration of nystagmus may be
calculated on the basis of the length of journey by air. Another possible prob- observed directly or recorded electri-
her previous menstrual cycles. The cal- lem is claudication (cramping pain often cally using electronystagmography.
endar method is unreliable because a due to narrowing of the arteries). In
woman’s menstrual cycle may vary. this last condition, pain is often caused calorie
C There are now more scientific and by walking and relieved by rest. A unit of energy. One calorie is the
effective contraceptive methods of this amount of energy that is needed to
type (see contraception, natural methods). caliper splint raise the temperature of 1 gram of
An orthopaedic device that corrects or water by 1°C. The term “calorie” is also
calf muscles controls a deformed leg or supports a used in medicine and dietetics to mean
The muscles extending from the back leg weakened by a muscular disorder, “kilocalorie”, which is a larger unit of
of the knee to the heel. The gastrocne- allowing an affected person to stand energy equal to 1,000 calories.
mius muscle starts behind the knee and and walk. For example, a person who Normally, when a person’s calorie
forms the bulky part of the calf; has lost the ability to flex the foot intake matches the amount of energy
beneath it lies the soleus muscle which upward and, as a result, drags the toes expended, body weight remains con-
starts at the back of the tibia (shin). on the ground with each step can be stant. If intake exceeds expenditure,
These two muscles join to form the fitted with a splint that keeps the foot weight is usually gained; if expenditure
Achilles tendon, which connects them to permanently at right angles to the leg, exceeds intake, weight is usually lost. In
the heel. Contraction of the calf mus- thereby allowing walking. general, fats contain more calories than
cles pulls the heel up and is important A caliper splint consists of one or proteins or carbohydrates.
in walking, running, and jumping. two vertical metal rods attached to Energy can also be measured in
leather or metal rings that are worn joules: 1 calorie equals 4.2 joules. (See
around the affected limb. A splint also calorimetry; diet and disease.)
LOCATION OF CALF MUSCLES extending just below the knee is suffi-
cient to control the position of the calorie requirements
The gastrocnemius muscle and the
ankle. Longer splints may be jointed to See energy requirements.
soleus muscle at the back of the leg
join to form the Achilles tendon. allow movement of the knee.
calorimetry
callosity The measurement of the calorie (ener-
See callus, skin. gy) value of foods or the energy
Gastrocnemius expenditure of a person. In direct
muscle
callus, bony calorimetry, a small measure of food is
A diffuse growth of new, soft bone that burned up inside a sealed container,
forms as part of the healing process in which is immersed in water. The resul-
a fracture. As healing continues, the cal- tant rise in water temperature is used to
lus is replaced by harder bone, and the calculate the calorie value.
original shape of the bone is restored. Energy production in humans can be
measured by oxygen uptake. Every litre
callus, skin of oxygen taken into the body pro-
An area of thickened skin, usually on duces 4.8 kilocalories of energy. The
Soleus muscle
the hands or feet, caused by regular or level of energy production is calculated
prolonged pressure or friction. A corn is by comparing the percentage of oxy-
a callus on a toe. If corns are painful, gen in air that is inhaled and exhaled.
Achilles tendon the thickened skin can be pared away
by a chiropodist using a scalpel. Calpol
A brand name for paediatric prepara-
caloric test tions containing the analgesic drug
A method of finding out whether the (painkiller) paracetamol.
Calcaneus labyrinth in the inner ear is diseased. A
caloric test may be performed as part of camouflaging preparations
investigations into vertigo (dizziness) Creams or powders that are applied to
and hearing loss. the skin to conceal skin disfigurements,
calf pain The outer-ear canal is briefly flooded such as birthmarks and scars.
Various disorders may be responsible with water of different temperatures,
for pain in the calf. Common causes above and below normal body temp- Campbell de Morgan’s spot
include cramp, muscle strain, and scia- erature. This flooding sets up convection A small (1–3 mm), bright red, domed
tica (inflammation of the sciatic nerve). currents in the semicircular canals in spot, also known as a cherry angioma,
More rarely, pain in the calf muscles the inner ear. If the labyrinth is normal, that appears on the trunk or limbs. A
may be due to blood clots in leg veins nystagmus (rapid reflex flickering of the Campbell de Morgan’s spot is a type of
(see thrombosis, deep vein). This disorder eyes) occurs for a predictable period. If haemangioma (a noncancerous blem-
is a particular risk if a person has been the labyrinth is diseased, this response ish). The spots are harmless. They are

138
 CANCERPHOBIA

caused by weakening of the walls of Possible causes of cancer include envi- reduced mortality from these tumours.
capillaries in the dermis (the inner ronmental factors (such as sunlight and Diagnosis of cancer after symptoms have
layer of the skin). Campbell de Mor- pollutants), alcohol consumption, diet- appeared is based on a physical examina-
gan’s spots are common in adults, ary factors, and, most particularly, tion, and confirmed by biopsy (removal
especially elderly people. smoking, which is responsible for of a sample of abnormal tissue for
more cancers than any other agent. All microscopic analysis) and imaging tests.
Campylobacter of these factors may provoke critical There are four main types of proce- C
A group of bacteria that are among the changes within body cells in people dure used to detect cancer: cytology
most common causes of gastrointes- who are already susceptible to develop- (cell) tests, imaging techniques, chemi-
tinal disorders. Campylobacter bacteria ing cancer. Susceptibility to certain cal tests, and direct inspection.
are harboured by animals and can be cancers may be inherited. TREATMENT AND OUTLOOK
passed on to humans through conta- SYMPTOMS Many cancers are now curable, usually
minated food, especially in poultry, Cancer symptoms depend on the site of by combinations of surgery, radiother-
causing food poisoning. These bacteria the growth, the tissue of origin, and apy, and anticancer drugs. For details of a
also cause a form of colitis, an inflam- the extent of the tumour. They may be a specific type of cancer, refer to the art-
matory disease of the colon. direct feature of the growth (for exam- icle on that organ (for example, see
ple, lumps or skin changes) or may lung cancer; stomach cancer).
canal result from disruption of the function
A narrow tubular passage or channel in of a vital organ or blockage of a part of cancerphobia
the body, such as the ear canal, which the body by the tumour. Unexplained An intense fear of developing cancer,
leads from the outer to the middle ear, weight loss is a feature of many differ- out of proportion to the actual risk,
or the alimentary canal, which is part ent types of cancer. that significantly affects the life of the
of the digestive system. DIAGNOSIS sufferer. An individual who has cancer-
Screening tests (see cancer screening) are phobia may become convinced that
cancer increasingly being used to detect early symptoms such as headaches, skin
Any of a group of diseases that are signs of certain types of cancer in peo- problems, constipation, or difficulty
characterized by the abnormal and ple who are thought to be at risk. Early in swallowing, are signs of cancer.
unrestrained growth of cells in body detection of cancer optimizes the Patterns of behaviour that are typical of
organs or tissues. Cancerous tumours chance of a cure; for this reason, obsessive–compulsive disorder (such as
can form in any tissue in the body, but screening for breast cancer, cancer of prolonged washing rituals) may be
they most commonly develop in major the cervix, and intestinal cancer has adopted in an attempt to reduce the
organs, such as in the lungs, breasts,
intestines, skin, stomach, or pancreas.
Cancerous tumours can also develop in TREATMENT OF CANCER
the nasal sinuses, the testes or ovaries,
The treatment of many cancers is still treatments is to suppress or arrest the
or the lips or tongue. Cancers may also primarily surgical. Excision of an early rate of cell division in any tumour cells
develop in the tissues of the bone mar- tumour will often give a complete cure. left after surgery. Anticancer drugs
row that form blood cells (see There may be small, undetectable often have unpleasant side effects
leukaemia) and in the lymphatic system, metastases (secondary tumours) at because it is sometimes difficult to
the muscles, or the bones. the time of operation, so surgery is direct specific drugs to their target,
Cancers differ from benign (non- commonly combined with radiotherapy and normal cells and tissues may be
cancerous) neoplasms (growths) in that and anticancer drugs. The aim of these disrupted along with the tumour cells.
they spread and infiltrate surrounding
normal tissue. The tumours can cause
blockages in hollow organs, such as
within the digestive tract. They can also
destroy nerves and erode bone. Cancer
cells may also spread through the blood
vessels or lymphatic system to other
organs to form secondary tumours,
known as metastases (see metastasis).
CAUSES Cancer
Treated
Tumour-forming cells develop when area
the oncogenes (genes controlling cell
growth and multiplication) in a cell or
cells undergo a series of changes. A
small group of abnormal cells develop
that divide more rapidly than normal,
lack differentiation (they no longer Before radiotherapy After radiotherapy
perform their specialized task), and The photograph shows a skin cancer on the This was the appearance a few weeks later,
back of the hand before treatment. after a course of radiotherapy.
may escape the normal control of hor-
mones and nerves.

139
 CANCER SCREENING

The condition is treated topically with

TESTS USED TO DETECT CANCER antifungal drugs such as clotrimazole or
with oral antifungals. The drugs are
Cytology These tests reveal the presence of potential or early cancer of the cervix.
tests abnormal cells. One example is the Another example is urine cytology, given in the form of creams, vaginal
cervical smear test, an investigation used to detect bladder cancer. Cells pessaries, or throat lozenges. Treatment
in which cells are scraped from the can also be removed from solid of candidiasis is usually successful, but
C cervix (neck of the uterus) and
examined microscopically to detect
lumps; this procedure is often
carried out on breast lumps.
the condition may recur.
Canesten cream
Imaging Imaging tests can sometimes reveal ultrasound scans can detect cancer A brand name for the antifungal drug
techniques changes in the appearance of tissue of the ovary. CT scanning and MRI
that are suggestive of cancer. One provide detailed images of internal
clotrimazole, used to treat fungal infec-
such test is a low-dose X-ray used in anatomy and are particularly useful tions of the skin and genitals (for
mammography to detect early for showing inaccessible areas, such example, candidiasis).
breast cancer. Another is ultrasound as the brain and the back of the
scanning; for example, pelvic abdominal cavity. canine tooth
See teeth.
Chemical Tests on blood, urine, or faeces can faeces may be due to cancer of the
tests show the presence of substances colon; high blood levels of prostate cannabis
suggestive of cancer. For example, specific antigen (PSA) are sometimes
microscopic amounts of blood in the due to prostate cancer. A preparation that is derived from the
hemp plant CANNABIS SATIVA and usually
Viewing Viewing tests involve looking inside a include colonoscopy, gastroscopy, used to produce euphoria and halluci-
techniques hollow organ using an endoscope (a cystoscopy, and laparoscopy nations (see marijuana).
tube with a viewing lens). They are (viewing of the colon, stomach,
usually performed only when cancer bladder, and abdominal cavity, cannula
is already suspected. Examples respectively).
A smooth, blunt-ended tube that is
inserted into a blood vessel, lymphatic
vessel, or body cavity, in order to intro-
risk of cancer. Psychotherapy, including situations it may multiply excessively. duce or withdraw fluids.
behaviour therapy, may be of benefit. Candidiasis may occur if antibiotic drugs Cannulas are used for blood transfu-
(See also phobia.) destroy the harmless bacteria that con- sions and intravenous infusions and for
trol the growth of the fungus, or if the draining pleural effusions (fluid around
cancer screening body’s resistance to infection is low- the lungs). If necessary, a cannula may
Tests that are carried out to detect can- ered. Certain disorders, for example be left in place for several days if con-
cer before symptoms have developed. diabetes mellitus, and the hormonal tinuous testing of, or introduction of,
Cancer screening is used particularly changes that occur during pregnancy fluids is required.
for groups of people who are thought or with oral contraceptives, may also
to be susceptible because of their age, encourage growth of the fungus. canthus
occupation, lifestyle, or genetic predis- Candidiasis can be contracted by The anatomical term for the corner of
position. Early detection often increases having sexual intercourse with an the eye (the angle at which the upper
the chance of a cure. Tests for cancers of infected partner. The infection is far and lower eyelids meet).
the cervix (see cervical smear test), breast more common in women than in men.
(see mammography), bladder, and colon SYMPTOMS capacity, iron-binding
have proved effective in reducing mor- Symptoms of vaginal infection include A measure of the level of transferrin, a
tality from these conditions. a thick, white discharge, genital irrita- protein that acts in addition to haemo-
tion, and discomfort on passing urine. globin (the oxygen-carrying pigment in
cancrum Less commonly, the penis is infected, the blood) to bind and transport iron
The medical term for canker or ulcera- usually causing balanitis (inflammation in the blood. Measuring iron-binding
tion. It mainly refers to the mouth and of the head of the penis). Oral candi- capacity may help to establish the cause
lips, when the condition is known as diasis produces sore, creamy-yellow, of anaemia (a reduced level of haemo-
cancrum oris. (See also noma.) raised patches inside the mouth. globin in the blood).
Candidiasis may spread from the Transferrin is formed mainly in the
candidiasis genitals or mouth to other moist areas liver. The amount produced is deter-
Infection by the fungus CANDIDA of the body. It may also affect the mined by the amount of iron that is
ALBICANS , also known as thrush or gastrointestinal tract, especially in peo- stored in the body. When iron stores are
moniliasis. Candidiasis affects areas of ple with impaired immune systems, low, as occurs in iron-deficiency anae-
mucous membrane in the body, most such as those taking immunosuppressant mia (see anaemia, iron-deficiency), more
commonly the vagina and the inside of drugs or who have HIV (the virus that transferrin is produced to enable the
the mouth. In infants, candidiasis can leads to AIDS). blood to carry as much iron as possi-
occur in conjunction with nappy rash. DIAGNOSIS AND TREATMENT ble. The level of transferrin and the
CAUSES Candidiasis is diagnosed by examina- iron-binding capacity of the blood are
The fungus is normally present in the tion of a sample taken from the white thereby raised, although the level of
mouth and the vagina, but in some discharge or from patches. iron in the body is low.

140
 CARBIMAZOLE

capacity, vital capillary haemangioma captopril

The maximum volume of air, usually See haemangioma. An ACE inhibitor drug. These drugs are
around 4.5 litres, that can be expelled used in the treatment of hypertension
from the lungs following maximum Caplan’s syndrome (high blood pressure), heart failure, and
inhalation. Vital capacity is measured as A combination of rheumatoid arthritis diabetic nephropathy (kidney damage).
part of lung function tests (see pul- and pneumoconiosis (a lung disorder
monary function tests). that is caused by inhalation of certain caput C
mineral dusts). In Caplan’s syndrome, The Latin word for head. The term is
cap, cervical large areas of fibrous (scar) tissue form commonly used of the caput succe-
A flexible contraceptive device that is in the lungs, often causing severe daneum: a soft, temporary swelling in
placed directly over the cervix to prevent shortness of breath. the scalp of newborn babies, which is
sperm from entering it (see contracep- caused by pressure during labour. The
tion, barrier methods of). capping, dental word “caput” was once also used to
See crown, dental. refer to the face, skull, and associated
cap, duodenal organs; to the origin of a muscle; or to
See duodenal cap. capsule any enlarged extremity, such as the
An anatomical structure enclosing an caput femoris, the head of the femur
Capgras’ syndrome organ or body part. For example, the (thigh bone).
The delusion (false belief) that a relative liver, kidneys, joints, and eye lenses are
or friend has been replaced by an identi- all enclosed in capsules. carbamazepine
cal impostor. Capgras’ syndrome, also The term “capsule” is also used to An anticonvulsant drug that is chemically
known as the “illusion of doubles’’, is describe a soluble, elongated shell, usu- related to the tricyclic antidepressants.
seen most frequently in patients with ally made of gelatine, which contains a Taken orally or as suppositories, carba-
paranoid schizophrenia but can also occur drug to be taken by mouth. The coating mazepine reduces the frequency of
in some organic brain disorders (see brain of some capsules prevents potentially seizures that are caused by abnormal
syndrome, organic) and affective disorders. irritant drugs from being released into nerve signals in the brain and is used
the stomach, or allows drugs to be mainly in the long-term treatment of
capillary released slowly to enable them to epilepsy. The drug is also prescribed to
Any of the vessels that carry blood be taken less frequently. relieve neuralgia (intermittent severe
between the smallest arteries, or arteri- pain caused by nerve damage or irrit-
oles, and the smallest veins, or venules capsulitis ation) and as a mood-stabilizing drug
(see circulatory system). Capillaries form Inflammation of a capsule, a structure in the treatment of psychiatric dis-
a fine network throughout the body’s that encloses an organ or joint. One orders such as mania.
organs and tissues. Their thin walls are example of capsulitis is frozen shoulder.
permeable; as a result, they allow blood carbaryl
and cells to exchange constituents such An insecticide used to treat head lice
as oxygen, glucose, carbon dioxide, STRUCTURE OF CAPILLARIES and crab lice. Carbaryl is applied topi-
and water (see respiration). cally as a liquid; however, it must not
These minute blood vessels have
Capillaries open and close to blood thin, permeable walls, which allow
come into contact with the eyes or
flow according to the requirements of the transfer of oxygen, glucose, and with areas of broken skin.
different organs for oxygen and nutri- water from blood to tissues.
ents. For example, when a person is carbenoxolone
running, most of the capillaries in the White blood An ulcer-healing drug that is used to treat
cell protruding
leg muscles are open, but at rest many through cell wall inflammation and ulceration of the
are closed. The opening and closing of oesophagus, but which has now largely
skin capillaries helps to regulate temper- been superseded by antibiotics and by
ature. The blood flow through each proton pump inhibitors. A gel contain-
capillary is controlled by a tiny circle of ing carbenoxolone is commonly used
muscle at its entrance. to relieve mouth ulcers.
DISORDERS
A direct blow to an area of the body carbimazole
may rupture the capillary walls, caus- A drug that is used to treat hyper-
ing bleeding under the skin, which in thyroidism (overactivity of the thyroid
turn results in swelling and bruising. Oxygen, gland). Carbimazole is slow to take
Capillaries become more fragile in glucose, effect, so beta-blockers may be given to
and water
elderly people, in people taking high relieve symptoms in the interim.
doses of corticosteroid drugs, and in Carbon dioxide, Long-term treatment with carbima-
those suffering from scurvy (vitamin C waste products, zole may reduce the production of
and excess water
deficiency). All such people have a ten- blood cells by the bone marrow, so
dency to develop purpura (small areas Red blood cell
regular blood counts are required. Side
of bleeding under the skin which often effects may include headaches, dizzi-
appear as reddish-purple patches). ness, joint pain, and nausea.

141
 CARBOCISTEINE

carbocisteine into simple sugars before they can be

A type of mucolytic drug that is used to absorbed by the body. This process is CARBOHYDRATE METABOLISM
thin sputum, making it easier to cough carried out by enzymes (chemical cata-
up. Carbocisteine may be helpful in lysts) in the digestive tract. Digestive enzymes act
on carbohydrates
chronic obstructive pulmonary disease The simple sugars (mainly glucose)
(see pulmonary disease, chronic obstruc- are then absorbed through the intes-
C tive) and cystic fibrosis. tinal wall and into the bloodstream
Carbohydrates
for distribution throughout the body. Starches, sugars, and cellulose
carbohydrates Some glucose is burned up imme-
A group of compounds, including diately (see metabolism) in order to
starches (complex carbohydrates) and generate energy for cells that need a Starches and Cellulose passes
sugars (simple carbohydrates), that are constant supply, such as brain cells and sugars are broken almost unaltered
composed of carbon, hydrogen, and red blood cells. Galactose and fructose down into through the
oxygen and supply the body with its are converted to glucose in the liver to monosaccharides system
main source of energy. be used by body cells. Surplus glucose
TYPES AND SOURCES is transported to the liver, muscles, and
Carbohydrates are found in fruits, cer- fat cells where it is converted into glyco-
eals, and root vegetables. They fall into gen and fat for storage.
two main groups: available carbohy- When blood glucose levels are high, Glucose Galactose Fructose
drates and unavailable carbohydrates. glucose storage is stimulated by insulin,
The main available carbohydrates are a hormone that is secreted by the
starches and sugars, which are meta- pancreas. When blood glucose levels
bolized into glucose for the body’s use. become low, insulin secretion dimin- Liver converts them to
Unavailable carbohydrates include cellu- ishes and glucagon, another hormone
lose, which cannot be broken down by produced by the pancreas, stimulates
digestive enzymes and makes up the the conversion of stored glycogen to
bulk of dietary fibre (see fibre, dietary). glucose for release into the blood- Liver, muscle, and fat
cells convert glucose to
CARBOHYDRATE METABOLISM stream. Fat cannot be converted to
The different types of carbohydrates are glucose, although it can be used as a
processed by the body in different fuel to conserve glucose. Glucose, which
ways. Monosaccharides (also known as In the disorder diabetes mellitus, is converted to
simple sugars), which include glucose carbohydrate metabolism is disturbed
(grape sugar), galactose (a milk sugar), by a deficiency of insulin.
and fructose (fruit sugar), can all be Glycogen, which
absorbed, unchanged, into the blood- carbolic acid is converted to
stream, whereas disaccharides (also See phenol.
known as “double” sugars), including
sucrose, maltose, and lactose (a milk carbon Fat, which may
be burned as fuel
sugar), need to be broken down into A nonmetallic element that is present
simple sugars before they are absorbed. in all the fundamental molecules of
Starches also have to be broken down living organisms, such as proteins, fats,
and carbohydrates, and well as in some
inorganic molecules, such as carbon
TYPES OF CARBOHYDRATE dioxide, carbon monoxide, and sodium Glucose is absorbed into the bloodstream for
distribution throughout the body or is used
bicarbonate. Pure carbon is the major
Monosaccharides are the simplest, directly by body cells.
consisting of a single saccharide
constituent of diamond, coal, charcoal,
molecule. Disaccharides consist of and graphite.
two linked saccharide molecules.
Polysaccharides consist of a long carbon dioxide (CO2) cises, CO2 levels in the blood rise, caus-
chain of many saccharide molecules. A colourless, odourless gas. Carbon ing the person to breathe more rapidly
Starch is an important carbohydrate dioxide consists of one carbon atom in order to expel carbon dioxide and to
and a major constituent in the diet. linked to two oxygen atoms and has take in more oxygen.
the chemical formula CO2. The gas is Carbon dioxide that is compressed
• Monosaccharides present in small amounts in the air and and cooled to -75ºC becomes solid dry
glucose, galactose, fructose is an important by-product of metabo- ice, which is used in cryosurgery (des-
lism in cells. It is produced by the truction of diseased tissues by freezing).
• Disaccharides breakdown of substances such as car-
sucrose, lactose, maltose bohydrates and fats to produce energy. carbon monoxide (CO)
It is then carried in the bloodstream to A colourless, odourless, poisonous gas.
• Polysaccharides the lungs, where it is exhaled. Carbon monoxide consists of one car-
starches, cellulose Carbon dioxide helps to control the bon atom linked to one oxygen atom
rate of respiration: when a person exer- and has the chemical formula CO. It

142
 CARCINOMA IN SITU

toxin is present in vehicle exhaust CHEMICAL CARCINOGENS screened by an official body (such as
fumes and is produced by inefficient Chemicals form the largest group of the Medicines Control Agency, which
burning of coal, gas, or oil. carcinogens. Major types include poly- assesses drugs in the UK) before it is
POISONING cyclic aromatic hydrocarbons (PAHs), allowed to be manufactured.
Carbon monoxide is toxic because it which occur in tobacco smoke, pitch,
binds with haemoglobin (the oxygen- tar fumes, and soot. Exposure to PAHs carcinogenesis
carrying molecule in red blood cells), may lead to cancer of the respiratory The development of a cancer caused by C
which prevents the blood from carry- system or skin. In addition, certain aro- the action of carcinogens (factors that
ing oxygen to the body tissues. As a matic amines used in the chemical and cause cancer) on normal cells.
result, the tissues are deprived of oxy- rubber industries may cause bladder Carcinogens are believed to alter the
gen, and asphyxiation occurs. The cancer after prolonged exposure. DNA in cells, particularly in oncogenes
initial symptoms of acute high-level PHYSICAL CARCINOGENS (genes that control the growth and
carbon monoxide poisoning include The best-known physical carcinogen is division of cells). An altered cell divides
dizziness, headache, nausea, and faint- high-energy radiation, such as nuclear abnormally fast, passing on the genetic
ness. Continued inhalation of the gas radiation and X-rays. Radiation may also changes to all of its offspring cells.
may lead to loss of consciousness, per- come from ultraviolet light, for example Thus, a group of cells is established that
manent brain damage, and even death. in sunlight. Another known physical is not affected by the body’s normal
Low-level exposure to carbon monox- carcinogen is asbestos (see asbestos- restraints on growth.
ide over a period of time may cause related diseases).
fatigue, nausea, diarrhoea, abdominal Exposure to radiation may cause can- carcinoid syndrome
pain, and general malaise. cerous changes in cells, especially in A rare condition caused by an intestinal
cells that divide quickly; for example or lung tumour, called a carcinoid,
carbon tetrachloride (CCl4) changes in the precursors of white which secretes excessive amounts of
A colourless, poisonous, volatile chem- blood cells in the bone marrow causes the hormone serotonin and often also
ical with a characteristic odour. Carbon leukaemia. The level of risk depends on other chemicals, such as bradykinin.
tetrachloride consists of one carbon the dosage and duration of exposure Carcinoid syndrome is characterized by
atom linked to four chlorine atoms and to the carcinogen. Over many years, bouts of facial flushing, diarrhoea, and
has the chemical formula CCl4. Former- exposure to ultraviolet radiation in sun- wheezing, but symptoms usually occur
ly used in domestic dry-cleaning fluids, light can cause skin cancer. only if the tumour has spread to the
its use is now restricted to industry. BIOLOGICAL CARCINOGENS liver or has arisen in a lung.
Carbon tetrachloride is an extremely Only a few biological agents are known Carcinoid tumours in the intestine,
dangerous chemical, and it can cause to cause cancer in humans. SCHISTOSOMA lung, and, more rarely, the liver are
dizziness, confusion, and liver and kid- HAEMATOBIUM , one of the blood flukes sometimes removed surgically, but, in
ney damage if a significant amount of responsible for the tropical disease most cases, surgery is unlikely to be of
the chemical is inhaled or swallowed. schistosomiasis, can cause cancer of the benefit. In these circumstances, symp-
(See also household poisons.) bladder; and ASPERGILLUS FLAVUS, a fungus toms may be relieved by drugs such as
that produces the poison aflatoxin in octreotide, which often inhibits the
carbuncle stored peanuts and grain, is believed to growth of the tumour.
A cluster of interconnected boils (pain- cause liver cancer.
ful, pus-filled, inflamed hair roots). Viruses that are associated with can- carcinoid tumour
Carbuncles are usually caused by infec- cer include some strains of the human A type of hormone-secreting cancerous
tion with the bacterium STAPHYLOCOCCUS papilloma virus, which are linked to tumour. Carcinoids most often occur in
AUREUS . The back of the neck and the cancer of the cervix; the hepatitis B and the small intestine or rectum but occa-
buttocks are the most common sites. C viruses, which are linked to liver can- sionally also develop in the lungs. (See
The swellings mainly affect people with cer; and some types of herpes virus, also carcinoid syndrome.)
reduced immunity, particularly those which are associated with Kaposi's sar-
with diabetes mellitus. coma and Burkitt’s lymphoma. carcinoma
Treatment is usually with an antibio- AVOIDANCE OF CARCINOGENS Any cancerous tumour (see cancer) that
tic drug. In addition, the application of In industry, known carcinogens may be arises from cells in the covering surface
hot compresses may encourage the pus- banned. Alternatively, as in the nuclear layer or lining membrane of an organ.
filled heads of the boils to burst, industry and in hospital X-ray depart- A carcinoma is distinguished from a
which relieves pain. Occasionally, inci- ments, they may be allowed only if sarcoma, which is a cancer arising in
sion and drainage (together with their use is considered essential, if bone, muscle, or connective tissue. The
removal of the core of the carbuncle) exposure to them is strictly limited, most common cancers of the lungs,
may be necessary if a carbuncle is per- and if regular medical screening is pro- breast, stomach, skin, cervix, colon,
sistent, and drainage and healing have vided for workers using them. and rectum are carcinomas.
not occurred spontaneously. Outside industry, people are exposed
to very few known, unavoidable, high- carcinoma in situ
carcinogen risk carcinogens. Any substance that The earliest, usually curable, stage of a
Any agent that is capable of causing could possibly be carcinogenic, such as cancer. In this stage, the disease has not
cancer, such as tobacco smoke, high- a food additive, a cosmetic, or a chemi- yet spread from the surface layer of
energy radiation, or asbestos fibres. cal for use in drugs, must be carefully cells in an organ or other tissue.

143
 CARCINOMATOSIS

carcinomatosis (the rapid, uncoordinated contraction with blood again. Cardiac massage is
The presence of cancerous tissue in dif- of individual heart muscle fibres) and continued until the heart resumes beat-
ferent sites of the body due to the asystole (the complete absence of heart ing or the person is declared dead.
spread of cancer cells from a primary muscle activity), which are the two There are two main types: external
(original) cancerous tumour. abnormalities of heart rhythm that can cardiac massage, which involves press-
SYMPTOMS lead to cardiac arrest. ing on the chest to squeeze the heart,
C The symptoms of carcinomatosis may Ventricular fibrillation may be cor- and internal cardiac massage, when the
include weight loss, lack of energy, and rected by defibrillation (the application exposed heart is massaged by hand.
various other problems depending on of an electric shock to the heart). Asys- (See also cardiopulmonary resuscitation.)
the sites of the metastases (secondary tole is more difficult to reverse but may
tumours). For example, metastases in respond to injection of adrenaline or to cardiac muscle
the lungs may cause coughing and an electrical pacemaker. See muscle.
breathlessness; those that develop in OUTLOOK
the liver may cause jaundice. In general, recovery after ventricular cardiac neurosis
DIAGNOSIS AND TREATMENT fibrillation is more likely than after a Excessive anxiety about the condition
A diagnosis of carcinomatosis may be cardiac arrest triggered by asystole. of the heart. Cardiac neurosis usually
confirmed by X-rays or by radionuclide follows a myocardial infarction (heart
scanning of the bones and lungs, by cardiac arrhythmia attack) or heart surgery, but sometimes
biochemical tests, or in the course of See arrhythmia, cardiac. occurs when the person has had no
an operation. Anticancer drugs or radio- previous heart trouble.
therapy may be given to destroy the cardiac asthma A person who has cardiac neurosis
metastases. The condition will not be Difficulty in breathing that is similar to experiences symptoms that are typical
improved by removing the primary asthma but is the result of pulmonary of heart disease, such as breathlessness
tumour unless the tumour is producing oedema (fluid on the lungs); the oed- and chest pain, and may be reluctant
a hormone that directly stimulates the ema, in turn, is due to heart failure (the to exercise or work for fear of having
growth of metastases. inability of the heart to cope with its a heart attack. Medical investigation
workload). Attacks of cardiac asthma reveals no physical problem, however.
cardiac aneurysm usually occur at night. The disorder is Psychotherapy may help an affected
Ballooning of an area of a ventricle not related to bronchial asthma and person to overcome the anxiety and
(lower chamber) of the heart, usually requires different treatment. resume a normal, active life.
as a result of damage following a myo-
cardial infarction (heart attack). (See also cardiac catheter cardiac oedema
ventricular aneurysm.) See catheterization, cardiac. An abnormal build-up of fluid in body
tissues that is caused by heart failure
cardiac arrest cardiac cycle (inability of the heart to cope with its
A halt in the pumping action of the The sequence of events, lasting for less workload). (See also oedema.)
heart. Cardiac arrest occurs when the than a second, that make up each beat
heart’s rhythmic muscular contractions of the heart. A heartbeat has three cardiac output
stop, and usually results from abnormal phases: diastole, atrial systole, and ven- The volume of blood pumped by the
electrical activity. It causes sudden col- tricular systole. In diastole, the heart heart each minute. Cardiac output is a
lapse, loss of consciousness, and the relaxes. During atrial systole, the atria measure that is used to assess how effi-
absence of pulse and breathing. (upper chambers of the heart) con- ciently the heart is working. At rest, a
CAUSES tract, and in ventricular systole, the healthy adult’s heart pumps between
The most common cause of cardiac ventricles (the heart’s lower chambers) 2.5 and 4.5 litres of blood per minute.
arrest is a myocardial infarction (heart contract. The sinoatrial node (the heart’s During exercise, however, this figure
attack). Other possible causes include natural pacemaker) regulates the tim- may rise to as much as 30 litres per
respiratory arrest, electrical injury, loss of ing of the phases by sending electrical minute. A low output during exercise
blood, hypothermia, drug overdose, and impulses to the atria and the ventricles. may indicate damage to the heart mus-
anaphylactic shock (an extremely severe cle or major blood loss.
type of allergic reaction). cardiac dysrhythmia
DIAGNOSIS AND TREATMENT See dysrhythmia, cardiac. cardiac stress test
The survival of the patient depends on One of a group of tests used to assess
prompt restoration of the heartbeat cardiac massage the function of the heart in people who
and the oxygen supply to the brain. Rhythmic compression of the heart. experience chest pain, breathlessness,
Cardiopulmonary resuscitation may be Cardiac massage is performed when the or palpitations during exercise. A car-
used to maintain the circulation until heart has stopped beating, in order to diac stress test establishes whether the
the heartbeat resumes. maintain blood circulation, especially patient has coronary artery disease (in
A diagnosis of cardiac arrest can only to vital organs such as the brain. It which the blood supply to the heart
be confirmed by monitoring the elec- involves repeatedly squeezing the heart muscle is impaired).
trical activity of the heart using ECG. to force blood out of it and into the An ECG machine records the patterns
This helps medical personnel distin- circulatory system, then releasing the of the heart’s electrical activity while
guish between ventricular fibrillation pressure on the heart so that it fills the heart is stressed. This is usually

144
 CARDIOPULMONARY RESUSCITATION

achieved by the patient exercising on a pump blood. These disorders include In hypertrophic cardiomyopathy, the
treadmill or stationary bicycle. Specific hypertension (high blood pressure), heart muscle is abnormally thickened.
changes in the electrical pattern as which causes the wall of the left ventri- This condition is usually inherited.
exercise levels increase indicate angina cle to thicken; pulmonary hypertension In dilated cardiomyopathy, which is
pectoris (chest pain due to impaired (raised blood pressure in the lungs), in often of unknown cause, metabolism
blood supply to the heart muscle). which the wall of the right ventricle (chemical activity) of the heart muscle
Cardiac stress testing may also be thickens; and one type of cardiomyo- cells is abnormal and the heart’s walls C
used in conjunction with radionuclide pathy (disease of the heart muscle), in tend to balloon out under pressure.
scanning in order to identify damaged which the walls of one or both ventri- Restrictive cardiomyopathy is a con-
areas of heart muscle. cles may thicken. dition in which the heart walls are
Dilation of a heart chamber may unusually inflexible, so that the heart
cardiology be due to heart valve incompetence cannot fill sufficiently with blood. It is
The study of the function of the heart (failure of a valve to close properly often caused by scarring of the endo-
and the investigation, diagnosis, and after a contraction). In aortic insuffi- cardium (the inner lining of the heart)
medical treatment of disorders of the ciency, failure of the aortic valve to or by amyloidosis (infiltration of the
heart and blood vessels, such as athero- close completely allows blood to flow muscle with a starchlike substance).
sclerosis (fat deposits on the artery walls) back from the aorta into the left ventri- SYMPTOMS AND SIGNS
and hypertension (high blood pressure). cle after each contraction, eventually Symptoms of cardiomyopathy include
Some disorders reduce the pumping enlarging the chamber. fatigue, palpitations, and chest pain.
efficiency of the heart. They include SYMPTOMS Palpitations may be due to an abnormal
arrhythmias (abnormalities in the rate Symptoms of cardiomegaly may not heart rhythm such as atrial fibrillation
or rhythm of the heartbeat; see arrhyth- occur until the heart has enlarged to (rapid, uncoordinated contractions of
mia, cardiac), coronary artery disease (in the point where it cannot cope with the upper chambers of the heart).
which the blood supply to the heart additional stress (for example, as a The condition may lead to heart fail-
muscle is impaired), cardiomyopathy (in result of exercise or infection). The ure, in which the pumping action of
which the heart muscle itself is abnor- heart’s reduced pumping efficiency the heart becomes less efficient. Symp-
mal), and heart valve disorders. leads to heart failure, with symptoms of toms of heart failure include breathing
Some babies are born with structural breathlessness and ankle swelling. difficulty and oedema (abnormal fluid
defects of the heart and/or the major DIAGNOSIS AND TREATMENT accumulation in body tissues).
blood vessels that emerge from it (see Cardiomegaly is diagnosed by a physi- DIAGNOSIS
heart disease, congenital). Diseases of the cal examination, chest X-ray, and ECG A chest X-ray may show enlargement of
lungs and blood vessels can also have (measurement of the electrical activity the heart, and echocardiography (an
adverse effects on heart function. of the heart). Treatment is directed at ultrasound technique for imaging the
Many people with heart problems the underlying cause. structure and movement of the heart)
are treated by their general practition- may show thickened heart muscle. A
ers, but some may be referred to a cardiomyopathy biopsy (small tissue sample removed for
cardiologist (a heart specialist). Investi- Any disease of the heart muscle that microscopic analysis) of heart muscle
gations may include tests such as weakens the force of cardiac contrac- may reveal muscle cell abnormalities.
echocardiography (viewing the structure tions, thereby reducing the efficiency TREATMENT
and movement of the heart using ultra- of blood circulation. Cardiomyopathies Symptoms of cardiomyopathy may be
sound) and detailed interpretation of may be the result of infectious, meta- treated with diuretic drugs to control
ECGs (electrocardiograms, which mea- bolic, nutritional, toxic, autoimmune, heart failure and antiarrhythmic drugs to
sure the electrical activity of the heart). or degenerative disorders. However, in correct the abnormal heart rhythm. In
If coronary artery disease is suspected, many cases, the cause is unknown. many cases, heart muscle function
the cardiologist may perform coronary TYPES deteriorates, and the only remaining
angiography (taking X-ray images of There are three principal forms of the option is a heart transplant.
blood vessels) and possibly widen any condition: hypertrophic, dilated, and
blocked blood vessels (see angioplasty, restrictive cardiomyopathy. cardiopulmonary bypass
balloon). A cardiologist may, in turn, The procedure by which the circulation
refer a patient to a cardiovascular sur- of blood around the body is main-
geon if surgical treatment is required. tained while the heart is stopped during
heart surgery. A heart–lung machine is
cardiomegaly used to maintain the supply of oxy-
Enlargement of the heart. This condi- genated blood to the body tissues.
tion may take the form of hypertrophy
(thickening) of the heart muscle or of cardiopulmonary resuscitation
dilatation (increase in volume) of one The administration of life-saving mea-
or more of the heart chambers. sures to a person who has suffered a
CAUSES cardiac arrest (in which the heart stops
Hypertrophy of the heart muscle Chest X-ray showing cardiomyopathy
pumping blood). A person in cardiac
occurs in conditions in which the heart The heart has become greatly enlarged as a result arrest shows no sign of breathing and
has to work harder than normal to of the heart-muscle abnormality. has no detectable pulse or heartbeat.

145
 CARDIOTOCOGRAPHY

Brain damage is likely if the brain is infection but may be associated with a early stages, dental caries does not usu-
starved of blood, and therefore oxygen, myocardial infarction(heart attack) or an ally cause any symptoms. Advanced
for more than three to four minutes. autoimmune disorder, such as systemic decay causes toothache (see pulpitis),
First, mouth-to-mouth resuscitation lupus erythematosus. however, which may be aggravated by
(see rescue breathing) is given in order eating very sweet, hot, or cold food.
to restart the casualty’s breathing. If this caries, dental Sometimes advanced decay can also
C step fails, repeated chest compressions, The gradual erosion of enamel (the cause halitosis (bad breath).
using the heel of the hand, are applied hard covering of a tooth) and dentine TREATMENT
to the lower part of the breastbone (see (the softer substance that lies beneath Treatment consists of drilling away the
external cardiac massage) until emer- the enamel). This condition is more area of decay and filling the cavity (see
gency medical help arrives. These commonly known as tooth decay. filling, dental). In advanced decay, it may
measures are used alternately to restore CAUSES be necessary to remove the infected
blood circulation to the brain. The main cause of dental caries is pulp and replace it with a filling (see
plaque, a sticky substance consisting of root-canal treatment) or to extract the
cardiotocography food deposits, saliva by-products, and tooth (see extraction, dental).
See fetal heart monitoring. bacteria that collects on the surface of PREVENTION
teeth. The breakdown of food deposits The risk of dental caries occurring is
cardiovascular by bacteria creates acid that eats into reduced by cutting down on sugar con-
A term that means “pertaining to the the enamel to form cavities. Left un- sumption, practising good oral hygiene,
heart and blood vessels”. checked, decay spreads to the dentine, and visiting the dentist regularly. Water
and as the cavity enlarges, bacteria may fluoridation and the use of fluoride
cardiovascular disorders invade and destroy the pulp tissue at toothpaste also helps to prevent caries.
Disorders of the heart (see heart disor- the core of the tooth.
ders box), blood vessels, and blood SYMPTOMS carminative
circulation (see arteries, disorders of; Initial decay usually occurs on the A medicine that relieves abdominal
veins, disorders of). grinding surfaces of the back teeth and wind (flatulence). Carminatives are used
on areas around the gum line. In the in the treatment of colic.
cardiovascular surgery
The branch of surgery that is con-
CAUSES OF CARIES (TOOTH DECAY)
cerned with the heart and blood
vessels. Cardiovascular surgery can be
The primary cause of tooth decay is
divided into two main areas.
dental plaque, a sticky substance that
One area, sometimes called cardio- forms on the teeth. Plaque consists of
thoracic surgery, includes operations to food remains, saliva by-products, and
prevent or repair damage to the heart the bacteria that live in the mouth. The
itself and to the major blood vessels bacteria feed mainly on the fermentable
within the chest cavity. Cardiothoracic carbohydrates (simple sugars and
surgery is used, for example, to help starches) in food, and, in breaking them
treat damage due to congenital heart down, create an acid that gradually
disease (see heart disease, congenital) or destroys enamel, forming a cavity. If the
a myocardial infarction (heart attack). process is not checked, the dentine is
The second area, which is known as eroded next, enlarging the cavity and Micrograph of dental caries
vascular surgery, is concerned with the enabling the bacteria to invade the The surface enamel of this decaying molar tooth
pulp at the centre of the tooth. is being broken down.
treatment of blood vessels elsewhere in
the body, such as in the legs. (See also
heart valve surgery, coronary artery bypass, Enamel
and heart transplant.) Dentine

Acid produced
cardioversion
An alternative name for defibrillation.
1 in the break-
down of food
gradually destroys
carditis enamel, forming
a cavity.
2to theUnchecked,
decay spreads
dentine.
A general term for inflammation of any
part of the heart or its linings. There Pulp cavity
are three types. Myocarditis (inflamma-
The cavity
tion of the heart muscle) is usually
caused by a viral infection. Endocarditis 3enlarge,
continues to
enabling
(inflammation of the internal lining of the bacteria to If untreated, the
the heart) is usually due to a bacterial
infection. Pericarditis (inflammation of
invade exposed
pulp at the
4die and
infected pulp will
the tooth
the outer covering of the heart) is usu- tooth’s centre. will be destroyed.
ally the result of a viral or bacterial

146
 CARPAL TUNNEL SYNDROME

carotenaemia carotid sinus syndrome

A harmless condition in which blood LOCATION OF CAROTID ARTERY A condition mainly affecting elderly
levels of carotene, an orange pigment in people, in which the carotid sinus, a
The common carotid artery runs up
certain vegetables, are very high as a each side of the neck and divides to
structure within the common carotid
result of excessive intake of these foods. form internal and external branches. artery of the neck that regulates blood
Carotenaemia may cause temporary pressure, is overly sensitive.
yellowing of the skin, especially on The carotid sinus is a pocket in the C
the palms and soles. Unlike jaundice, artery at the point where the vessel
carotenaemia does not cause yellowing divides to form two branches. It con-
of the whites of the eyes. tains sensors that continually monitor
blood pressure. When the blood pres-
carotene Internal sure is raised, the sinus sends messages
A yellow or orange pigment found in carotid to the brain, which signals blood ves-
carrots, tomatoes, and leafy green vege- sels to widen and the heart rate to slow,
tables. The most important form of Carotid thus lowering the pressure.
carotene is beta-carotene, an antioxidant. sinus In carotid sinus syndrome, the sinus
Beta-carotene is converted in the intes- reacts too readily: simply turning the
tines into retinol (see vitamin A), which neck suddenly or coughing can trigger
is essential for vision and healthy skin. the sensors. As a result, the brain slows
Excessive intake of foods containing the heart rate and lowers blood pres-
carotene may cause carotenaemia (tem- Right sure excessively, causing the affected
common
porary yellowing of the skin). carotid External
person to faint. This problem may be
carotid avoided by the insertion of a pacemaker,
carotid artery which will help to maintain a normal
Any of the main arteries of the neck Left heart rate, overriding any inappropriate
and head. There are two common common messages from the carotid sinus.
carotid
carotid arteries (left and right), each of
which divides into two main branches carpal tunnel syndrome
(internal and external). Numbness, tingling, and pain in the
The left carotid artery arises from carotid bruit thumb, index finger, and middle fin-
the aorta and runs up the neck on the An abnormal noise in a carotid artery gers. Carpal tunnel syndrome is caused
left side of the trachea (windpipe). The (one of the major arteries supplying by compression of the median nerve at
right carotid artery arises from the the neck and head), which is due to the wrist. The carpal tunnel, through
subclavian artery (which branches off turbulent blood flow. A doctor can hear which the nerve passes, is a narrow gap
the aorta) and follows a similar route the noise with a stethoscope placed on formed by the carpal bones of the wrist
on the right side of the neck. Just the side of a person’s neck, over the and a ligament that lies over them. The
above the level of the larynx (voice- artery. A carotid bruit indicates narrow- condition may affect one or both of the
box), each carotid artery divides to ing (stenosis) of the artery, usually due hands and is sometimes accompanied
form an external carotid artery and an to fatty deposits on the blood vessel by weakness in the thumb. Symptoms
internal carotid artery. lining (see atherosclerosis). may be worse at night.
The external arteries have multiple CAUSES
branches that supply most of the tissues carotid doppler scanning Carpal tunnel syndrome is common
in the face, scalp, mouth, and jaws. The A method for assessing blood flow among people who use computer key-
internal arteries enter the skull to sup- through the carotid arteries (the major boards, who make constant, repetitive
ply the brain and eyes. At the base of arteries supplying the neck and head) hand movements. The condition also
the brain, branches of the two internal by the use of ultrasound scanning. occurs without obvious cause in mid-
carotids and the basilar artery join to Carotid doppler scanning is used to dle-aged women. In addition, it is quite
form a ring of blood vessels called the investigate certain disorders, such as common in pregnancy; in women who
circle of Willis. Narrowing of these ves- carotid artery stenosis (narrowing of have begun using oral contraceptives; in
sels may be associated with transient the artery), transient ischaemic attacks, those who suffer from premenstrual syn-
ischaemic attack (TIA); obstruction of and stroke, that may be the result of drome; and in men and women who
them causes a stroke. narrowing of the common carotid suffer from rheumatoid arthritis, myxo-
The carotid arteries have two special- arteries and their branches. edema (thickening and coarsening of
ized sensory regions in the neck: the An ultrasound transducer is moved the skin and other body tissues), and
carotid sinus, which monitors blood over each side of the neck in the area of acromegaly (a condition in which there
pressure, and the carotid body, which the carotid arteries. The transducer is abnormal enlargement of the skull,
monitors the oxygen content of the emits ultrasound waves, which are jaw, hands, feet, and internal organs).
blood and helps to regulate breathing. reflected off the moving blood cells TREATMENT
The carotid artery is one of the points and blood-vessel walls to produce an The condition often disappears without
at which the pulse can be measured. image on a screen. This image reveals any treatment. Persistent symptoms
(See also carotid bruit; carotid doppler any narrowing of the arteries or turbu- may be treated by the injection of a
scanning; carotid sinus syndrome.) lence in blood flow. corticosteroid drug under the ligament.

147
 CARPOPEDAL SPASM

Alternatively, the ligament may be cut cartilage. During childhood, the carti- harden as they dry. Casts are removed
surgically in order to relieve pressure lage is gradually converted to bone by a using an electric saw that cuts through
on the nerve. process known as ossification. the cast but does not damage the skin.
TYPES
carpopedal spasm There are three main types of cartilage: castor oil
Involuntary contraction of muscles in hyaline cartilage, fibrocartilage, and A colourless or yellow-tinged oil that is
C the hands and feet. Carpopedal spasm is elastic cartilage. Each type is composed obtained from the leaves of the castor
due to low levels of calcium in the of a different proportion of collagen oil plant, RICINUS COMMUNIS. If taken oral-
blood. This problem, in turn, may be and has a particular function. ly, castor oil irritates the lining of the
caused by hyperventilation (abnormally Hyaline cartilage is a tough, smooth small intestine and has a powerful laxa-
rapid breathing) or by disorders such tissue that lines the surfaces of joints, tive action that completely empties the
as hypoparathyroidism. such as the knee, providing an almost bowel. Zinc and castor oil are com-
frictionless layer over the bony parts of bined in a soothing ointment to treat
carpus the joint. If the lining becomes worn conditions such as nappy rash.
The eight bones of the wrist. (as occurs in osteoarthritis) or damaged,
the movement of that joint may be castration
carrier painful or severely restricted. The surgical removal of the testes (see
A person who is able to pass on an Fibrocartilage contains a large pro- orchidectomy). The term “castration” is
infectious or inherited disease without portion of collagen and is solid and sometimes also used to refer to removal
actually suffering from it themselves. strong. This type of cartilage makes up of the ovaries (see oophorectomy).
the discs that are situated between the Castration is performed when the
car sickness bones of the spine (see disc, interverte- testes or ovaries are diseased. It may
See motion sickness. bral). It also forms the shock-absorbing also be carried out in order to reduce
pads of tissue within joints. the level of testosterone (a male sex hor-
cartilage Elastic cartilage is soft and rubbery. mone produced in the testes) or of
A type of connective tissue (a material It is found in structures such as the oestrogen (a female sex hormone pro-
that holds body structures together) outer ear and the epiglottis. duced in the ovaries) in people who
made up of varying amounts of the have certain types of cancer that are
gel-like substance collagen. Cartilage is caruncle stimulated by these hormones.
not as hard as bone, but it nevertheless A general term for a small, fleshy swel- Orchidectomy and oophorectomy
forms an important structural compo- ling. Caruncles can be normal, such as are performed less frequently since the
nent of various parts of the skeletal the red, raised tissue in the inner cor- introduction of gonadorelin analogues,
system, including the joints. Much of ner of the eye. Some are abnormal, which are drugs that also act to reduce
the fetal skeleton is formed entirely of appearing as polyp-like growths; this the amount of testosterone and oestro-
type may be found, for example, at the gen produced by the body.
opening of the urethra (the tube by
TYPES OF CARTILAGE which urine leaves the bladder). catabolism
A chemical process by which con-
The three main types of cartilage Casal’s necklace stituents of food stored in the body
have different amounts of collagen,
vary in toughness and elasticity, and
A red rash forming a clearly defined (for example, fats) are broken down,
exist at different sites in the body. ring around the neck. It is a symptom releasing energy into the body cells
of pellagra, a disorder caused by lack of (see biochemistry; metabolism).
Fibrocartilage the B vitamin niacin in the diet.
Elastic catalepsy
cartilage cascara A physical state in which the muscles
A type of stimulant laxative drug, which of the face, body, and limbs stay in a
can be used when rapid onset of action semi-rigid, statuelike position for min-
is needed. Cascara is now rarely used. utes, hours, or even days. Catalepsy
Hyaline sometimes occurs in people who have
cartilage caseous abscess schizophrenia or epilepsy but may also be
An abscess (collection of pus) contain- due to brain disease or certain drugs.
ing matter that resembles curds or
cottage cheese. Caseous abscesses are catalyst
most commonly due to tuberculosis. A substance, such as an enzyme, that
increases the rate of a chemical reaction
cast without being permanently changed
A rigid casing applied to a limb or other itself by that reaction.
part of the body to hold a broken bone
or dislocated joint in position as it cataplexy
heals. Most casts are made of bandages A sudden loss of muscle tone, causing
impregnated with resin or plaster of an involuntary collapse without loss of
Paris, which are applied while wet and consciousness. Triggered by intense

148
 CATATONIA

emotion, particularly laughter, it occurs and those with other eye disorders, a catatonia
almost exclusively in sufferers of sleep contact lens or spectacle lens fitted after A state in which a person becomes
disorders such as narcolepsy. the operation may be preferable. mute or adopts a bizarre, rigid pose.
The eyes usually remain open and the
cataract catarrh person may seem awake, but they make
Loss of transparency of the lens of the Oversecretion of mucus by inflamed no voluntary movements. The state is
eye, as a result of changes in its protein mucous membranes (see rhinitis), sinuses seen in a rare form of schizophrenia and C
fibres. At an advanced stage, the front (see sinusitus) or air passages. some types of brain disease.
part of the lens becomes densely
opaque, but the cataract never causes
total blindness. A densely opalescent PROCEDURE FOR CATARACT SURGERY
lens will still transmit light, but the
clarity and detail of the image will be In a normal, healthy lens there is no opacities, however, such as that shown
interference with the passage of light on the right, cause deteriorating vision.
lost. Cataract usually occurs in both
rays. Even when peripheral opacities The affected lens cannot be restored
eyes, but in most cases one eye is more develop, vision is not limited until the to its former transparency, hence the
seriously affected than the other. central zone is affected. Dense nuclear need for surgical replacement.
CAUSES
Almost everyone over 65 has some
Dense nuclear cataract
degree of cataract; the condition might
be considered part of the normal aging
process. Regular exposure to ultraviolet
light increases the risk.
Other causes of cataract include an
injury to the eye, particularly if a for-
eign body enters the lens. Cataract is
also common in people with diabetes Normal lens
mellitus and may develop at an earlier
age if blood sugar levels are not well
controlled. Long-term use of cortico-
steroid drugs may contribute to cataract.
Congenital cataract may be due to an Appearance of cataract
In preparation for surgery, measurements are
infection of the mother in early preg- taken of the cornea and the eye’s length to
nancy, especially with rubella (German Peripheral cataract calculate the power of the lens implant that will
measles), or to the toxic effects of cer- be needed to restore vision fully. The operation
tain drugs in pregnancy. It may also be may be performed using general or local
anaesthesia; there is no pain in either case.
associated with Down’s syndrome or the Instruments of remarkable delicacy and
rare genetic disorder galactosaemia. precision are used for the procedure, usually
SYMPTOMS with the help of microscope magnification.
Cataract is entirely painless and causes
only visual symptoms. The onset of
symptoms is almost imperceptible,
although night driving may be affected
in the early stages. There is slow, pro-
gressive loss of visual acuity (increasing Artificial
Probe lens
blurring of vision). The person may Cornea sucks out
become shortsighted and notice distur- softened
lens
bances in colour perception. tissue
TREATMENT
When vision has become significantly Plastic
impaired, cataract surgery is performed Lens loop
Iris capsule
to remove the lens and replace it with Artificial
an implant. Provided the eye is other- lens
wise healthy, cataract surgery generally held
in place
gives excellent results. by loop

cataract surgery
An ultrasound probe is The ultrasound probe An artificial lens is placed
Removal of the lens from the eye. Catar-
act surgery is done to restore sight in
1capsule
inserted into the lens
through a small
2emitting
softens the lens by
sound waves. It then
3 inside the lens capsule.
The incision in the cornea is
people whose vision is impaired by a incision in the cornea. The sucks out the softened lens left to heal naturally, or it may
cataract. The lens is usually replaced incision is made using a tissue. Only the front part of be closed with a few surgical
diamond tipped instrument. the lens capsule is removed. stitches.
with a plastic implant during the oper-
ation. Alternatively, for young people

149
 CATHARTHIS

catharthis catheterization, urinary a catheter into the bladder directly

A word that means purification or The insertion of a sterile catheter (a through the abdominal wall, and this is
cleansing. The term “catharsis” is used flexible tube) into the bladder in order carried out under local anaesthesia (see
in medicine to refer to the process of to drain urine from the body. anaesthesia, local).
cleaning out the bowels. In addition, WHY IT IS DONE
the term was used by Sigmund Freud Urinary catheterization is carried out cation
C in psychoanalytic theory to describe the when a person is unable to empty the An ion of positive charge. An example
expression of previously repressed feel- bladder normally or is incontinent (see of a cation is the sodium ion in saline
ings and memories. Freud believed that incontinence, urinary). The procedure is solution. (See also electrolyte.)
the revival of “forgotten” memories also performed during certain opera-
and the expression of the emotions tions in which a full bladder might cation exchange resin
associated with them could bring relief block the surgeon’s view of surround- A type of drug used to remove excess
from anxiety, tension, and a variety of ing organs; in bladder function tests potassium that has accumulated in the
other psychological symptoms. such as cystometry and cystourethrogra- body because of renal failure.
phy; and to monitor urine production
cathartic in critically ill patients. CAT scanning
A term that means “having the power HOW IT IS DONE An abbreviation for computerized axial
to purify or cleanse”. A cathartic drug There are two principal techniques: tomographic scanning, which is com-
stimulates movement of the bowels urethral catheterization (described in monly known as CT scanning.
(see laxative drugs). the illustrated box below), and supra-
pubic catheterization. cat-scratch fever
catheter Suprapubic catheterization is used if An uncommon disease that develops in
A flexible tube that is inserted into the it is not possible to pass a catheter up people (mostly children) who have
body to drain or introduce fluids or to the urethra (for example, if the urethra suffered a scratch or bite from a cat.
carry out other functions. Catheters are is abnormally narrow). This form of The fever is due to infection with a
commonly used to drain urine from catheterization involves the insertion of bacterium called BARTONELLA HENSELAE.
the bladder (see catheterization, urinary).
Other procedures using catheters may
be performed in order to investigate URETHRAL CATHETERIZATION OF THE BLADDER
the condition of the heart (see cathet-
A urinary catheter is usually passed Catheter Bladder
erization, cardiac), to widen obstructed
into the bladder through the urethra.
blood vessels, or to control bleeding. First, the doctor or nurse cleans the
Prostate
(See also balloon catheter.) opening of the urethra with antiseptic
solution to avoid introducing infection
catheterization, cardiac into the urinary tract. He or she then
A diagnostic procedure in which a fine, applies a local anaesthetic gel to the
sterile catheter (flexible tube) is intro- urethra. The procedure usually takes
duced into the heart through a vein or about 10 minutes.
artery in the arm or leg. Cardiac
catheterization is used to diagnose and
assess the extent of congenital heart
disease (see heart disease, congenital)
and coronary artery disease, and to diag-
nose and treat some disorders of the Bag
heart valves (see valvuloplasty).
During the procedure, the pressure
within the chambers of the heart may
2000
be measured, samples of blood and 1600

1000

tissue may be taken for laboratory

analysis, or a radiopaque dye (a sub- 500

stance that is opaque to X-rays) may be 100

50

injected into the arteries in order for

the cavities of the heart to be visible on
an X-ray (see angiography). Balloon Hole in tip of
inflated catheter to
The procedure causes little discom- Catheter allow urine
fort and is performed under local to drain.
anaesthesia (see anaesthesia, local). A Inserting a catheter Self-retaining catheter
small incision is made in an artery or The catheter is passed up the If the catheter is to remain in the bladder,
vein near the skin surface, and the urethra until urine flows down a self-retaining type is used. This catheter has
catheter is introduced into the vessel. the tube, indicating the tip is a balloon at its tip that can be inflated and filled
in the bladder. with sterile water.
The tube is passed along the blood ves-
sels and into the heart.

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 CAVERNOUS SINUS THROMBOSIS

SYMPTOMS allergic reactions to dander (scales from area may be red and tender, or blue,
The main symptom, appearing three to animal skin, hair, or feathers) that may cold, and clammy. The condition may
ten days after the bite or scratch, is a cause asthma or urticaria (nettle rash). be aggravated by light sensations, such
swollen lymph node near the affected PREVENTION as touch, or by emotional factors.
area. The node may become painful and Diseases from cats can be avoided by In some cases, treatment with antide-
tender, and an infected blister may good hygiene, such as hand-washing, pressant drugs or anticonvulsant drugs is
develop at the site of the injury. A fever, particularly after touching a cat. All pets effective. A few people benefit from C
rash, and headache may occur. should have regular worming and flea sympathectomy, in which nerves supply-
DIAGNOSIS AND TREATMENT treatment and veterinary care if ill. ing the affected area are severed.
Diagnosis of cat-scratch fever is con-
firmed by biopsy (removal of a small cauda equina caustic
sample of tissue for microscopic analy- A “spray’’ of nerve roots resembling a Describes substances that have a burn-
sis) of the swollen lymph node and by a horse’s tail that descends from the ing or corrosive action on body tissues
skin test. Analgesic drugs (painkillers) lower spinal cord and occupies the lower or a burning taste. An example is caus-
may be used to relieve the fever and third of the spinal canal. tic soda, the common name for sodium
headache. In most cases, the illness clears hydroxide. Caustic agents such as silver
up completely within two months. caudal nitrate are used to destroy warts.
This word is used to refer to the lower
cats, diseases from end of the spine. The word “caudal” cauterization
Cats carry various parasites and infec- means “of the tail”. The application of a heated instrument
tious organisms that can be spread to to destroy tissues, stop bleeding, or pro-
humans. Some of these are specific to caudal block mote healing. Cauterization may be used
cats; others may also affect dogs. A type of nerve block in which a local to treat conditions such as haemorrhoids
SPECIFIC DISEASES anaesthetic is injected into the lower (piles) and cervical erosion. It has been
The most serious disease that can be part of the spinal canal (the central largely replaced by electrocoagulation (use
contracted from an infected cat is rab- space within the spine). Caudal block of high-frequency electric current and,
ies. Anyone who is bitten by a cat (or may be used to anaesthetize the but- increasingly, laser to seal blood vessels).
any other animal) in a country where tocks and genitals as part of obstetric
rabies is present should seek medical and gynaecological procedures. Caverject preparations
advice without delay. A brand name for preparations of alpros-
Cat-scratch fever is an uncommon ill- cauliflower ear tadil, a prostaglandin drug used to treat
ness that is caused by infection with Painful, swollen distortion of the pinna impotence, normally by self-injection.
the bacterium BARTONELLA HENSELAE fol- (ear flap) resulting from blows or fric-
lowing a scratch or bite from a cat. tion that have caused bleeding in the cavernous sinus thrombosis
Cats commonly carry the protozoan soft cartilage of the ear. Blockage of a venous sinus (a channel
(single-celled parasite) TOXOPLASMA GONDII, Immediate treatment following an for venous blood located deep inside
which causes the disease toxoplasmosis. injury involves the use of ice-packs to the skull behind an eye socket) by a
Infection with the parasite, which is reduce the swelling. In severe cases, a thrombus (an abnormal blood clot).
usually from contact with a cat’s faeces, doctor may drain blood from the ear Cavernous sinus thrombosis is usually a
is not generally serious, but it can have and apply a pressure bandage. complication of a bacterial infection in
severe effects in pregnant women. an area drained by the veins entering
Infections in early pregnancy can lead the sinus. At first, only the veins behind
to miscarriage or severe malformation of one eye are affected, but within a few
the fetus. Later in pregnancy, infections Affected days the thrombosis may spread to the
can result in nervous system disorders area sinus behind the other eye.
in the fetus and may even lead to blind- CAUSES
ness in early childhood. Among the infections that can lead to
Cat faeces may also carry eggs of the Example of cavernous sinus thrombosis are cellulitis
cauliflower ear
cat roundworm, a possible cause of Following injury to (a severe skin infection) of the face,
toxocariasis. Rarely, a larva from an the ear, there has infections of the mouth, eye, or middle
ingested roundworm egg migrates to been bleeding into ear, sinusitis (infection of the air spaces
and lodges in an eye, causing deteriora- the soft cartilage. of the facial skull), and septicaemia
The ear flap has
tion of vision or blindness. Children been deformed, with
(infection in the bloodstream).
who have been playing in sand or soil loss of the normal SYMPTOMS
that has been contaminated by cat fae- folds of skin. Symptoms of cavernous sinus thrombo-
ces are at risk of coming into contact sis include severe headache, high fever,
with the worm eggs. causalgia pain and loss of sensation in and above
Other cat-related disorders in humans A persistent, burning pain, usually in the affected eye due to the pressure on
include tinea (fungal infections of the an arm or leg. Causalgia most often the fifth cranial nerve, and proptosis
skin, hair, or nails), particularly ring- occurs as a result of injury to a nerve (protrusion of the eyeball) due to swel-
worm, (ringlike fungal patches, often by a deep cut, limb fracture, or gunshot ling around and behind the eye. In
on the scalp), bites from cat fleas, and wound. The skin overlying the painful some cases, vision may become blurred

151
 CAVITY, ABDOMINAL

cytes (white blood cells responsible for and types of proteins made in the cell.
fighting infection) in a blood sample. Inside the nucleus are chromosomes,
CD4 lymphocytes are destroyed by HIV, which are made of the nucleic acid
and reduced levels of these cells indi- DNA. This acid contains the instructions
cate the progression of HIV and the for protein synthesis, which are carried
eventual development of AIDS. into the cytoplasm by a type of RNA
C (another nucleic acid) and are decoded
cefaclor in particles called ribosomes. The
A common antibiotic that belongs to nucleus also contains a spherical struc-
the group of cephalosporin drugs. ture called the nucleolus, which plays a
role in the production of ribosomes.
cefadroxil ORGANELLES
A cephalosporin drug, which is used to In the cytoplasm there are various tiny
Cavernous
sinus treat bacterial infections. structures called organelles, each with a
particular role. Energy is generated by
cefalexin mitochondria breaking down sugars and
A cephalosporin drug, which is used to fatty acids. Substances that would dam-
Thrombus
treat bacterial infections. age the cell if they came into contact
with the cytoplasm are contained in
cefotaxime particles called lysosomes and peroxi-
A cephalosporin drug, which is used to somes. A system of membranes in the
Thrombus in cavernous sinus
treat bacterial infections. cytoplasm, called the endoplasmic
The clot obstructs blood flow in the cavernous reticulum, transports materials through
sinus, causing pressure behind the eye socket. cefuroxime the cell. Flattened sacs called the Golgi
A cephalosporin drug, which is used to complex receive and process proteins
and eye movements may be paralysed treat bacterial infections. from the endoplasmic reticulum.
due to pressure on the optic nerve and Enzymes and hormones are secreted
other cranial nerves. celecoxib by vesicles (small saclike structures) at
TREATMENT A COX-2 inhibitor drug (a type of non- the cell surface. Some waste products
Treatment with antibiotic drugs and anti- steroidal anti-inflammatory drug)used to and other materials are transported and
coagulant drugs can save vision. Left relieve the pain and inflammation of stored in vacuoles (spaces created by
untreated, blindness will result, and the rheumatoid arthritis and osteoarthritis. the cytoplasm). The cytoplasm has a
infection may eventually prove fatal. Side effects of celecoxib include nausea network of fine tubes (microtubules)
and diarrhoea. Abdominal discomfort and filaments (microfilaments) known
cavity, abdominal may also occur, but can be minimized as the cytoskeleton, which gives the
See abdomen. by taking the drug with food. cell a definite shape.
cavity, dental cell cell death
A hole in a tooth, commonly caused by The basic structural unit of all living See apoptosis.
dental caries (see caries, dental). organisms. The human body comprises
billions of cells, which are structurally cell division
cavity, oral and functionally integrated to perform The processes by which cells multiply.
See mouth. the complex tasks necessary for life. In Mitosis is the most common form of
spite of variations in size and function, cell division, giving rise to daughter
cavity, pelvic most of the cells have a similar form. cells identical to the parent cells. Meio-
The area of the body that lies below the CELL MEMBRANE sis produces egg (see ovum) and sperm
abdomen, framed by the pelvic bones Each cell is a microscopically small bag cells that differ from their parent cells
and lower spine. The pelvic cavity con- containing liquid cytoplasm. It is sur- in that they have only half the normal
tains the lower digestive and urinary rounded by a membrane that regulates number of chromosomes.
organs, nearly all of the reproductive the passage of useful substances (such
organs in females, and part of the as oxygen and nutrients) into the cell cellular immunity
reproductive system in males. and waste materials (such as carbon The part of the body’s defence mecha-
dioxide) and manufactured substances nisms (see immune system) that attacks
cavity, pleural (such as hormones) out of the cell. and destroys harmful cells directly
The space between the two layers of the Some cells, such as those lining the rather than by using antibodies (pro-
pleura (membrane) that lines the chest small intestine, have microvilli, projec- teins created to combat infection).
wall and the outside of the lungs. tions that increase the cells’ surface area Lymphocytes (a type of white blood
to facilitate absorption. cell) mount a response against infectious
CD4 count NUCLEUS organisms and other abnormal cells,
A blood test used to monitor HIV infec- All cells, except red blood cells, have a such as cancer cells. There are two main
tion and AIDS. The procedure involves nucleus. The nucleus controls all major types: T-lymphocytes, which provide
counting the number of CD4 lympho- cell activities by regulating the amount cellular immunity, and B-lymphocytes,

152
 CELLULOSE

CELL TYPES
Despite their fundamental similarities in structure, the cells (nerve cells, for instance) cannot be replaced once they have
of the body are differentiated so that they can perform a variety been destroyed, while other cells (those that form toe- and
of specific tasks, such as carrying oxygen (red blood cells), fingernails, for instance) regrow and continue to function even
destroying invading microorganisms (white blood cells), after a person’s death. There are four main types of cells,
and making hormones (secretory cells in glands). Some cells which are grouped according to their primary functions. C
Epithelial cells Microfilament Mitochondrion Blood cells
These make up the Red and white blood
tissues that cover the cells, and platelets,
outside of the body Villus circulate individually
and line the digestive, Nucleolus in the blood to carry
respiratory, and urinary nutrients and combat
tracts. The epithelium infection and injury.
includes glandular tissue,
which is specialized
for secretion.

Vesicle secreting Microtubule

enzymes at cell surface

Nucleus
Peroxisome

Ribosomes
Nuclear membrane

Cell membrane Endoplasmic

reticulum

Muscular tissue Cells in the nervous tissue

Muscle is formed from different types of Golgi These cells conduct electrochemical
muscle cells that are specialized to contract. Lysosome complex messages throughout the body.

which produce antibodies. T-lympho- the thighs and buttocks. Cellulite usual- Untreated cellulitis at the site of a
cytes recognize specific antigens ly affects women rather than men and wound may progress to bacteraemia
(substances that the body identifies as is often attributed to water retention. (bacterial infection of the blood) and
foreign), including cancer cells and septicaemia (blood poisoning). Facial
cells infected by viruses. One group of cellulitis infections may spread to the eye socket.
T-lymphocytes, known as killer T-cells, A bacterial infection of the skin and the TREATMENT
attach themselves to the abnormal cells tissues beneath it, which usually affects Treatment of cellulitis is with an anti-
and release toxic proteins that destroy the lower legs but can occur anywhere biotic drug such as a penicillin drug or
them. (See also humoral immunity.) on the body. Cellulitis is most com- erythromycin. (See also erysipelas.)
monly caused by streptococci bacteria,
cellular pathology which enter the skin via a wound. cellulose
See pathology, cellular. SYMPTOMS A carbohydrate consisting of chains of
There may be fever and chills; and the glucose (a simple sugar). Cellulose is
cellulite affected area is hot, red and swollen. the main constituent of plant-cell
The popular term for the subcutaneous Cellulitis is more severe in people with walls. Because it cannot be digested,
fat that gives the skin a dimpled, or reduced immunity, such as those who cellulose is an important source of
orange-peel, appearance, especially on have an immunodeficiency disorder. dietary fibre (see fibre, dietary).

153
 CELSIUS SCALE

means of a fine tube, attached to a cephalic

CELSIUS SCALE monitor, that is passed through a vein Relating to the head, as in cephalic pre-
0°C 37°C 100°C close to the heart and into the right sentation, the head-first position of a
atrium. By monitoring the pressure, baby in the birth canal.
doctors can estimate the volume of
32°F 98.6°F 212°F blood circulating around the body. This cephalopelvic disproportion
C action may be of value following A complication of childbirth (see child-
severe haemorrhage and in cases where birth, complications of) in which the
Celsius scale the blood pressure is too low to deliver mother’s pelvis is too narrow in pro-
A temperature scale in which the melt- an adequate blood supply to organs portion to the size of the baby’s head.
ing point of ice is defined as zero and tissues (see shock).
degrees (0°C) and the boiling point of cephalosporin drugs
water is 100 degrees (100°C). On this centrifuge COMMON DRUGS
scale, the normal body temperature in This is a machine that separates the dif- •Cefaclor •Cefadroxil •Cefalexin •Cefotaxime
humans is 37°C. The scale is named ferent components of a body fluid for •Cefoxitin •Cefuroxime
after the Swedish astronomer Anders analysis. When a fluid such as blood is
Celsius (1701–1744). “Centigrade” is spun at high speed around a central A large group of antibiotic drugs,
an obsolete name for the same scale. axis, groups of particles of varying den- derived from the fungus CEPHALOSPORIUM
To convert a Celsius temperature to sity, such as red and white blood cells, ACREMONIUM, which are effective against a
Fahrenheit, multiply the figure by 1.8, are separated by centrifugal force and wide range of infections. Cephalospor-
then add 32. To convert Fahrenheit to can be analysed independently. ins are used to treat ear, throat, and
Celsius, subtract 32, then multiply by respiratory tract infections and condi-
0.56. (See also Fahrenheit scale.) cephalexin tions, such as urinary tract infections and
An alternative spelling of cefalexin, a the sexually transmitted infection gon-
cementum common cephalosporin drug. orrhoea, in which the causative bacteria
Bonelike tissue surrounding the root of are resistant to other types of antibiotic.
a tooth (see teeth). cephalhaematoma HOW THEY WORK
An extensive, soft swelling on the scalp Cephalosporin drugs interfere with the
centigrade scale of a newborn baby. Cephalhaematoma development of bacterial cell walls and
The obsolete name for the Celsius scale. is caused by bleeding into the space inhibit the production of protein in the
between the skull and its fibrous cover- bacterial cells. As a result, the bacteria
centrally acting ing (the periosteum or pericranium) die. Some types of bacteria, however,
antihypertensive drugs due to pressure exerted on the baby’s produce an enzyme (a protein that acts
A type of antihypertensive drug used in head during delivery. The swelling is as a catalyst) called beta-lactamase that
the treatment of hypertension (high neither painful nor serious and it grad- can inactivate some of the older ceph-
blood pressure). Centrally acting anti- ually subsides, although this process alosporin drugs. Newer cephalosporins
hypertensives, such as clonidine and may take several weeks. are not affected by this enzyme.
methyldopa, act on the mechanism in SIDE EFFECTS
the brain that controls blood-vessel size. Occasionally, cephalosporin drugs may
cause allergic reactions, such as rash,
central nervous system itching, and fever. Rarely, anaphylactic
The anatomical term for the brain and shock (a very severe allergic reaction)
spinal cord, often abbreviated to CNS. occurs. Other side effects include diar-
The central nervous system is made up rhoea and blood disorders.
of neurons (nerve cells) and support-
ing tissue, and works in tandem with cerebellar ataxia
the peripheral nervous system (PNS), Jerky, staggering gait and other uncoor-
which carries signals between the CNS dinated movements caused by disease
and the rest of the body. of, or damage to, the cerebellum. Other
The CNS receives sensory informa- features may include dysarthria (slurred
tion from organs such as the eyes and speech), hand tremor, and nystagmus
ears, and from sensory receptors in the (abnormal jerky eye movements).
body. It analyses this information, then Causes include stroke, multiple sclero-
initiates an appropriate motor response sis, brain tumour, damage as a result of
in the body, such as contracting a mus- alcohol dependence, and an inherited
cle. (See also nervous system.) disorder of the cerebellum.
central venous pressure cerebellar syndrome
The pressure within the right atrium, Cephalhaematoma A collection of symptoms, due to certain
This baby was born with a cephalhaematoma on
the chamber of the heart that receives one side of the scalp at the back of the head. The types of brain disorder, that include tre-
oxygen-depleted blood from the body. condition is not serious and the swelling gradually mor, speech disturbance, and abnormal
Central venous pressure is measured by subsides over a period of a few weeks. eye movements (nystagmus) and gait.

154
 CEREBROVASCULAR ACCIDENT

cerebellum DISORDERS to develop spastic paralysis (abnormal

A region of the brain at the back of the Disease or damage to the cerebellum muscle stiffness), athetosis (involuntary
skull, behind the brainstem. The cerebel- may result in cerebral ataxia, which is writhing movements), or ataxia (loss of
lum is concerned primarily with the characterized by jerky, staggering gait, coordination and balance). Other ner-
maintenance of posture and balance slurred speech, and other uncoordin- vous system disorders, such as hearing
and the coordination of movement. ated movements of the body. Alcohol defects or epileptic seizures, may be
STRUCTURE intoxication impairs cerebellar function present. About 70 per cent of children C
The cerebellum is linked to the brain- and may produce similar symptoms. have mental impairment, but the rest
stem by thick nerve tracts. It consists of are of normal or high intelligence.
two hemispheres. From the inner side cerebral haemorrhage DIAGNOSIS AND TREATMENT
of each hemisphere arise three nerve Bleeding that occurs within the brain If the condition is suspected from the
fibre stalks, which link with different due to a ruptured blood vessel (see symptoms and from neurological and
parts of the brainstem and carry signals intracerebral haemorrhage; stroke). developmental assessments, imaging
between the cerebellum and the rest of tests such as CT scanning and MRI may be
the brain. Nerve fibres from the stalks cerebral malaria performed to identify brain damage.
fan out towards the deep folds of the A potentially fatal complication of Although there is no cure for cere-
cortex (outer part) of each cerebellar malaria (a disease transmitted by mos- bral palsy, much can be done to help
hemisphere, which consists of layers of quitoes) that affects the brain and affected children. A team of profession-
what is often referred to as grey matter causes loss of consciousness. als working with the family can
(interconnected nerve cells). maximize the child’s ability to func-
FUNCTION cerebral oedema tion. Physiotherapy can help a child to
Information about the body’s posture An abnormal accumulation of fluid in develop muscular control and maintain
and the state of contraction or relax- the brain. The resulting compression of balance. Speech therapy may improve
ation in its muscles is conveyed from brain tissues may cause symptoms such speech and communication.
muscle tendons and the labyrinth in as headache and visual disturbances.
the inner ear via the brainstem to the There are various causes for cerebral cerebral thrombosis
cerebellum. Working with the basal oedema, including injury, anoxia (lack The formation of a thrombus (blood
ganglia (nerve cell clusters deep within of oxygen), and poisoning. clot) in an artery within the brain. The
the brain), the cerebellum uses this clot may block the artery, cutting off
data to fine tune messages sent to mus- cerebral palsy the supply of blood, nutrients, and
cles from the motor cortex in the A disorder of posture and movement oxygen to the region of the brain tissue
cerebrum (the main mass of the brain). that results from damage to the devel- supplied by the artery. This problem
oping brain before, during, or just after may result in a stroke.
birth, or in early childhood. Cerebral
LOCATION OF CEREBELLUM palsy is nonprogressive. The disorder cerebrospinal fluid
varies in severity from slight clumsi- A clear, watery fluid that circulates
The cerebellum is situated behind
ness of hand movement and gait to between the ventricles (cavities) within
the brainstem and is connected to
it by a collection of nerve tracts.
complete immobility. the brain, the central canal in the spinal
CAUSES cord, and the space between the brain
Cerebrum
In most cases, damage occurs before or and spinal cord and their protective
at birth, sometimes as a result of cere- coverings, the meninges. Cerebrospinal
bral hypoxia (an inadequate supply of fluid functions as a shock-absorber,
oxygen to the brain). More rarely, the helping to prevent or reduce damage to
cause is a maternal infection that the brain and spinal cord after a blow
spreads to the baby in the uterus. to the head or back. It contains glucose,
In rare cases, cerebral palsy is caused proteins, salts, and white blood cells.
by kernicterus, which results from an Examination of the fluid, samples of
excess of bile pigment in babies with which are usually obtained by lumbar
haemolytic disease of the newborn. Possible puncture, is used in the diagnosis of
causes after birth include encephalitis many conditions affecting the brain
(inflammation of the brain tissue), and spinal cord, including meningitis
Brainstem meningitis (inflammation of the protec- and subarachnoid haemorrhage.
tive membranes covering the brain), Accumulation of cerebrospinal fluid
head injury, or intracerebral haemorrhage within the skull during the develop-
Cranial nerves
Cerebellum (bleeding within the brain). ment of the fetus, or in infancy, may
SYMPTOMS cause the skull to become enlarged (a
Spinal cord Cerebral palsy may not be recognized condition known as hydrocephalus).
until well into the baby’s first year. Ini-
tially, the infant may have hypotonic cerebrovascular accident
(floppy) muscles, be difficult to feed, Any sudden rupture or blockage of a
and show delay in sitting up without blood vessel in the brain. The problem
support. An affected child may go on causes serious bleeding and/or local

155
 CEREBROVASCULAR DISEASE

obstruction to blood circulation, and

leads to a stroke (damage to part of the STRUCTURE OF THE CEREBRUM
brain due to interrupted blood supply).
Blockage may be due to thrombosis The cerebrum dwarfs the rest of the Central sulcus
brain. Much of its surface is hidden
(clot formation) or to embolism (a clot
within the folds, as shown by the
fragment, or an air bubble carried in
C the circulation). Rupture of vessels may
vertical cross-section below.
result in different patterns of bleeding:
intracerebral haemorrhage (bleeding in Right hemisphere
the brain) or subarachnoid haemorrhage
(bleeding around the brain).
Left hemisphere
cerebrovascular disease
Any disease affecting an artery supply-
ing blood to areas inside the brain. Gyrus
Such diseases include atherosclerosis
(narrowing of the arteries) and defects
Longitudinal
in arterial walls that cause aneurysm (a fissure
balloon-like swelling in an artery).
The disease may eventually cause a Brainstem
cerebrovascular accident, which com-
Grey Longitudinal Corpus
monly results in a stroke. Extensive matter fissure callosum
narrowing of blood vessels throughout
the brain can be a cause of dementia.
Sylvian fissure
cerebrum
The largest and most developed part of
the brain, and the site of most con-
scious and intelligent activities. Ventricle Cerebellum

STRUCTURE
The main components of the cerebrum Basal ganglia
are two large hemispheres that grow
Spinal cord
out from the upper part of the brain-
stem (an extension of the spinal cord). White matter
The surface of the cerebrum is made up
of a series of folds called gyri, which
are separated by fissures called sulci,
with a deep longitudinal fissure sepa- FUNCTION DISORDERS
rating the two hemispheres. Specific sensory processing takes place Damage to particular areas of the cere-
The four main surface regions of in separate regions. For example, visual brum may cause specific syndromes.
each hemisphere – the frontal, pari- perception is located in a part of the For example, damage to the frontal
etal, temporal, and occipital lobes – are occipital lobe called the visual cortex. lobe may cause mental apathy, whereas
named after the bones that are over- The cortex also contains “motor’’ a parietal lobe injury may result in geo-
lying them. Each hemisphere has a areas concerned with initiating signals graphical disorientation. Disease of the
central cavity, called a ventricle, that is for movements of the skeletal muscles. temporal lobe may cause amnesia
filled with cerebrospinal fluid. This cavi- Linked to the sensory and motor areas (memory loss), and visual defects may
ty is surrounded by an inner layer, of the cortex are association areas. result from occipital lobe damage.
consisting of clusters of nerve cells These regions integrate information Quite often, however, cerebral dis-
called the basal ganglia. There is a mid- from various senses and also perform ease causes nonspecific symptoms such
dle layer of white matter composed functions such as comprehension and as convulsions and headaches.
mainly of nerve fibres, which carry recognition, memory storage and re-
information between particular areas call, thought, and decision-making. certification
of the cortex and between the cortex, Some cortical functions are localized An outdated term for procedures to
central brain, and brainstem. The outer to one “dominant’’ hemisphere (the commit a person to be compulsorily
surface layer of each hemisphere is the left in almost all right-handed and detained for mental health treatment.
cerebral cortex, which is also known as many left-handed people). Two clearly
the grey matter, where much of the sen- defined areas in the dominant hemi- cerumen
sory information from organs such as sphere are Wernicke’s area, which is The medical term for earwax.
the eyes and the ears is processed. A responsible for the comprehension of
thick band of fibres called the corpus spoken and written language, and Cerumol
callosum carries nerve signals between Broca’s area, which is concerned with A brand-named preparation used for
the two cerebral hemispheres. language expression. the removal of earwax.

156
 CERVICAL RIB

cervical DIAGNOSIS AND TREATMENT degeneration begins earlier due to an

This term can mean either relating to The condition is often detected during injury, such as a whiplash neck injury
the neck or relating to the cervix (the a routine cervical smear test. Only women sustained in a road traffic accident.
neck of the uterus). with symptoms need treatment. Affec- SYMPTOMS
ted tissue may be destroyed using The main symptoms of cervical osteo-
cervical cancer cauterization (application of a heated arthritis are neck pain and stiffness.
See cervix, cancer of. instrument), cryosurgery (freezing), dia- Pressure on the nerves between affected C
thermy (heat), or laser treatment. vertebrae may cause pain in the arms
cervical dysplasia and shoulders, numbness tingling and
Changes in the surface cells of the cervix cervical incompetence weakness in the hands. Symptoms tend
(the neck of the uterus) that may in Abnormal weakness of the cervix (the to flare up from time to time with peri-
time become cancerous. neck of the uterus) that can result in ods of mild discomfort between.
TYPES recurrent miscarriages. Normally, the Other symptoms, such as dizziness,
There are three grades of cervical dys- cervix remains closed until the onset of unsteadiness, and double vision when
plasia: mild, moderate, and severe. They labour. An incompetent cervix may turning the head, may also occur as a
are based on the severity of the changes gradually widen under the weight of result of pressure on blood vessels run-
seen in cells obtained from a cervical the fetus from about the 12th week of ning through the vertebrae to the
smear test. Abnormalities can also be pregnancy onwards, or may suddenly brain. Rarely, pressure on the spinal
classified as grades of cervical intra- open during the second trimester. cord can cause weakness or paralysis in
epithelial neoplasia. In mild dysplasia, DIAGNOSIS AND TREATMENT the legs and loss of bladder control.
abnormal cells may return to a normal The condition is detected by a pelvic DIAGNOSIS AND TREATMENT
state without treatment. Severe dyspla- examination or by ultrasound scanning. X-rays and other imaging procedures
sia, left untreated, may progress to Treatment is with a suture (stitch) such as MRI (a technique that produces
cervical cancer (see cervix, cancer of). applied like a purse string around the cross-sectional or three-dimensional
CAUSES cervix at about the 12th week of preg- pictures of body structures) are used to
The cause is not known, but risk factors nancy. The suture is left in position diagnose cervical osteoarthritis.
include smoking and unprotected sex until the pregnancy is at or near full Treatment of severe neck pain and
at an early age or with many partners. term and is then cut to allow the stiffness may include heat treatment,
TREATMENT mother to deliver the baby normally. supporting the neck in a collar, and the
Treatment depends on the severity of analgesic drugs (painkillers). Physiother-
the condition. For mild or moderate cervical intraepithelial apy may improve neck posture and
dysplasia, the abnormal cells may be des- neoplasia movement and is useful when the pain
troyed by laser treatment, or by freezing Also known as CIN, abnormalities in has eased. Pressure on the spinal cord
at colposcopy (inspection of the cervix the cells of the cervix (the neck of the may be relieved by surgery (see decom-
with a viewing instrument). Alternativ- uterus) that may become cancerous. pression, spinal canal).
ely, loop excision (surgical removal of The CIN grading system is used to dis-
an area of the cervix) may be carried tinguish levels of change in the surface cervical rib
out. If the dysplasia is severe, loop exci- cells of the cervix. The term is applied A congenital abnormality, which is of
sion or cone biopsy are used. to biopsy (tissue) samples taken during unknown cause, in which the lowest of
colposcopy, (inspection of the cervix the seven cervical vertebrae (neck bones)
cervical ectopy with a viewing instrument) following
A condition affecting the cervix (the an abnormal cervical smear test. Grades
neck of the uterus) in which a layer of CIN 1–3 broadly correspond to mild to LOCATION OF CERVICAL RIB
mucus-forming cells that are more severe cervical dysplasia in the cells
The overdeveloped seventh cervical
characteristic of the inner lining of the obtained from a smear test.
vertebra forms a rib parallel to a
cervix appear on its outside surface. normal one.
There is no loss of tissue or ulceration cervical mucus method
of the cervix. The tissue may, however, A form of contraception based on iden-
be more fragile, and tend to bleed and tifying days on which to abstain from
secrete more mucus, than normal. sexual intercourse and thereby avoid
CAUSES pregnancy. This technique involves
Cervical ectopy may be present from monitoring the changes in the mucus Seventh
birth. Other possible causes include secreted by a woman’s cervix. (See con- cervical
Cervical rib vertebra
injury to the cervix during labour and traception, natural methods of.)
long-term use of oral contraceptives.
SYMPTOMS cervical osteoarthritis
Most women with cervical ectopy have A degenerative disorder, also called cer-
few or no symptoms. Some, however, vical spondylosis, that affects the joints
experience vaginal bleeding at unex- between the cervical vertebrae (the
pected times and may have a vaginal bones in the neck). Cervical osteoarth-
discharge. The cervix has a fragile, red- ritis mainly occurs in middle-aged and
dened area on the surface. elderly people, but occasionally the

157
 CERVICAL SMEAR TEST

has overdeveloped to form an extra rib WHEN IT IS DONE

that lies parallel to and above the first A cervical smear test should be carried ANATOMY OF THE CERVIX
normal rib. The abnormality can vary out within six months after a woman
from a small, bony swelling to a fully first starts to have sexual intercourse. A The cervix contains a central canal
for the passage of sperm and
developed rib and it may occur on only repeat test may be carried out between menstrual blood and for childbirth.
one or on both sides. six and twelve months later. If no
C SYMPTOMS abnormality is detected on these
The canal and outer surface of the
cervix are lined with two types of
In many cases, there are no symptoms. smears, tests should subsequently be cells: mucus-secreting glandular
If the rib presses on the lower brachial performed at approximately three- cells and protective squamous cells.
plexus (the group of nerves passing yearly intervals until the age of 65.
Uterus Bladder
from the spinal cord into the arm), HOW IT IS DONE
however, there may be pain, numbness, Cervical smear tests are usually per-
and pins-and-needles affecting both formed by doctors or nurses in general
the forearm and hand. practice clinics or at sexual health
DIAGNOSIS AND TREATMENT clinics. A small sample of cells is taken
An X-ray will show the presence of a from the surface of the cervix using a
cervical rib, but other possible causes spatula or special brush and is exam-
of pain and tingling in the hand or arm ined under a microscope. If all the cells
(such as carpal tunnel syndrome or a disc appear normal, nothing further needs
prolapse) still need to be excluded. to be done. If any cells show dysplasia,
Exercises designed to strengthen the this will be graded according to
shoulder muscles and improve posture severity, and repeat smear tests and
may bring relief. Severe or persistent further investigations, such as col-
symptoms may, however, require surgery poscopy (inspection of the cervix with a
Vagina
in order to remove the rib. viewing instrument), may be required.
cervical smear test cervical spondylosis External os Cervix

A test that is used to detect cervical dys- An alternative name for the neck
plasia (abnormal changes in the cells of disorder cervical osteoarthritis.
the cervix, the neck of the uterus) that
could develop into cancer (see cervix, cervicitis
cancer of). A cervical smear test can also Inflammation of the cervix (the neck of
detect viral infections of the cervix, the uterus). The condition is usually
such as herpes simplex, papilloma (see due to a sexually transmitted infection,
warts, genital), and CHLAMYDIA TRACHOMATIS. such as gonorrhoea, chlamydial infections,

CERVICAL SMEAR
or genital herpes (see herpes, genital).
Regular cervical smear tests should begin within six months of a woman first
having sexual intercourse, then be done every three years as a matter of routine.
However, cervical infection may also
The procedure is risk-free, although it may be slightly uncomfortable, and the result from injury to the cervix during
actual collection of the cells from the cervix takes only a few seconds. childbirth or surgery.
SYMPTOMS
Cervicitis often does not produce
Normal cell
nucleus
symptoms, although there may be a
vaginal discharge, irregular vaginal
bleeding, and lower abdominal pain.
COMPLICATIONS
Normal cells If it is left untreated, cervicitis can
Spatula as seen spread to cause endometritis (inflamma-
under the
microscope
tion of the lining of the uterus),
Speculum
salpingitis (inflammation of the fallopi-
Bladder an tubes), or pelvic inflammatory disease.
Cervix large dark- If a pregnant woman has cervicitis,
stained nucleus her baby may be infected during deliv-
of abnormal cell
Procedure for cervical smear ery, resulting in neonatal ophthalmia (eye
The woman lies on her back with her legs bent
and relaxed so that they fall open at the knees.
infection) or, less commonly, pneumo-
The vagina is held open with a speculum. Cells Abnormal nia due to chlamydial infection.
are collected with a spatula or a special brush cells as seen DIAGNOSIS AND TREATMENT
and either smeared on to a glass slide or put in under the The condition is diagnosed by means
a preservative for later microscopic examination. microscope of internal examination and by taking
swabs of the vaginal discharge, which

158
 CERVIX, CANCER OF

are then analysed in order to verify cervix smear test, or swabs taken from the
the identity of the organism that is A small, cylindrical organ, several cervix. In cases of suspected cancer or a
responsible for the condition. centimetres in length and less than precancerous condition, a colposcopy
Treatment is with antibiotic drugs or 2.5 cm in diameter, comprising the (inspection of the cervix with a view-
antiviral drugs. If symptoms persist, the lower part and neck of the uterus ing instrument) may be performed.
area may be cauterized by electrocoagu- (womb). The cervix separates the body
lation (an electric current is applied), and cavity of the uterus from the cervix, cancer of C
cryotherapy, (freezing), or laser treatment. vagina. The fibrous, smooth muscle tis- One of the most common forms of
sue of the cervix creates a form of cancer affecting women worldwide.
sphincter (circular muscle), which can Cancer of the cervix (the neck of the
BIOPSY OF THE CERVIX
stretch open in pregnancy and childbirth. uterus) has well-defined precancerous
If a woman has recurrent abnormal FUNCTION stages in which abnormal changes
smears, colposcopy and punch The cervical canal runs through the occur in cells on the surface of the
biopsy or loop excision of the cervix. It allows the passage of blood cervix (see cervical dysplasia). These
abnormal areas will be carried out. during menstruation and of sperm from type of changes can be detected by a
If the areas cannot be seen the vagina into the uterus following cervical smear test. In many cases, this
completely by colposcopy, a larger sexual intercourse, and forms part of detection allows early treatment lead-
sample of tissue is removed by cone the birth canal during childbirth. After ing to a complete cure. If left untreated,
biopsy. This procedure is used for puberty, mucus is secreted by the glan- however, cancer of the cervix may
treatment as well as diagnosis. dular cells in the canal to assist the spread to the organs in the pelvis.
Cervix Uterus Vagina entry of sperm into the upper cervix. TYPES
In addition, the mucus protects the There are two main types of cervical
sperm and provides them with energy. cancer: the squamous type and a much
During pregnancy, the internal mus- rarer form called adenocarcinoma.
cular fibres increase in size, thereby The squamous type of cervical can-
lengthening the cervix and acting as a cer is thought to be associated with
barrier for the retention of the fetus. some types of human papillomavirus
Towards the end of pregnancy, the (HPV), which may be contracted dur-
cervix begins to shorten in readiness ing sexual intercourse. The other factors
for labour and delivery. During labour that predispose a woman to developing
the cervical canal widens up to 10 cm this type of cancer are smoking, start-
in diameter to allow the baby to pass ing to have sex at an early age, having
from the uterus. Soon after childbirth, many sexual partners, and having a
the muscles in the cervix contract and depressed immune system.
the canal returns to its original size. The second type of cervical cancer,
DISORDERS adenocarcinoma, sometimes occurs in
The cervix may be injured, or may women who have never had sexual
Colposcopic view of cervix develop infections or other disorders intercourse. Its causes are unknown.
This end-on view of the cervix shows moderate (see cervix disorders box, below). Such SYMPTOMS
dysplasia (abnormal changes in the cells), conditions are usually investigated by In many cases, cancer of the cervix is
with a discharge at the central canal.
means of a pelvic examination, a cervical detected before symptoms develop. If
Punch biopsy
Small samples
are taken from DISORDERS OF THE CERVIX
any abnormal area.
Bleeding is minimal The cervix (neck of the uterus) may cervix include those due to the human
following a punch be susceptible to injuries, infections, papillomavirus and the herpes simplex
biopsy and no tumours, and other conditions. virus (see warts, genital; herpes, genital).
stitches are
needed.
Injury Tumours
Cone biopsy Minor injury to the cervix may occur Polyps are noncancerous growths that
If the abnormal area during childbirth, particularly if labour occur on the cervix. Cancerous growths
extends into the is prolonged. Persistent damage to (see cervix, cancer of) are preceded by
cervical canal, out muscle fibres as a result of injury may changes in the surface cells (cervical
of view of the
colposcope, a cone- lead to cervical incompetence. dysplasia), which can be detected by
shaped sample, a cervical smear test.
including abnormal Infection
cells, is taken using The most common cervical infections Other disorders
a scalpel, laser, or,
most commonly, loop
are sexually transmitted diseases, such Cervical ectopy is a condition in which
excision. No stitches as gonorrhoea, chlamydial infections, and mucus-secreting cells form on the
are needed. trichomoniasis. Viral infections of the outside of the cervix.

159
 CESTODES

the condition is advanced, there may be insects commonly called cone-nosed or change of life
vaginal bleeding or a bloodstained dis- assassin bugs. The parasites live in the A phrase that is popularly used to
charge at unexpected times, such as bloodstream and can affect the heart, describe the menopause, in which a
between periods, after sexual inter- intestines, and nervous system. drop in hormone levels has a variety of
course, or after the menopause. There Symptoms include swelling of the physical and mental repercussions.
may be pain if the cancer has spread lymph nodes and fever. Long-term com-
C into the deeper parts of the cervix and plications include damage to the heart. chaperone
then out into the pelvic tissues. The drug nifurtimox kills the parasites An individual who accompanies a doc-
DIAGNOSIS AND TREATMENT but has unpleasant side effects. tor during the physical examination of
If a smear test has an abnormal result, a patient. Chaperones provide protec-
colposcopy (inspection of the cervix chalazion tion for both doctor and patient against
with a viewing instrument) or a cone A round, painless swelling in the upper accusations of improper conduct.
biopsy may be carried out. or lower eyelid caused by obstruction The term “chaperone” is also used to
A localized cancer in its early stages of one of the meibomian glands, which refer to a protein that helps other pro-
may be destroyed by electrocoagulation lubricate the edges of the eyelids. Cha- teins to fold up into their correct
(application of an electric current), lazions are sometimes called meibomian three-dimensional shapes.
diathermy (heat treatment), laser treat- cysts. They can occur at any age and
ment, or cryosurgery (freezing). may be more common in people suf- chapped skin
If the cancer has spread into the fering from the skin conditions acne, Sore, cracked, rough skin, usually on
cervical canal, a cone biopsy may be rosacea, or seborrhoeic dermatitis. the hands and face (particularly the
sufficient to remove all of the diseased If the cyst becomes infected, the eye- lips), caused by dryness. Chapping is
tissue. In more advanced cases affect- lid becomes more swollen, red, and caused by the lack, or removal, of the
ing the pelvic organs, radiotherapy may painful. A large swelling putting pres- natural oils that keep skin supple. It
be given. In certain severe cases, radi- sure on the cornea at the front of the tends to occur in cold weather, when
cal surgery, in which the bladder, eye can cause blurring of vision. About oil-secreting glands produce less oil, or
vagina, cervix, uterus, and rectum are one-third of chalazions disappear with- after repeated washing or wetting.
removed, may be recommended possi- out treatment, but large cysts may need Chapping can be prevented by wear-
bly along with chemotherapy. to be removed surgically. ing protective gloves or applying
barrier creams before immersing the
cestodes hands in water, then drying the skin
The scientific name for tapeworms, a well. Areas of chapped skin can be
group of long, flat, multisegmented treated with hand or face cream.
parasites (see tapeworm infestation).
charcoal
cetirizine A form of carbon that is used in medi-
An antihistamine drug that is used to cine mainly as an adsorbent agent (a
relieve the symptoms of certain condi- substance that binds to toxins) in the
tions such as allergic rhinitis (hay fever) emergency treatment of some types of
and urticaria (nettle rash). poisoning and drug overdose.
cetrimide Charcot–Marie–Tooth disease
An antiseptic that is used in many A chalazion on the lower lid An inherited muscle-wasting disease of
preparations for cleansing the skin. Small chalazions often disappear spontaneously. the legs (see peroneal muscular atrophy).
Larger ones may need to be removed surgically.
CFC-free inhalers Charcot’s joint
Pressurized aerosol inhalers (devices for challenge, food A joint damaged by repeated injuries
delivering drugs to treat asthma and See exclusion diet. that go unnoticed due to loss of sensa-
other lung disorders) in which chloro- tion in the area (see neuropathic joint).
fluorocarbons, or CFCs (used to propel chancre, hard
drugs out of the inhalers), have been An ulcer, usually on the genitals, that check-up
replaced by alternative propellants. This develops during the first stage of syph- See examination, physical.
change has been made in response to ilis (a sexually transmitted infection).
evidence that CFCs are harmful to the cheilitis
ozone layer in the earth’s atmosphere. chancroid Inflammation, cracking, and dryness of
A sexually transmitted infection, found the lips. There are several possible caus-
CFC propellants mainly in the tropics, that is charact- es of cheilitis, including ill-fitting
See chlorofluorocarbon propellants. erized by enlargement of the lymph dentures, a local infection, an allergy to
nodes in the groin and painful genital cosmetics, excessive sunbathing, or
Chagas’ disease ulcers. Chancroid is caused by the bac- deficiency of riboflavin (vitamin B2).
An infectious parasitic disease found terium HAEMOPHILUS DUCREYI. Prompt Treatment is given for the underlying
only in parts of South and Central treatment of the condition with antibi- cause; in the meantime, a soothing skin
America. Chagas’ disease is spread by otic drugs is usually effective. cream can help to relieve the soreness.

160
 CHEST PAIN

chelating agents cherubism travels from the back of the chest

Chemicals to treat metal poisoning, An inherited disease, also known as around to the front may be due to pres-
which act by combining with metals familial fibrous dysplasia of the jaw. sure on a nerve root where it leaves the
such as lead, arsenic, and mercury to Cherubism is so called because it pro- spine; nerve compression may result
form less toxic substances. Penicillamine duces swelling at either side of the jaw, from disorders such as osteoarthritis of
is a commonly used chelating agent. giving the face a cherubic appearance. the vertebrae. Pain in the side of the
chest may be caused by pleurodynia C
chemical formula chest (inflammation of the muscles between
See formula, chemical. The upper part of the trunk. The chest, the ribs and of the diaphragm muscle,
also known as the thorax, extends from associated with a viral infection). The
chemical pathology the base of the neck down to the viral infection herpes zoster (shingles)
See pathology, chemical. diaphragm muscle. may cause severe pain along the course
of a nerve in the chest wall. In Tietze’s
chemist chest compression syndrome, inflammation at the junc-
A pharmacist – a health-care profes- Another name for external cardiac mas- tions of the rib cartilages causes pain on
sional who prepares drugs, makes up sage. Chest compressions are carried the front of the chest wall.
and supplies prescriptions, and may out as part of the life-saving technique A common cause of pain within the
also give advice on the treatment of cardiopulmonary resuscitation. chest is acid reflux (regurgitation of acid
common or minor illnesses. from the stomach into the oesophagus);
chest pain this problem may cause heartburn, a
chemosis Pain in the chest often has no serious pain behind the sternum (breastbone).
Swelling of the conjunctiva (the mem- cause, but in some cases it may be a More serious causes include disorders
brane covering the eye and lining the symptom of an underlying disorder involving the lungs, such as pleurisy
eyelid). Chemosis is most commonly requiring urgent treatment. The pain (inflammation of the membranes sur-
associated with allergic and infective may be in the chest wall (in the skin, rounding the lungs and lining the
conjunctivitis. Treatment may include the the underlying muscles, or the ribs) or inside of the chest wall). Pleurisy may
use of eyedrops containing an antihista- in an organ within the chest. be due to pneumonia (inflammation of
mine drug or antibiotic drug. causes the lungs due to infection) or, rarely,
Common causes of pain in the chest pulmonary embolism (a blood clot that
chemotherapy wall are a strained muscle or an injury, has lodged in an artery in the lung).
The term usually used to refer to treat- such as a broken rib. A sharp pain that Cancerous lung tumours (see lung
ment with anticancer drugs. The word
“chemotherapy” may also describe the
use of antibiotic drugs to treat infectious DIAGNOSING CHEST PAIN
diseases, particularly tuberculosis. To make an accurate diagnosis of the as breathing difficulty. In addition,
Chemotherapy for cancer works by underlying cause, it is important for the doctor will perform a physical
destroying cancer cells or preventing the patient to describe the location, examination, including listening to chest
them from multiplying. The drugs also quality (e.g. burning, pressing, or sounds with a stethoscope and feeling
affect healthy tissues, however, so the sharp), severity, and duration of the for areas of tenderness in the chest wall.
treatment is often given in short cours- pain, any factors that relieve it or make He or she may also arrange for other
es, with drug-free periods in between it worse, and any other symptoms, such diagnostic procedures to be carried out.
to allow normal cells to recover. Nor-
mal tissues often affected include bone Pericarditis Angina
Sharp pain in the Can spread from
marrow (causing anaemia), the mouth, centre of the chest, the chest into the
the intestinal lining, the hair follicles, relieved by sitting neck and jaw
and the ovaries and testes; sometimes or leaning forward

causing severe side effects.

chenodeoxycholic acid
A constituent of bile that is necessary Angina and
for the absorption of fat from the diet Acid reflux heart attack
Burning pain Severe, crushing
and also for the excretion of cholesterol. behind the
pain in the centre
of the chest, often
breastbone spreading into the
cherry angioma left arm
An alternative name for a Campbell de
Morgan’s spot (a small, bright red, non-
cancerous spot on the trunk or limbs). Pleurodynia,
shingles and nerve
cherry-red spot root pressure
Sharp pain around
A red spot that can be seen on the retina the side of the
chest wall
of infants who have the inherited meta-
bolic disorder Tay–Sachs disease.

161
 CHEST THRUST

cancer; mesothelioma) may also cause Cheyne–Stokes respiration chigoe

pain as they enlarge in size and press An abnormal pattern of breathing in A painful, itchy swelling, about the size
on the pleura and the ribs. which the rate and depth of respiration of a pea, caused by a sand flea that lives
Pain in the centre of the chest may vary rhythmically. Cheyne–Stokes res- in sandy soil in Africa and tropical
be due to a heart disorder. The common piration is characterized by repeated America. When stepped on, the flea
disorder angina pectoris produces pain cycles, each lasting a few minutes, of penetrates the skin of the feet and lays
C that may spread from the chest to the deep, rapid breathing that becomes eggs. Chigoe fleas should be removed
throat, jaw, or arms. It is caused by an slower and shallower and then stops for with a sterile needle, and the wounds
inadequate blood supply to the heart, between 10 and 20 seconds. treated with an antiseptic.
commonly due to coronary artery disease. The pattern of Cheyne–Stokes respir-
Myocardial infarction (heart attack) causes ation may be due to a malfunction in chilblain
a similar pain to angina but is usually the part of the brain that controls An itchy, purple-red swelling, usually
more severe and is not relieved by rest. breathing (as occurs in some cases of on a toe or a finger. Chilblains are
Acute pericarditis (inflammation of the stroke and head injury). It may be due to caused by excessive constriction (nar-
membrane covering the heart) produces heart failure or occur in healthy people rowing) of small blood vessels below
severe pain that may be relieved slightly at high altitude, especially during sleep. the surface of the skin in cold weather.
when the person leans forwards. Mitral They are most common in young chil-
valve prolapse may cause sharp pain, chickenpox dren and elderly people, and women
usually on the left side of the chest. A common, mild infectious disease, are more susceptible to them. They
Chest pain may also be a result of also called varicella, most often occur- generally heal without treatment.
anxiety and emotional stress (see hyper- ring in children. Symptoms are a rash
ventilation; panic attack). and slight fever. In adults, chickenpox child abuse
TREATMENT is uncommon but usually more severe. Maltreatment of children. Child abuse
The treatment of chest pain depends on An attack gives lifelong immunity, but includes physical injury, sexual abuse,
the underlying cause. For example, the causative virus remains dormant in emotional mistreatment, and/or neg-
antibiotic drugs may be given for chest nerves and may reappear later in life to lect; it occurs at all levels of society.
pain due to pneumonia, and surgery is cause herpes zoster (shingles). Child abuse can cause severe physical
needed to treat some lung tumours or CAUSE AND SYMPTOMS and psychological damage in the vic-
some cases of coronary artery disease. Chickenpox is caused by the varicella tims. In addition, being deprived or
zoster virus, which is spread in air- ill-treated in childhood may predispose
chest thrust borne droplets. A widespread rash some affected people to repeat the pat-
A first-aid technique that is used to develops two to three weeks after infec- tern of abuse with their own children.
unblock the airway of a person who is tion and consists of clusters of small,
choking. Chest thrusts involve standing red, itchy spots that become fluid-filled childbed fever
behind the casualty, reaching around blisters within a few hours. After several See puerperal fever.
his or her chest, and placing one fist, days, the blisters dry out to form scabs.
thumb inwards, against the lower Scratching the blisters can lead to childbirth
breastbone. The fist is then grasped secondary infection and scarring. In The event during which a baby leaves
with the other hand, and the casualty’s adults, or in anyone whose immune the mother’s uterus (womb) and enters
chest wall is thrust sharply inwards system is suppressed by drug treatment the outside world. The process of
and upwards up to five times. The or illness, serious complications invol- childbirth, known as labour, normally
pressure simulates the coughing reflex ving the lungs can occur. takes place between 38 and 42 weeks
and may expel the obstruction. People with chickenpox are highly of pregnancy, as timed from the moth-
For an infant, the technique involves infectious from about two days before er’s last menstrual period.
the first-aider laying the baby face- the rash appears to about a week after- For most women who receive a high
upwards and head downwards along wards. Nonimmune pregnant women standard of medical care during preg-
his or her forearm, placing two finger- should be particularly careful to avoid nancy (see antenatal care) and delivery,
tips of the other hand on the baby’s children with chickenpox or anyone childbirth presents no serious prob-
lower breastbone, and giving up to five with shingles, because the disease may lems. The development of specialized
sharp thrusts into the chest. be serious in pregnancy and newborn equipment and the availability of blood
babies could suffer a severe attack. transfusions and antibiotic drugs have
chest X-ray TREATMENT made childbirth much safer for both
One of the most frequently performed In most cases, no specific treatment is mother and baby. In developing coun-
medical tests, usually carried out to needed. Paracetamol helps to reduce tries, however, the number of women
examine the heart or lungs. Chest X- fever, and calamine lotion may be used who die from childbirth remains high
rays are used to confirm diagnoses of to relieve itching. Anyone at high risk (see maternal mortality).
heart disorders, such as enlargement of who has been exposed to the virus may ONSET OF LABOUR
a heart chamber, or lung diseases, such be given treatment with immunoglobulin, It is often difficult to determine pre-
as tuberculosis or lung cancer. They which may prevent the condition from cisely when labour has started. During
may also be used to examine the ribs developing. In severe cases of chicken- the last three months of pregnancy, the
after an injury. The procedure is simple, pox, in both children and adults, uterus begins to contract in preparation
quick, and painless. (See also X-rays.) aciclovir (an antiviral drug) is given. for the birth. Such contractions, called

162
 CHILDBIRTH

STAGES OF CHILDBIRTH

At the onset of labour, painful and regular uterine is often carried out, and the frequency, strength, and duration
contractions begin and the cervix (the neck of the womb) of the mother’s contractions are recorded. During the second
starts to dilate (widen). The mother is usually examined stage of labour, the contractions become stronger and the
vaginally every two to four hours to assess the extent of woman feels the urge to push; however, she is advised to
dilation. The duration of the first stage of labour depends push only during a contraction. Once the baby is delivered, he C
on several factors, but primarily on whether the baby is the or she is usually laid on the mother’s abdomen, but may first
mother’s first or a subsequent child. Fetal heart monitoring be warmed, dried, and checked by a midwife or doctor.

THE FIRST STAGE Uterus

With the first contractions, ELECTRONIC FETAL MONITORING
the normally thick, tough
cervix becomes thinned and This may be performed if the fetus is at risk, or as a
softened and is gradually routine check. The fetal heart rate and the mother’s
pulled up until it becomes uterine contractions are recorded.
effaced (merged with the walls
of the uterus). The cervix then
begins to dilate (stretch open)
with each contraction. It is
fully dilated when the opening
is about 10 cm in diameter.
This stage of labour can take
12 hours or more for first
babies, but only a few hours Cervix Cervix
for subsequent babies. closed dilated

THE SECOND STAGE

As the baby’s head descends, it reaches the pelvic floor muscles, which
cause the head to rotate until eventually the baby’s chin is pointing down
towards the mother’s rectum. As the baby is pushed further down the birth
canal, the mother’s anus and perineum (the area between the vulva and
anus) begin to bulge out, and soon the baby’s head can be seen at the
opening of the vagina. As the head emerges, the perineal tissues are
stretched very thin; sometimes it is necessary to perform an episiotomy Fetal monitoring devices
Fetal heart rate
In the procedure shown above, the
(cutting of the tissues under local anaesthetic) to prevent them from tearing.
baby’s heartbeat is detected by a
As soon as the baby’s head emerges, it turns, usually aided by the midwife,
metal plate strapped to the lower belt.
so it is once more in line with the body. With the next few contractions, one
A plate beneath the upper belt detects
shoulder is delivered at a time; then the rest of the baby slides out. After
the contractions. An alternative
delivery, the cord is clamped and cut.
method is to attach an electrode to the
baby’s head; the electrode is linked to
The head the monitor by a wire passed through
emerges the mother’s vagina. Uterine contractions
At this point, an
episiotomy is
sometimes
performed to THE THIRD STAGE
prevent tissues Three to 10 minutes after the birth, the placenta (afterbirth) separates from
from tearing. the uterine wall and is removed by gentle traction on the cord. Drugs such
as ergometrine or oxytocin may be used to aid its expulsion and to reduce
bleeding. Rarely, the placenta may have to be manually removed, under
Widened vagina general or epidural anaesthetic, by an obstetrician. Any tears or incisions
are cleaned and stitched. This may be done while the mother holds her baby.

Umbilical cord Placenta being delivered

The placenta is usually expelled within
a few minutes of the baby’s birth.
Delivery of
the baby
Once both of the Placenta
shoulders are
out, the rest of
the baby’s body
emerges easily. Umbilical
cord
Baby’s head
is supported

Shoulders
slide out

163
 CHILDBIRTH, COMPLICATIONS OF

Slow progress in the first stage of a

PAIN RELIEF IN LABOUR AND DELIVERY normal labour may be due to inade-
Method Why given Possible effects on baby
quate contractions of the uterus. It is
usually treated with intravenous infu-
Narcotic Routine pain relief during Baby may be less responsive at birth,
sions of synthetic oxytocin. If the
analgesics labour and may have respiratory problems, mother cannot push strongly enough,
C but these effects are reversible or if the contractions are ineffective in
the second stage of labour, the baby
Epidural Routine pain relief during Effects are uncommon unless may be delivered by forceps delivery, vac-
labour, delivery of twins, mother’s blood pressure falls uum extraction, or caesarean section.
breech delivery, and Rarely, eclampsia (convulsions associ-
caesarean section
ated with raised blood pressure) may
Nitrous oxide Pain relief during labour and None
develop during labour. This disorder
delivery; used for short requires treatment with anticonvulsant
periods only drugs and oxygen, and a caesarean sec-
tion will be necessary.
Pudendal block Forceps delivery None Bleeding before labour (antepartum
haemorrhage) or during labour may be
Local anaesthetic Forceps delivery or None caused by premature, partial separation
into perineum episiotomy of the placenta from the wall of the
uterus. Less commonly, it may result
General Caesarean section Baby may show reduced from a condition called placenta praevia,
anaesthesia responsiveness at birth
in which the placenta lies over the
opening of the cervix. Blood loss after
the delivery (postpartum haemorrhage) is
Braxton Hicks’ contractions may be mis- the baby rotates to face the mother’s usually due to failure of the uterus to
taken for the onset of labour. However, back. Once the baby’s head is delivered, contract after delivery, or to retention
when the contractions become pro- the rest of the body follows with the of part of the placenta.
gressively more painful and occur more next contractions. After delivery, the FETAL PROBLEMS
regularly and with shorter intervals umbilical cord, which connects the baby If the baby lies in the breech position
between, labour has probably started. to the placenta, is clamped and cut. (see breech delivery), or in any other
At the onset of labour, the cervix (the In the third stage of labour, the deliv- malpresentation (not lying in the normal
neck of the uterus) becomes thinned ery of the placenta (the afterbirth) head-down position in the uterus),
and softened and then begins to dilate takes place. This event happens within caesarean section may be necessary.
with each contraction. During this about ten minutes of the baby’s birth. Multiple pregnancies (see pregnancy,
time, there may be a “show’’, which is PAIN RELIEF multiple) carry an increased risk of
when the mucous plug that blocks the Pain relief is available during normal problems during delivery due to the
cervical canal during pregnancy is labour and delivery. There are various difficulty of predicting the position of
expelled as a bloody discharge. “Break- forms, including opioid analgesic drugs, the second or subsequent babies. It is
ing of the waters’’, which is the epidural anaesthesia, and pudendal block. also more likely that babies in multiple
rupture of the amniotic sac (the fluid- (See also childbirth, complications of; pregnancies will be born prematurely.
filled membranous bag that protects childbirth, natural.) FETAL–MATERNAL PROBLEMS
the fetus in the uterus), may occur If the mother’s pelvis is too small in
either as a slow trickle of fluid from the childbirth, complications of proportion to the head of her baby (a
vagina or as a sudden gush. Problems that occur during labour and condition known as cephalopelvic dis-
STAGES OF LABOUR delivery. Complications may affect the proportion), the baby may have to be
Childbirth occurs in three stages (see mother, the baby, or both. Some are delivered by caesarean section.
illustrated box on p.163 for details). potentially life-threatening, especially
The first stage of childbirth covers to the baby if they impair the baby’s childbirth, natural
the period lasting from the onset of oxygen supply (see fetal distress). The use of relaxation and other tech-
labour to the point when the woman’s MATERNAL PROBLEMS niques to help cope with pain and
cervix is fully dilated, which is when If contractions begin, or if the mem- minimize the use of drugs and medical
the opening has widened to about branes rupture, before the 37th week intervention during childbirth.
10 cm in diameter. The duration of this of pregnancy, premature labour may
stage varies from woman to woman occur, with the delivery of a small, child development
and from birth to birth. immature baby (see prematurity). The acquisition of physical, mental,
The second stage of labour lasts from Premature rupture of the amniotic sac and social skills in children. Although
full dilation of the cervix until the (the fluid-filled, membranous bag that there is wide variation in individual
delivery of the baby. In this stage, the protects the fetus in the uterus) can rates of progress, most children devel-
mother feels the urge to push with lead to infection in the uterus, requir- op certain skills within predictable age
each strong contraction. As the baby’s ing prompt delivery of the baby and ranges (see the illustrated boxes oppo-
head descends into the mother’s vagina, treatment with antibiotic drugs. site and overleaf).

164
 CHILD GUIDANCE

FACTORS AFFECTING DEVELOPMENT Speaking to and playing with children skills are acquired varies enormously
The capability for acquiring new skills is essential for their language develop- from child to child. A child may devel-
is dependent upon the maturity of the ment and to help them practise new op more rapidly in one area than in
child’s nervous system. Individual rates physical skills. Introducing children to another. A more detailed assessment is
of maturity are determined genetically other children also provides them with required only if a child’s progress is
and modified by environmental factors a great deal of stimulation. significantly slower than average or if a
in the uterus and after birth. For exam- DEVELOPMENTAL MILESTONES parent is concerned for other reasons C
ple, premature children miss out on a Development is assessed in early child- (see developmental delay).
portion of the growing time in the hood by looking at the child’s abilities
uterus; therefore, the time that they in four major areas: physical skills; child guidance
take to progress should, be calculated hearing and language; vision and fine A form of care provided by a multidis-
from the full-term pregnancy date, not movement; and social behaviour and ciplinary diagnosis and advice team,
the actual date of birth. play. Children acquire particular skills at which helps children suffering from
Sight and hearing are both crucial to widely recognized stages known as emotional or behavioural difficulties
a child’s general developmental pro- developmental milestones. (see behavioural problems in children).
gress; any defect in these areas will All children acquire skills in much Indications of such problems include
affect the child’s ability to watch, listen, the same order (for example, a child poor performance at school, disruptive
learn, and imitate. Intelligence also will not learn to stand before learning or withdrawn behaviour, breaking the
affects the speed of development. to sit); however, the rate at which these law, and drug abuse.

CHILD DEVELOPMENT: 0–18 MONTHS

Locomotion
By 6 months 9 months 1 year 18 months
Babies can lift up their heads and Babies try to crawl, sit without Children can crawl on hands and Children can walk well with feet
chests and roll from front to back support, and pull themselves up to knees and walk around furniture closer together. They can stoop to
and back to front. They can sit up standing or sitting positions. They (holding on). They may be able to pick up objects, run with care,
with support, bounce up and can step purposefully on alternate walk alone or with one hand held. walk upstairs with one hand held,
down, and bear weight on their feet if they are supported. and crawl backwards downstairs.
legs if supported.

Vision and fine movement

By 6 months 9 months 1 year 18 months
Babies look intently at everything Babies are visually very alert. Their Children can grasp small objects Children can build a tower of
and everybody. They follow moving grasp involves mostly the index and well and release grasped objects three blocks (when shown), enjoy
objects with their eyes and reach middle fingers. They can manipulate easily. Both hands are used turning pages of a book, can grip
for objects with one or both hands. objects with both hands, but have equally. They can hold a block a crayon, scribble, and make dots.
Objects are transferred from hand difficulty voluntarily releasing in each hand and bang the They may use one hand more than
to hand and brought to the mouth. grasped objects. blocks together. the other.

Hearing, understanding, and speech

By 6 months 9 months 1 year 18 months
Babies turn their heads to locate Babies listen to sounds and Children turn when they hear their Children comprehend short
sources of sound and have begun understand “no” and other words. own name spoken. They have communications spoken directly
to understand the tone of their They babble in long strings (making some understanding of how other to them but do not understand
mother’s voice. They enjoy making sounds such as ba-ba, da-da, ma- people feel; they know what most the difference between
vowel sounds and tuneful noises. ma) and start using sound to household objects are used for; statements, commands, and
They laugh and squeal. attract attention. (Deaf babies’ they may babble meaningfully to questions. Vocabulary may
utterances are monotonous and do themselves; and they may say contain six to 20 words.
not develop in complexity.) two or three words.

Social behaviour and play

By 6 months 9 months 1 year 18 months
Babies enjoy looking at their Babies look for objects that are Children spend less time putting Children actively explore their
images in mirrors and playing shown and then hidden, thus objects in their mouths and more homes. They enjoy moving things
peekaboo games. They can grasp showing the beginnings of time releasing objects by throwing into and out of boxes and looking at
objects and can also shake, bang, memory. They imitate hand them, dropping them, putting picture books. They use spoons and
and otherwise manipulate them. clapping, wave bye-bye, and show them in boxes. They play pat-a- cups and can take off their shoes
They will not, however, look for great determination in getting cake and like to be around a and socks. They are also determined,
objects that are shown and then objects. They continue to be shy familiar adult to whom they impetuous, selfish, and cannot be
hidden. They are shy with with strangers. demonstrate affection. reasoned with. They alternate
strangers. between clinging to a familiar adult
and struggling to break free.

165
 CHILL

CHILD DEVELOPMENT: 2–5 YEARS

Locomotion
2 years 3 years 4 years 5 years
Children can climb furniture and Children can climb with agility, Children walk up and down stairs Children can stand and hop on
C walk up and down stairs (using
two feet to each step).
throw and kick balls, ride tricycles,
and run around corners.
with one foot on each step, and
can stand, walk, and run on tiptoe.
one foot, and are skilful in rolling,
sliding, and swinging.

Vision and fine movement

2 years 3 years 4 years 5 years
Children can build towers of six or Children hold crayons with an Children hold a pencil with a Children can match 10 or 12
seven blocks, can unscrew a lid, adult grasp and can undo buttons, mature grasp, can copy simple colours, can copy many more
and show a definite right- or left- but may need help buttoning them letters (i.e. O,T, H or V), and letters, and can draw the full body
handedness. up. Their handedness is clearly can build a tower of more than of a person with a recognizable
established. 10 blocks. head and facial features.

Hearing, understanding, and speech

2 years 3 years 4 years 5 years
Children begin to listen to general Children listen to conversation Children can repeat softly spoken Children enjoy reciting rhymes,
conversation. They obey simple and enjoy nursery stories. They words at a distance of 1 m. They telling stories, and having books
instructions and can use 50 or understand the difference speak fluently and with correct read to them.
more words meaningfully. They between statements, commands, grammar, and can provide their
constantly talk to themselves and and questions. They have large full names, ages, and addresses.
can put two or more words vocabularies and speak clearly in They tell long stories, confusing
together to communicate. sentences; there may be some errors. fact and fantasy.

Social behaviour and play

2 years 3 years 4 years 5 years
Children ask the names of Children constantly ask questions. Children continue asking Children ask the meaning of
everything and enjoy participating They can dress and undress and eat questions constantly. They are abstract words. They like to build
in nursery rhymes and songs. They with a fork and spoon. They are dry more independent and skilful complex structures out of bricks or
ask for food and drink and indicate and clean during the day and in dressing, undressing, eating, other objects. They continue in
toilet needs. They begin to play with sometimes at night. Three year olds and washing. They need to play imaginative and dramatic play. They
toys more imaginatively, though can play with toys imaginatively and with other children and can share enjoy companionship and under-
they may not like to share them. will share with others. They can be with others. They can understand stand the need for rules and fair
They are constantly demanding and reasoned with and have fewer past, present, and future. play. They have an understanding
will throw tantrums if their desires tantrums. They are also more of time and are generally sensible,
are thwarted. affectionate to younger siblings. restrained, and independent.

Child guidance professionals include Chinese medicine dren, ankle injuries in adolescents,
the specialists such as psychiatric social Traditional Chinese medicine is based fractures in athletes and joggers, bun-
workers, psychiatrists, and psychologists. on the theory that a universal life-force, ions and hammer toes in people of all
These people often work closely togeth- called chi, manifests itself in the body ages, and the care of ulcers, toenails,
er in hospital paediatric departments, in as two complementary qualities called and infections of the feet suffered as a
schools, or in child-guidance clinics. yin and yang. According to this belief, complication of diabetes mellitus. A per-
Various methods of assessment and vigorous yang and restraining yin must son who specializes in chiropody is
therapy may be employed, depending be in balance, and the chi must flow called a chiropodist.
on the age of the child and the problem evenly for good health.
involved. For young children, play thera- Treatments for illness aim to restore chiropractic
py may be used to help with diagnosis. the balance between yin and yang and A system of treatment for a range of
Older children may be offered coun- normalize the flow of chi in the body. disorders, that is based on manipula-
selling, psychotherapy, or group therapy. They include Chinese herbal medicine, tion of the spine. The main principle of
Family therapy may be of benefit in cases physical techniques such as acupressure chiropractic is the theory that disease
where there are relationship difficulties and acupuncture, and t’ai chi. stems from the misalignment of bones,
between child and one or both parents. which causes various problems with
chiropody the nerves and muscles.
chill The examination, diagnosis, treatment,
A shivering attack accompanied by and prevention of diseases and mal- chlamydial infections
chattering teeth, pale skin, goose pim- functions of the foot and its related A group of infectious diseases caused
ples, and feeling cold. Chill frequently structures. Chiropody is concerned with by chlamydiae, a group of bacteria that
precedes a fever. Repeated or severe many different types of foot problem, can multiply only by invading the cells
shivering suggests serious illness. including walking disorders in chil- of another life-form.

166
 CHOCOLATE CYST

TYPES chloral hydrate Chloromycetin

Two main species of chlamydiae cause A type of sleeping drug. A brand name for the antibiotic drug
disease in humans. They can be treated chloramphenicol, which is often used in
with antibiotic drugs. chlorambucil eye and ear preparations.
The first species, CHLAMYDIA TRACHOMATIS, An anticancer drug that is used in the
is responsible for some sexually trans- treatment of some types of cancer, such chloroquine
mitted infections, including about half as Hodgkin’s disease. A drug used mainly in the prevention C
of all cases of nongonococcal urethritis in and treatment of malaria. It is also used
men and pelvic inflammatory disease in chloramphenicol as an antirheumatic drug to treat rheuma-
women. It can also cause the tropical An antibiotic drug commonly used as toid arthritis and lupus erythematosus.
eye disease trachoma. drops to treat superficial eye infections. Possible side effects of chloroquine
A second species, CHLAMYDIA PSITTACI, is Chloramphenicol is also used to treat include nausea, headache, diarrhoea,
responsible for psittacosis. This is a rare life-threatening infections of unknown rashes, and abdominal pain. Long-term
form of pneumonia that is transmitted cause. Rarely, tablets or injections are use may damage the retina of the eye.
to humans from birds. associated with aplastic anaemia.
Chlamydia is also responsible for a type chlorphenamine
of pneumonia (see Chlamydia pneumoniae). chlorate poisoning An antihistamine drug that is used to
The toxic effects of chemicals called treat a number of allergic conditions
Chlamydia pneumoniae chlorates, which are present in some such as allergic rhinitis (hay fever),
An infectious organism that can cause a defoliant weedkillers. allergic conjunctivitis, angioedema (aller-
mild form of pneumonia, which occurs Symptoms of chlorate poisoning in- gic facial swelling) and urticaria (nettle
particularly in young adults. clude ulcers the mouth, abdominal rash). Chlorphenamine is also a com-
pain, and diarrhoea. Chlorates can also ponent of some cold remedies.
Chlamydia psittaci cause kidney and liver damage, corro-
An organism that mainly affects birds sion of the intestines, and methaemo- chlorpheniramine
but can occasionally spread to people globinaemia (a harmful chemical change An alternative name for chlorphenamine.
who are in contact with pigeons, par- in the blood pigment haemoglobin).
rots, parakeets, or poultry. It causes a Even small doses can be fatal; medical chlorpromazine
type of pneumonia called psittacosis. help is needed immediately if chlorate A widely prescribed antipsychotic drug
poisoning is suspected. used to relieve symptoms of major psy-
Chlamydia trachomatis chotic illnesses such as schizophrenia
An organism that belongs to the chla- chlordiazepoxide and mania. The drug reduces delusional
mydiae group and has several strains. In A benzodiazepine drug mainly used in and hallucinatory experiences and may
men, it is a major cause of the sexually the treatment of anxiety. have an effect on irritability and overac-
transmitted infection nongonococcal ure- tivity. It is also used as an antiemetic drug
thritis, which may cause a discharge chlorhexidine to treat nausea and vomiting, especially
from the penis. In women, the infec- A type of disinfectant mainly used to when these problems are the result of
tion usually causes no symptoms, but cleanse the skin before surgery or treatment with other drugs, radiother-
can lead to pelvic inflammatory disease before taking a blood sample. apy, or anaesthesia.
and possibly salpingitis (inflammation Chlorpromazine may cause photosen-
of the fallopian tubes). A baby born to chlorine sitivity (increased sensitivity of the skin
a woman with chlamydial infection A poisonous, yellowish-green gas with to sunlight) and, in some cases, parkin-
may acquire an acute eye disorder powerful bleaching and disinfectant sonism (a movement disorder), slow
called neonatal ophthalmia. properties. If inhaled in even very small reactions, and blurred vision.
In some parts of Africa and Asia, cer- amounts, chlorine gas is highly irritat-
tain strains of CHLAMYDIA TRACHOMATIS ing to the lungs; inhalation of large chlorpropamide
cause trachoma, a serious eye disease amounts is rapidly fatal. A drug that is used to treat diabetes mel-
that is the most common cause of (see hypoglycaemics, oral).
litus
blindness worldwide. chlorofluorocarbon propellants
Aerosol propellants, commonly known choanal atresia
chloasma as CFCs, that contain compounds of A congenital abnormality of the nose in
A skin condition, also called melasma, gases such as carbon, chlorine, fluorine, which one or both of the nasal cavities
in which blotches of pale brown pig- and hydrogen. CFCs have contributed are not fully developed.
mentation appear on the face, notably to the damage to the ozone layer.
on the forehead, nose, and cheeks. The chocolate cyst
condition is aggravated by sunlight. chloroform A brown swelling in an ovary. Chocolate
Chloasma sometimes develops during A colourless liquid producing a vapour cysts may develop in endometriosis, a
pregnancy. More rarely, it is associated that was formerly used as a general condition in which endometrial tissue
with the menopause or the use of oral anaesthetic (see anaesthesia, general). (which forms the lining of the uterus)
contraceptives. The areas of abnormal However, chloroform is associated with is found in sites outside the uterus. The
pigmentation usually fade in time, but liver damage and heart problems and colour is the result of clotted blood
the condition may recur. safer drugs are now used instead. within the cysts.

167
 CHOKING

choking the duct and may affect the liver. The severe, constant pain in the right side of
Partial or complete inability to breathe main symptoms of acute ascending the abdomen under the ribs, accompa-
due to an obstruction of the airways. cholangitis are recurrent bouts of jaun- nied by fever and, occasionally, jaundice.
Choking is often caused by food or dice, abdominal pain, chills, and fever. Repeated mild attacks of acute chole-
drink entering the trachea (the wind- Mild attacks are treated with antibiotic cystitis can lead to a chronic form of
pipe) or the bronchi (the main airways drugs and fluids. Severe attacks may be the condition, in which the gallbladder
C to the lungs) instead of passing from accompanied by life-threatening septi- shrinks, its walls thicken, and it ceases
the pharynx (throat) into the oesophagus caemia (blood poisoning) and kidney to store bile. Symptoms include indi-
(gullet). Normally, coughing dislodges failure. In these cases, the infected gestion, pains in the upper abdomen,
the food or drink. An obstruction that material may be drained from the bile nausea, and belching; they may be
partially blocks the airway, and which duct during surgery or endoscopy (a aggravated by eating fatty foods.
cannot be dislodged by coughing, is procedure in which instruments are TREATMENT AND COMPLICATIONS
more serious. If the airway is complete- passed through a viewing tube). Treatment of cholecystitis usually invol-
ly blocked, total suffocation will occur SCLEROSING CHOLANGITIS ves the use of analgesic drugs, antibiotic
if the obstruction is not removed. In this rare condition, all the bile ducts drugs, and an intravenous infusion of
If an obstruction cannot be cleared within and outside the liver become nutrients and fluids. In some affected
by the use of first-aid techniques, such narrowed. This causes cholestasis (stag- people, complications develop. These
as the Heimlich manoeuvre, or removed nation of the bile in the liver), chronic may include peritonitis (inflammation of
by hand, it may be necessary to per- jaundice, and itchiness of the skin, and the lining of the abdominal cavity), if
form an emergency tracheostomy (the the liver is progressively damaged. the gallbladder bursts, and empyema (an
making of an incision into the trachea The drug colestyramine may relieve accumulation of pus). Both of these
and insertion of a tube through it into itching. The only other treatment avail- complications require urgent surgical
the lungs) to restore the airway. The able is a liver transplant. treatment. Cholecystectomy (removal of
object may then be removed by laryngo- the gallbladder) is the usual treatment
scopy or bronchoscopy (procedures that chole- for chronic cholecystitis.
involve a viewing tube through which A prefix that means “relating to the bile
instruments are passed). or the biliary system”, as in cholecystitis cholecystography
(inflammation of the gallbladder). An X-ray procedure in which a contrast
cholangiocarcinoma medium (a substance that is opaque
A cancerous growth in one of the bile cholecalciferol to X-rays) is used for viewing of the
ducts. Cholangiocarcinomacauses jaun- An alternative name for colecalciferol, gallbladder and common bile duct. The
dice and weight loss. also called vitamin D3 (see vitamin D). technique of cholecystography is usu-
ally used for the detection of gallstones
cholangiography cholecystectomy but has largely been replaced by ultra-
An imaging procedure involving the Surgical removal of the gallbladder. sound scanning of the gallbladder.
use of a contrast medium (a substance Cholecystectomy is usually performed
that is opaque to X-rays) to make the to deal with the presence of trouble- cholecystokinin
bile ducts visible on X-rays. It is used to some gallstones. It is also used in cases A hormone that is produced in the duo-
diagnose biliary stones (which are sim- of acute cholecystitis (inflammation of denum (the first section of the small
ilar to gallstones, but they develop in the gallbladder) and as an emergency intestine) in response to the ingestion
the bile ducts instead of the gall- treatment for rupture of the gallbladder of fats and certain other food sub-
bladder) and narrowing or tumours of or empyema (accumulation of pus). stances. Cholecystokinin stimulates the
the bile ducts. The procedure is being Cholecystectomy may be carried out gallbladder to release bile into the duo-
superseded by ultrasound scanning and using conventional surgery or, more denum, and triggers the secretion of
MRI, both of which can be used to commonly, by minimally invasive surgery digestive enzymes from the pancreas,
locate stones. using a laparoscope (a type of viewing thus aiding the breakdown of foods to
tube through which instruments can release nutrients. Cholecystokinin is
cholangitis be passed), as shown in the illustrated also found in the brain, where it has a
Inflammation of any of the bile ducts, box opposite. function as a neurotransmitter.
such as the common bile duct, which
leads from the liver and gallbladder to cholecystitis choledochal cyst
the small intestine (see biliary system). Acute or chronic painful inflammation A widening of the common bile duct,
There are two forms of the condition: of the gallbladder. which carries the digestive juice bile
acute ascending cholangitis and scle- CAUSES AND SYMPTOMS from the liver and gallbladder to the
rosing cholangitis. Acute cholecystitis is usually caused by duodenum. The disorder is congenital
ACUTE ASCENDING CHOLANGITIS a gallstone obstructing the outlet from (present at birth), but symptoms may
This form of cholangitis is usually due the gallbladder. The trapped bile inside not develop until early adulthood; they
to bacterial infection of the duct and its becomes more concentrated, because consist of abdominal pain and jaundice
bile. The infection, in turn, generally water is absorbed from it, and irritates (yellow coloration of the skin and eyes
results from blockage of the duct – for the gallbladder walls. Bacterial infec- due to the accumulation of bilirubin, a
example, by a gallstone (see bile duct tion of the bile may result. The main bile pigment). Surgery is needed to
obstruction). The infection spreads up symptom of acute cholecystitis is correct the abnormality.

168
 CHOLESTASIS

cholelithiasis ease causes profuse watery diarrhoea, the disease occur regularly in northeast
See gallstones. which can lead to dehydration and India, but worldwide cholera is con-
death in severe untreated cases. trolled by sanitation.
cholera CAUSE AND INCIDENCE SYMPTOMS
An infection of the small intestine by Infection is acquired by ingesting con- Cholera starts suddenly, between one
the bacterium VIBRIO CHOLERAE. The dis- taminated food or water. Outbreaks of and five days after infection, with diar-
rhoea that is often accompanied by C
vomiting. More than 500 ml of fluid
CHOLECYSTECTOMY may be lost each hour and, if this fluid
is not replaced, severe dehydration and
Surgery to remove the gallbladder Laparoscopic cholecystectomy
then death may occur within hours.
(cholecystectomy) can be performed (pictured here), despite taking twice
conventionally or laparoscopically. The as long as conventional surgery The fluid loss is caused by the action of
procedure is performed under general (about two hours), has the advantage a toxin produced by the cholera bac-
anaesthesia; it is most often carried of requiring only small incisions and terium that greatly increases the
out when the gallbladder has been allowing most patients to make a full passage of fluid from the bloodstream
found to contain gallstones. recovery in 7 to 10 days. into the large and small intestines.
TREATMENT
Sites of Treatment is with water containing
incision salts and sugar (see oral rehydration ther-
Liver apy) and, in severe cases, by intravenous
infusion. Antibiotic drugs can shorten the
Stomach period of diarrhoea and infectiousness.
After adequate rehydration, affected
Gallbladder people usually make a full recovery
from the infection.
PREVENTION
Cholera is controlled worldwide by the
improvement of sanitation, and in par-
ticular by ensuring that sewage is not
Cholecystogram of the gallbladder permitted to contaminate water sup-
Gallstones, which become more prevalent with
age, are revealed by a cholecystogram (X-ray Suction instrument plies used for drinking. Vaccination
image of the gallbladder). against cholera is not recommended.
Travellers planning to visit cholera-
infected areas are advised to consume
Instrument only water that has been boiled, or bot-
Instrument tled drinks from reliable sources.
Laparoscope
Gallbladder cholestasis
Stagnation of bile in the small bile ducts
Liver
within the liver, leading to jaundice and
liver disease. The obstruction to the
flow of bile may be intrahepatic (with-
in the liver) or extrahepatic (in the bile
ducts outside the liver).
CAUSES
Intrahepatic cholestasis may develop as
a result of viral hepatitis (see hepatitis,
viral) or as an adverse effect of various
drugs. The flow of bile will improve
gradually as the inflammation from
hepatitis subsides or when a causative
drug is discontinued.
The bile ducts outside the liver can
become blocked by abnormalities such
as gallstones or tumours (see bile duct
obstruction). Rarely, the ducts are absent
Procedure for cholecystectomy from birth (see biliary atresia).
The abdominal cavity is inflated with gas to through other incisions. While watching the TREATMENT
provide a clear view, then a laparoscope fitted monitor, the surgeon removes the gallbladder, Bile duct obstruction and biliary atresia
with a video camera is introduced through a ensuring that there is no leakage from the bile are often treated surgically to ensure or
small incision. Further instruments are passed duct or blood vessels.
restore the free passage of bile from the
liver to the duodenum.

169
 CHOLESTATIC JAUNDICE

cholestatic jaundice Sometimes, however, medication (such the front of the chest. Chondritis may
Jaundice (yellow discoloration of the as simvastatin) may be required to re- also affect the cartilage lining the hip
skin) that occurs as a result of cholesta- duce the risk of arterial diseases. and knee joints; this inflammation may
sis (obstruction in the flow of bile to eventually lead to osteoarthritis.
the intestine). cholesterolosis
Abnormal deposits of cholesterol in chondro-
C cholesteatoma the lining of the gallbladder that may A prefix denoting a relationship to car-
A rare but serious condition in which be associated with the development tilage, as in chondrocyte, a cell that
skin cells proliferate and grow inwards of gallstones. Cholesterolosis is some- produces cartilage.
from the ear canal into the middle ear. times known as strawberry gallbladder
Cholesteatoma usually occurs as a result because of the appearance of an affec- chondrocalcinosis
of long-standing otitis media (a middle- ted gallbladder. The presence of calcium pyrophosphate
ear infection) together with a defect in in joint cartilage. The condition, which
the eardrum (see eardrum, perforated). If cholestyramine occurs in pseudogout (a form of arthri-
left untreated, it may grow and damage An alternative spelling for the lipid- tis), causes pain and swelling.
the small bones in the middle ear and lowering drug colestyramine.
surrounding structures. chondroma
Cholesteatoma needs to be removed cholic acid A noncancerous tumour composed of
surgically through the eardrum or by One of the acids contained in bile. cartilage, affecting the bones. Chondro-
mastoidectomy (removal of the mastoid mas most often occur in the hands and
bone, which is located behind the ear, cholinergic crisis feet (see chondromatosis).
together with the cholesteatoma). A condition that affects people with
myasthenia gravis who are undergoing chondromalacia patellae
cholesterol treatment with cholinesterase inhibitors. A painful knee disorder, one cause of
A fat-like substance that is an important The problem is caused by an overdose anterior knee pain, in which the carti-
constituent of body cells and also is of cholinesterase inhibitors. During a lage (connective tissue composed of
involved in the formation of hormones cholinergic crisis, the muscle weakness the gel-like substance collagen) behind
and bile salts. Cholesterol is made by that is associated with myasthenia gra- the patella (kneecap) is damaged. Ado-
the liver from various foods, especially vis worsens dramatically, and needs lescents are most commonly affected.
those containing saturated fats (see fats emergency medical treatment. CAUSE
and oils), although a small amount is Chondromalacia patellae may result
absorbed directly from cholesterol-rich cholinesterase inhibitors from knee injuries or sporting activities
foods such as eggs and shellfish. COMMON DRUGS in which the knee is bent for long per-
Both cholesterol and fats (triglycer- • Neostigmine • Pyridostigmine iods (such as horse-riding). This action
ides) are transported in the blood as may weaken the inner part of the
lipoproteins. These are particles with a A group of drugs, also known as anti- quadriceps muscle (which is at the
core, which is made of varying propor- cholinesterases, that are used to relieve front of the thigh), causing the patella
tions of cholesterol and triglycerides, muscle weakness resulting from myas- to tilt when the knee is straightened
and an outer layer made of proteins. thenia gravis. In this disease, abnormal and rubs against the lower end of the
CHOLESTEROL-RELATED DISEASES activity of the immune system causes femur (thigh bone). The rubbing causes
High blood cholesterol levels increase the destruction of receptors on muscle the cartilage that covers both bones to
the risk of atherosclerosis (accumulation cells that bind with acetylcholine, a roughen, causing pain and tenderness.
of fatty deposits on the lining of the neurotransmitter that makes the mus- TREATMENT
arteries) and with it the risk of coronary cles contract. Cholinesterase inhibitors Treatment of chondromalacia patellae
artery disease or of stroke (damage to block the action of acetylcholinester- is with analgesic drugs (painkillers) and
part of the brain due to interruption of ase, the enzyme that normally breaks exercises to strengthen the thigh mus-
its blood supply). In general, choles- down acetylcholine, allowing the neu- cles. Rarely, surgery is needed.
terol transported in the bloodstream as rotransmitter more time to act. The
low-density lipoproteins (LDLs) or as drugs are also used to reverse the chondromatosis
very low-density lipoproteins (VLDLs) effects of muscle-relaxant drugs given A condition in which multiple non-
is a risk factor for these conditions, with general anaesthesia. cancerous tumours, called chondromas,
while cholesterol in the form of high- arise in the bones, most commonly in
density lipoproteins (HDLs) seems to chondritis the bones of the hands and feet. The
protect against arterial disease. Inflammation of cartilage (connective tumour cells consist of cartilage (con-
Levels of cholesterol in the blood are tissue composed of the gel-like sub- nective tissue composed of the gel-like
influenced by diet, genetic factors, and stance collagen). It is usually caused by substance collagen). Chondromatosis
metabolic diseases such as diabetes pressure, stress, or injury. usually causes no symptoms.
mellitus. Cholesterol levels can be mea- Costochondritis is inflammation of
sured by blood tests. They are measured the cartilage between the ribs and the chondrosarcoma
in millimoles per litre (mmol/L). The sternum (breastbone). This condition A cancerous growth of cartilage (con-
optimun level is less than 5.0. Higher causes tenderness over the sternum and nective tissue composed of the gel-like
levels may require dietary modification. pain if pressure is exerted on the ribs at substance collagen). Chondrosarcoma

170
 CHOROIDITIS

occurs within or on the surface of large chorea has occurred as a side effect of a chorionic villi
bones, such as the femur (thigh bone), drug, the drug may be withdrawn and The short, fingerlike projections that
causing pain and swelling. a substitute provided. extend from the surface of the chorion
The condition usually appears in (the membrane that surrounds a fetus).
middle age. The tumour may develop choreoathetosis (See also chorionic villus sampling; villus.)
slowly from a noncancerous tumour A condition characterized by uncon-
(see chondroma; dyschondroplasia) or trollable movements of the limbs, face, chorionic villus sampling (CVS) C
may grow rapidly from an area of pre- and trunk. In this disorder, the jerky, A method of diagnosing genetic abnor-
viously normal bone. If a limb is rapid movements typical of chorea are malities in a fetus. The test involves
affected, amputation of the bone above combined with the slower, continuous taking a small sample of tissue from the
the tumour usually results in a perman- writhing movements of athetosis. chorionic villi at the edge of the placenta
ent cure. Treatment of sites such as the Choreoathetosis may occur in chil- for laboratory analysis. The cells have
pelvis or ribs is more difficult. dren with cerebral palsy. It may also be a the same chromosome makeup as those
side effect of certain drugs. that form the fetus, so they can be used
chordae tendineae to detect genetic abnormalities. After
Stringlike strands of fibre that attach the choriocarcinoma removal, the villi cells are transported
flaps of the mitral and tricuspid heart A rare, cancerous tumour that develops to a laboratory for chromosome analysis.
valves to the walls of the ventricles from placental tissue (see placenta) in CVS is offered to women at a higher-
(lower heart chambers). The chordae the uterus. Choriocarcinoma usually than-normal risk of having a child with
tendineae, which are popularly known occurs as a complication of a hydatidi- a genetic disease, such as thalassaemia,
as the heartstrings, prevent the valves form mole (a noncancerous tumour that or a chromosomal abnormality, such as
from turning inside out. arises in placental tissue); however, it Down’s syndrome. It is normally performed
sometimes develops after a normal at around the 10th week of pregnancy
chordee pregnancy, a miscarriage, or an abor- and can be carried out via the abdomen
Abnormal curvature of the penis, usu- tion. Occasionally, the tumour may not (below) or vaginally, depending on the
ally downwards. Chordee most often appear until months or even years after location of the placenta. CVS slightly
occurs in males with hypospadias, a the pregnancy that gave rise to it. increases the risk of miscarriage.
birth defect in which the opening of SYMPTOMS
the urethra lies on the underside of the There may be no early symptoms. The
penis instead of at the tip. It is usually tumour may become apparent because Ultrasound
transducer
corrected by surgery, between the ages of persistent bleeding from the vagina
of one and three years. after a miscarriage or abortion, or for
more than eight weeks following child- Chorionic villi
chorea birth. If it is left untreated, the tumour
A condition that is characterized by destroys the walls of the uterus; and the
irregular, rapid, jerky movements, usu- cancer may also spread in the blood-
ally affecting the face, limbs, and trunk. stream to the vagina and vulva and then
The movements are involuntary and, to the liver, lungs, brain, and bones.
unlike tics, they are not predictable but DIAGNOSIS AND TREATMENT
occur at random. Chorea disappears Any woman who has been treated for a
during sleep. The disorder is sometimes hydatidiform mole is screened regular-
combined with athetosis (continued ly by ultrasound scanning. Blood and
writhing movements); this combined urine levels of human chorionic gona-
condition is known as choreoathetosis. dotrophin (HCG), a hormone that is
TYPES AND CAUSES normally produced by the placenta, are
Chorea arises from disease or distur- also measured because high levels of
bance of structures lying deep within this hormone in the body are associat- Uterus Fetus
the brain (in particular, the paired nerve ed with choreocarcinoma. Sampling via the abdomen
cell groups called the basal ganglia). The Treatment with anticancer drugs is A few chorionic villi are sucked from the placenta
condition is a feature of Huntington’s dis- usually very successful. Hysterectomy through a hollow needle inserted into the abdomen.
ease and Sydenham’s chorea. It may also (surgical removal of the uterus) may
occur in pregnancy, when it is called also be necessary. choroid
chorea gravidarum. In addition, chorea A layer of tissue at the back of the eye,
may be a side effect of certain drugs, chorion beneath the retina. The choroid contains
including oral contraceptives; certain One of the two membranes that sur- a network of blood vessels that supply
drugs for psychiatric disorders; and round the embryo. The chorion lies nutrients and oxygen to the retina and
drugs for treating Parkinson’s disease. outside the amnion, has small finger- to the surrounding tissues in the eye.
TREATMENT like projections called the chorionic
If the cause of chorea is an underlying villi, and develops into the placenta. choroiditis
disease, the condition may be treated Inflammation of the choroid (the blood-
with drugs that inhibit the nerve path- chorionic gonadotrophin rich layer of tissue at the back of the
ways concerned with movement. If See gonadotrophin, human chorionic. eye). Choroiditis may occur on its own

171
 CHOROID PLEXUS

or as part of a generalized inflamma- chromium ment of two. The condition causes

tion affecting the whole eye (see A metallic element that plays a vital role physical abnormalities, defective sexual
uveitis). The condition is often the in the activities of several enzymes (sub- development, and infertility.
result of infections such as toxocariasis stances that control the rate of chemical In boys, one or more extra X chro-
or toxoplasmosis, and, more rarely, of reactions) in the body. mosomes causes Klinefelter’s syndrome.
sarcoidosis, syphilis, and histoplasmosis, Chromium is needed in only minute This condition results in defective sex-
C although it sometimes has no obvious amounts (see trace elements). In excess, ual development and infertility.
cause. Chorioditis is painless but causes it is toxic. It causes inflammation of the The presence of an extra X chromo-
blurring of vision. skin, and, if inhaled, damages the nose. some in women or of an extra Y
Treatment of chorioditis includes Chromium fumes may increase the risk chromosome in men normally has no
corticosteroid drugs to reduce the inflam- of lung cancer. physical effect but increases the risk of
mation and antibiotic drugs for any mild learning difficulties.
causative infection. chromosomal abnormalities DIAGNOSIS
Variations from normal in the number If suspected, chromosomal abnormali-
STRUCTURE OF CHOROID or structure of chromosomes contained ties can be diagnosed by chromosome
in a person’s cells. In most cases, the analysis in early pregnancy, using
The choroid lines the inside of the chromosomal abnormality is present in amniocentesis or chorionic villus sampling.
eyeball. It thickens around the lens all of the body’s cells. The possible Because chromosomal abnormalities
to form the ciliary body. Muscles effects range from virtually none to a affect every one of a person’s cells, no
stretching between the choroid and lethal condition, depending on the par- cure is possible. Many disorders caused
the lens contract to adjust the shape ticular type of abnormality. by autosomal chromosome defects
of the lens in focusing. CAUSES result in early death. Others, such as
Choroid Retina The cause of a chromosomal abnormal- Down’s syndrome, are compatible with
Iris
ity is generally a fault in the process of survival but cause physical and mental
chromosome division, either during disability. Hormonal or surgical treat-
the formation of an egg or sperm, or ment, or a combination, can help to
during the first few divisions of a fertil- correct some of the developmental
ized egg. Occasionally, a parent passes defects caused by Klinefelter’s and
on an abnormal arrangement of his or Turner’s syndromes.
her own chromosomes. Anyone who has a child or other
TYPES family member affected by a chromo-
Chromosomal abnormalities are classi- somal abnormality may wish to
fied according to whether they involve consider genetic counselling to establish
the 44 autosomes (pairs of very similar the risk of his or her future children
chromosomes) or the two sex chromo- being affected by the condition.
somes (X and Y). A whole extra set of
chromosomes per cell is called poly- chromosome analysis
ploidy; this is lethal in early pregnancy. Study of the chromosomes in cells to
Capillaries
of choroid Sclera Lens AUTOSOMAL ABNORMALITIES find out if a chromosomal abnormality is
These abnormalities cause physical and present or to establish its nature.
mental defects of varying severity. Some WHY IT IS DONE
types of autosomal abnormality, known Some pregnancies are associated with a
choroid plexus as trisomy, involve the presence of an higher-than-average risk of the baby
A network of thin-walled blood vessels extra chromosome on one of the 22 having a chromosomal abnormality.
in the eye or brain. The choroid plexus pairs of autosomes. The most common Risk factors include an older mother,
of the eye supplies blood to the retina. trisomy is Down’s syndrome, which is the birth of a previous child with a
In the brain, the choroid plexus lines caused by the presence of three num- chromosomal defect, or a defect or
the ventricles (cavities) and produces ber 21 chromosomes. translocation (rearrangement) in the
cerebrospinal fluid. Sometimes, part of a chromosome is mother’s or the father’s chromosomes.
missing, as in cri du chat syndrome. In In many cases, there are no identifiable
Christmas disease translocation, a part of a chromosome is risk factors, and so all pregnant women
A rare genetic bleeding disorder in joined to another, causing no ill effects are offered a preliminary blood test
which there is deficient production of in the person but a risk of abnormality (see antenatal screening) to identify
one of the proteins in blood that is in his or her children. those at high risk of a fetal abnormality.
needed for blood coagulation (see SEX CHROMOSOME ABNORMALITIES If the fetus is at high risk, a sample of
blood clotting). Normally, a female has two X chromo- cells is taken for chromosome analysis.
Christmas disease has similar features somes and a male has an X and a Y. If a serious abnormality, such as Down’s
to haemophilia. However, the deficient Abnormalities may occur if there are syndrome, is identified, the parents will
proteins are different. In Christmas dis- missing or extra sex chromosomes. be offered termination of the pregnan-
ease the deficiency is of a protein called In Turner’s syndrome, a girl is born cy (see abortion, induced) and genetic
factor IX, while in haemophilia the with only a single X chromosome in counselling to assess the risk of a subse-
deficiency is of the protein factor VIII. her cells instead of the normal comple- quent pregnancy being affected.

172
 CHROMOSOMES

Chromosome analysis is also carried There are two types of sex chromo-
out when a baby is stillborn without an Short arm some, called X and Y. In females, the sex
obvious cause, or when a baby is born chromosomes are a matched pair of X
with abnormal physical characteristics Centromere
chromosomes. In males, one is an X
that suggest a chromosomal defect, and the other is a Y. The mother’s egg
such as Turner’s syndrome. contributes an X chromosome to every
The analysis of the sex chromosomes Long arm offspring. The father’s sperm contri- C
may be carried out in order to establish butes the other chromosome in the
the chromosomal sex of a child whose pair: an X in girls or a Y in boys.
genitals have an ambiguous appearance The Y chromosome is thought to
Appearance of a dividing chromosome
(see genitalia, ambiguous); to confirm or Just after a chromosome has copied itself, the
provide all of the information required
to exclude the diagnosis of chromosomal copies are joined at a constriction (centromere) for the development of male sexual
abnormalities; or to investigate infertility. that divides them into long and short “arms”. characteristics. In the absence of the Y
HOW IT IS DONE chromosome, the female pattern of
Fetal cells for analysis can be obtained contains the chemical machinery for development takes place.
by amniocentesis or chorionic villus sam- decoding these instructions (see genet- CHROMOSOME DIVISION
pling. Chromosome analysis in children ic code; nucleic acids). When a cell divides, all of its
and adults uses white blood cells taken All of an individual’s body cells components, including the chromo-
from a blood sample. (with the exception of egg or sperm somes, are duplicated into the two
cells) carry the same chromosomal offspring cells.
chromosomes material, which has been copied by a The process by which most body
Threadlike structures that exist inside process of cell division from the original cells divide is called mitosis. Shortly
the nuclei (see nucleus) of cells and material in the fertilized egg. Each before cell division, the DNA in each
carry inherited information governing human cell normally contains 46 chro- chromosome is copied; if viewed under
all cellular activities and functions. mosomes made up of 23 pairs. Half of a microscope, chromosomes at this
Each chromosome contains around each pair of chromosomes comes from stage appear as double rods joined at an
30,000 genes (units of inheritance), the mother and half from the father. area called the centromere. As cell divi-
which are arranged in single file along TYPES OF CHROMOSOMES sion proceeds, the duplicated chromo-
a long double filament of DNA. The In each set of chromosomes, 22 pairs somes are pulled apart, divided at the
sequence of chemical units, or bases, are autosomal, which are the same in centromeres, so that each daughter cell
in the DNA provides the coded instruc- both sexes, and the remaining pair are will receive a single copy of each of the
tions for cellular activities. Each cell the sex chromosomes. usual 46 chromosomes.

PROCEDURE FOR CHROMOSOME ANALYSIS

1cellsInaiscollection
antenatal testing,
of fetal
obtained by
The cells are
2medium
suspended in a
containing
amniocentesis or by substances that
chorionic villus sampling. encourage them to
In a test on a baby, child, divide. Chemicals are
or adult, white blood cells then added that stop
are obtained from a the cells from dividing
sample of blood. at a stage where their
chromosome content
is most easily visible.

The cells are spread on a

3A selected
microscope slide and stained.
few (in which the
The chromosomes
4arranged
are matched up and
into the 22 pairs
chromosomes are clearly visible 1 2 3 4 5 of autosomes and the sex
and well separated) have their chromosomes. A study of
nuclei photographed or are the complete set will
closely examined through a high- reveal any abnormalities.
powered microscope. 6 7 8 9 10 11 12

13 14 15 16 17 18

19 20 21 22 X Y Male Female

173
 CHRONIC

ple who have had a stroke or some

CHROMOSOMES: EGG AND SPERM CELLS other acute illness may be left with
permanent disabilities, but their condi-
These differ from other body cells in that they contain only 23 chromosomes –
one from each of the 22 autosome pairs plus an X chromosome (in the case of an tion is not chronic.
egg) and either an X or a Y (in the case of a sperm). Because they have only half
the normal complement, they are called haploid, while other cells are diploid. chronic bronchitis
C See pulmonary disease, chronic obstructive.
chronic fatigue syndrome
A condition that causes extreme fatigue
over a prolonged period, often for sev-
eral years. It is most common in
PIX women aged between 25 and 45.
46 46 CAUSES
XX XY The cause is unclear. In some cases, the
condition develops after a viral infec-
Female Male
tion or after a stressful event such as
Normal diploid cell Normal diploid cell bereavement. In other cases, there is no
Chromosomes
under
such preceding illness or event.
microscope SYMPTOMS
23 23 23 23 The main symptom of chronic fatigue
(X) (X) Haploid cells (X) (Y) syndrome is persistent tiredness. Other
Eggs Egg and sperm Sperm symptoms vary, but commonly include
cells have half the impairment of short-term memory or
normal number of 23 23
23 23
chromosomes (X) (Y) concentration, sore throat, tender lymph
(X) (X) nodes, muscle and joint pain, muscle
and are called
haploid cells fatigue, unrefreshing sleep, and head-
aches. The disorder is often associated
with depression or anxiety.
DIAGNOSIS
There is no diagnostic test for chronic
fatigue syndrome, and investigations of
XX XY
Female Male the condition are usually aimed at
excluding other possible causes of the
symptoms, such as anaemia. A physical
examination, blood tests, and a psycho-
When egg or sperm cells are formed, precise nature of the abnormality can logical assessment may be carried out.
by a process called meiosis, there are be investigated by detailed chromosome If no cause can be found, a diagnosis of
two important departures from the analysis. (See also genetic disorders.) chronic fatigue syndrome can be made
normal process of chromosome divi- from the symptoms.
sion. First, after the DNA has been chronic TREATMENT
copied (before division takes place), A term that is used to describe a disor- Analgesic drugs (painkillers) or antide-
some sections of chromosomal materi- der or a set of symptoms that has pressant drugs may help to relieve the
al are exchanged between the two persisted over a long time. The term symptoms. Physiotherapy or psychothera-
members of each chromosome pair. “chronic illness” implies a continuing py may also be helpful. Chronic fatigue
This helps to ensure that each of a per- disease process with progressive deteri- syndrome is a long-term disorder, but
son’s eggs or sperm contains a oration (sometimes despite treatment). the symptoms clear up after several
different combination of chromosomal Chronic disorders are usually contrast- years in some people.
material, and this is the reason why ed with acute disorders, which are of
siblings (with the exception of identi- sudden onset and are short in duration. chronic glaucoma
cal twins) have a unique appearance. A chronic illness produces little See glaucoma.
Next, the cells undergo two consecu- change in symptoms from day to day,
tive divisions. Therefore, the original and an affected person may be able, to chronic heart failure
parent cell gives rise to four separate carry out normal activities. The term See heart failure.
egg or sperm cells, each of which has “acute”, in contrast, suggests rapid
only 23 chromosomes. onset of severe symptoms such as high chronic obstructive lung
DISORDERS fever, intense pain, or breathlessness, disease
Defective chromosome division during with a rapid change in the person’s See pulmonary disease, chronic obstructive.
the formation of eggs and sperm (or, condition from one day to the next.
more rarely, during the first few divi- A person with a chronic disease may chronic obstructive pulmonary
sions of a fertilized egg) can lead to suffer an acute exacerbation (flare-up) disease
various chromosomal abnormalities. The of symptoms. On the other hand, peo- See pulmonary disease, chronic obstructive.

174
 CIRCULATORY SYSTEM

chronological age linings of the respiratory tract, where circulation, disorders of

The most common measurement of an they move rhythmically to propel dust Conditions affecting the flow of blood
individual’s age. and mucus out of the airways. around the body. (See arteries, disorders
of; veins, disorders of.)
Churg–Strauss syndrome ciliary body
A condition characterized by vasculitis A structure in the eye containing mus- circulatory collapse
(inflammation in the walls of small cles that alter the shape of the lens to A life-threatening condition in which C
blood vessels), which mainly affects adjust focus. (See also accommodation.) the circulatory system is unable to
adults in their thirties who have asthma. maintain an adequate blood flow to the
It is thought to be due to an allergy of cimetidine organs and tissues of the body (see
unknown cause. An H2-receptor antagonist, which is a shock). Circulatory collapse can occur
The vasculitis can cause a variety of type of ulcer-healing drug. Cimetidine when the heart stops beating (see car-
symptoms, depending on the parts of can be taken in tablet or liquid form, diac arrest), or be due to loss of blood
the body that are affected. Common or it may be injected. The drug pro- or problems with the blood vessels.
problems include abdominal pain, if motes healing of gastric and duodenal
the bowel is involved, and skin rashes. ulcers (see peptic ulcer) and reduces the circulatory system
The disease may be severe or even life- symptoms of oesophagitis (inflamma- The heart and blood vessels, which
threatening, although in most cases it tion of the gullet). together are responsible for the main-
responds well to treatment with oral Side effects include fatigue, dizzi- tenance of a continuous flow of blood
corticosteroid drugs. The drug treatment ness, and skin rashes. Rarely, the drug through the body. Also known as the
may need to be continued, at a low may cause impotence and gynaecomastia cardiovascular system, the circulatory
dose, for some time to prevent a recur- (breast enlargement in men). system provides the body tissues with a
rence of the condition. supply of oxygen and nutrients, and
CIN carries away carbon dioxide and other
chylomicron The abbreviation for cervical intraepi- waste products.
A globule of fat (see fats and oils) that thelial neoplasia. STRUCTURE AND FUNCTION
is carried into the bloodstream from The circulatory system has two main
the intestine following the digestion of cinnarizine parts: the systemic circulation, which
a meal containing fat. An antihistamine drug used to control supplies blood to the whole body apart
nausea and vomiting due to travel sick- from the lungs; and the pulmonary cir-
Cicatrin ness, or to reduce nausea and vertigo in culation to the lungs, which supplies
The brand name for an antibacterial disorders of the inner ear such as the blood with fresh oxygen (see circu-
skin preparation. labyrinthitis and Ménière’s disease. High latory system box, overleaf).
doses of the drug are sometimes used Oxygen-rich blood from the pul-
ciclosporin to improve circulation in people with monary circulation enters the systemic
An immunosuppressant drug that is used peripheral vascular disease and Raynaud’s circulation via the left ventricle of the
following transplant surgery. The drug disease. Side effects of cinnarizine may heart. The ventricle pumps it under
reduces the risk of tissue rejection and include drowsiness, lethargy, a dry high pressure into the aorta (the body’s
the need for large doses of corticosteroid mouth, and blurred vision. main artery), from where it travels
drugs. Ciclosporin may need to be through arteries and smaller arterioles
taken indefinitely after a transplant. It is Cipramil to all parts of the body. Within the body
also used to treat rheumatoid arthritis A brand name for citalopram, an anti- tissues, the arterioles branch into net-
and other autoimmune disorders. depressant drug. works of fine blood vessels known as
Because ciclosporin suppresses the capillaries. Oxygen and other nutrients
immune system, it increases the suscepti- ciprofloxacin pass from the blood through the thin
bility of the body to various infections. An antibiotic drug that is used to treat capillary walls and into the tissues;
Swelling of the gums and increased infections of the respiratory, gastro- carbon dioxide and other waste pro-
hair growth are fairly common side intestinal, and urinary tracts. Cipro- ducts pass in the opposite direction.
effects. The drug may also cause kidney floxacin may also be used as an initial Deoxygenated blood is returned to the
damage, so it is necessary for anyone treatment for anthrax. heart via venules (small veins), veins,
who is taking it to undergo regular and the venae cavae (the two principal
monitoring of kidney function. Ciproxin veins in the body).
A brand name for ciprofloxacin, an Within the systemic circulation,
Cilest antibiotic drug. there is also a bypass (the portal cir-
The brand name for a combined oral culation) that carries nutrient-rich
contraceptive. circadian rhythms blood from the stomach, intestine, and
Any pattern of physiological functions other digestive organs via the portal
cilia that is based on a cycle approximately vein to the liver. Nutrients and other
Hairlike, mobile filaments that exist on 24 hours long (also called a diurnal substances pass into the liver cells for
the surface of some epithelial cells rhythm). One example of this pattern is processing, storage, breakdown, or re-
(see epithelium). Cilia are found in par- the daily cycle of sleeping and wakeful- entry into the general circulation.
ticularly abundant amounts in the ness. (See also biorhythms.) Blood passes out of the liver through

175
 CIRCULATORY SYSTEM

CIRCULATORY SYSTEM

The heart and blood vessels create a continuous Resin cast of coronary arteries
flow of blood around the body to provide tissues The photograph on the left shows a resin cast of the
with oxygen and nutrients. The circulatory system arteries that supply oxygenated blood to all parts of
the heart muscle. The larger vessels are called the
also removes waste products. The systemic
C circulation deals with the supply of blood to all
coronary arteries. They branch off the root of the
aorta, the largest artery in the body, which receives
parts except the lungs; the pulmonary (lung) oxygenated blood directly from the heart.
circulation reoxygenates the blood.

SYSTEMIC CIRCULATION PULMONARY CIRCULATION

Internal
jugular Trachea
Internal carotid vein Lung
(windpipe)
artery
Subclavian
vein
Superior
vena Aorta
External carotid cava
artery

Subclavian
artery
Aorta Right atrium Left
atrium

Pulmonary
vein

Heart Right ventricle

Brachial artery
Inferior
Superior vena cava
mesenteric
artery
Inferior Aorta Left ventricle Alveoli
vena
cava
Blood circulation
The right side of the heart receives deoxygenated blood from the systemic
(“body”) circulation via the venae cavae. The heart pumps this blood to the
Radial
artery lungs, where it is oxygenated and returns to the left side of the heart
(pulmonary circulation). It is then pumped via arteries to the tissues, where
the blood releases oxygen. Deoxygenated blood then returns to the heart.
Iliac artery

Iliac CAPILLARY NETWORK

vein
All tissues contain a network of tiny capillaries. Blood
enters these vessels from the arterioles and is drained
Femoral
artery
Femoral vein by venules.

Great saphenous
vein

Peroneal artery

Small saphenous
vein

Key
Oxygenated blood
Artery Arteriole Capillary bed Venule Vein
Deoxygenated blood

176
 CLAVICLE

the hepatic vein and rejoins the main tal hypertension (abnormally high blood activities such as driving vehicles until
systemic circulation via the inferior pressure in the veins leading from the they have learned how strongly citalo-
(lower) vena cava. intestines and spleen to the liver). pram affects them.
Venous blood returns to the right CAUSES
atrium of the heart to enter the pul- The most common cause of cirrhosis is CJD
monary circulation. It is pumped from excessive alcohol consumption. Another The abbreviation for Creutzfeldt–Jakob
the right ventricle through the pulmo- possible cause is one of the forms of disease. C
nary artery to the lungs, where carbon chronic hepatitis (inflammation of the
dioxide is exchanged for oxygen. The liver). Other causes, which are rare, CK
reoxygenated blood then returns via include disorders of the bile ducts; The abbreviation for creatine kinase.
the pulmonary veins to the heart and haemochromatosis, in which increased
re-enters the systemic circulation. iron absorption occurs; Wilson’s disease clamp
On its journey from the heart to the (an increase in copper absorption); cystic An instrument that is used during sur-
body tissues, blood is forced along the fibrosis, which causes obstruction of the gical procedures to compress the cut
arteries at high pressure. In contrast, bile ducts with mucus; and heart failure. end of an organ or blood vessel tem-
blood flowing through the veins and SYMPTOMS AND COMPLICATIONS porarily, in order to prevent leakage of
back to the heart is at low pressure. It is Cirrhosis may go unrecognized until blood or other fluids.
kept moving by muscles in the limbs, symptoms such as mild jaundice, oede-
which compress the veins and thus ma (an accumulation of fluid in body clap
squeeze blood through them, and by tissues) and vomiting of blood develop. A slang term for gonorrhoea.
valves in the veins that prevent the There may be enlargement of the liver
blood from flowing backwards. (See and spleen. Men may experience loss of clarithromycin
also lymphatic system; respiration). body hair and enlargement of the An antibiotic drug that belongs to the
breasts due to an imbalance in sex hor- macrolide group. Clarithromycin is
circumcision mones caused by liver failure. used to treat infections of the skin and
Surgical removal of the foreskin of the Complications of cirrhosis include the respiratory tract.
penis. Circumcision is usually per- ascites (an accumulation of fluid in the
formed on newborn babies for abdominal cavity), oesophageal varices classic migraine
religious or hygienic reasons. In some (enlarged veins within the oesophagus A type of migraine attack accompanied
cases, it may be medically required to wall), and hepatoma (liver cancer). Cir- by an aura (neurological disturbances),
treat phimosis (a tight foreskin that rhosis may also cause toxins to build nausea, and vomiting.
causes ballooning on urination), recur- up in the brain, producing symptoms
rent attacks of balanitis (infection under such as confusion and coma (see hepa- claudication
the foreskin due to retained secre- tic encephalopathy). A cramplike pain in a muscle, most
tions), or paraphimosis (painful com- TREATMENT often in the legs, due to inadequate
pression of the shaft of the penis by a Treatment is focused on slowing the blood supply. Claudication in the legs is
retracted foreskin). rate at which liver cells are being dam- usually caused by blockage or narrow-
aged, if possible by treating the cause. ing of arteries due to atherosclerosis
circumcision, female Any complications will also be treated. (see peripheral vascular disease). In
Removal of all or some parts of the In some cases, however, the cirrhosis intermittent claudication, pain is felt in
female external genitalia: the clitoris, progresses and a liver transplant may the calves after walking a certain dis-
labia majora, and labia minora (see need to be considered. tance and is relieved by rest.
labia). Female circumcision is some- A rarer cause is spinal stenosis (nar-
times combined with narrowing of the cisplatin rowing of the canal carrying the spinal
entrance to the vagina. An anticancer drug used to treat some cord), causing pressure on the nerve
Female circumcision is common in cancers of the testis and the ovary. roots that pass into either leg.
certain parts of Africa but has no valid
medical purpose. It can cause retention citalopram claustrophobia
of urine and injuries during sexual An antidepressant drug belonging to a An intense fear of being in enclosed
intercourse and childbirth. group called selective serotonin re- spaces, such as lifts or tunnels, or of
uptake inhibitors (SSRIs). Citalopram being in crowded areas. The usual treat-
cirrhosis takes up to four weeks to reach its full ment is behaviour therapy involving
A condition of the liver that results effect; it gradually improves the user’s techniques that gradually lessen the
from long-term damage to liver cells. mood, energy levels, and level of inter- patient’s anxiety. (See also phobia.)
In cirrhosis, bands of fibrosis (internal est in everyday activities.
scarring) develop, leaving nodules of The drug may cause gastrointestinal clavicle
regenerating cells that are inadequately problems such as nausea, vomiting, or The collarbone. The two clavicles, one
supplied with blood. Liver function is diarrhoea, but these usually diminish on each side, form joints with the top
gradually impaired; the liver no longer with continued use. Citalopram may of the sternum (breastbone) and the
effectively removes toxic substances also cause drowsiness and, for this rea- scapula (shoulderblade). The clavicles
from the blood (see liver failure). The son, people taking the drug should support the arms and transmit forces
distortion and fibrosis also lead to por- avoid alcohol, and should not carry out from the arms to the central skeleton.

177
 CLAVULANIC ACID

Most fractures of the clavicle occur as a curls under. A painful corn may form on allergic rhinitis (hay fever). Clemastine
result of a fall on to the shoulder or on the tip of the toe or on the top of the can cause drowsiness so driving and
to an outstretched arm. When the clavi- bent joint. Protective pads can relieve hazardous work should be avoided.
cle is broken, the arm must be pressure from footwear. In severe cases,
supported in a sling and a figure-of- surgery may be required. clergyman’s knee
eight bandage must be used to keep the Inflammation of the bursa (the fluid-
C fractured bone ends together. Healing clear liquid diet filled sac) that cushions the pressure
takes about three weeks. A diet consisting solely of clear or point above the tibial tubercle (the
strained fluids, such as broth, ginger bony prominence just below the knee).
ale, or fruit juices. A clear liquid diet The condition is caused by prolonged
LOCATION OF CLAVICLE provides little nourishment. It is mainly kneeling. (See also bursitis.)
used for very short periods, such as
The two clavicles run across the front during the first 24 hours following climacteric
of each shoulder, joining the top of surgery or in the initial stages of an See menopause.
the sternum to each scapula. They
help to support the arms.
episode of diarrhoea and vomiting.
clindamycin
Scapula Clavicle cleft lip and palate An antibiotic drug that may be pre-
A split in the upper lip and/or palate scribed as a skin preparation to treat
Sternum
that is present at birth. Cleft lip is a ver- severe acne or in creams to treat bac-
tical, usually off-centre split in the terial vaginal infections. Sometimes, it
upper lip; it may be a small notch, or is also given as tablets or by injection.
may extend to the nose. The gum may Clindamycin can have serious side
also be cleft, and the nose may be effects. In particular, it may cause a
crooked. The term “harelip” refers only potentially life-threatening form of
to a midline cleft lip, which is rare. bowel inflammation called antibiotic-
Cleft palate is a gap that may extend associated colitis. For this reason, the
from the back of the palate to behind drug is prescribed only when other
the teeth and be open to the nasal cavi- types of antibiotic cannot be used.
ty. The condition is often accompanied
by other problems such as partial deaf- clinic
ness and possibly other birth defects. A hospital department or health-care
TREATMENT institution for the treatment of particu-
Surgery to repair a cleft lip may be lar diseases (such as conditions that are
clavulanic acid undertaken in the first few days after specific to women or to men, or sexu-
A substance that is combined with the birth or when the baby is about three ally transmitted infections).
penicillin drug amoxicillin to produce months of age. Surgery improves the
the antibiotic drug co-amoxiclav. child’s appearance; after repair, speech clinical diagnosis
defects are rare. A cleft palate is usually A procedure in which a doctor deter-
claw-foot repaired at about 12 months, but fur- mines the nature of a disorder on the
A deformity of the foot in which the ther surgery, orthodontic treatment, and basis of an individual’s description of
arch of the foot is exaggerated and the speech therapy may be required. his or her symptoms and a physical
tips of the toes turn under. Claw-foot examination. Unlike pathological diagno-
may be present from birth, or it may cleidocranial dysplasia sis, a clinical diagnosis does not depend
result from damage or disruption to Also called cleidocranial dysostosis, a on the analysis of tissue specimens
the nerve or blood supply to the mus- rare, autosomal dominant genetic disor- taken from the body.
cles of the foot. Surgery may improve der causing malformation of the bones,
the condition. particularly those in the skull and clinical pharmacology
shoulders. An affected person typically The branch of pharmacology (the sci-
claw-hand has absent or underdeveloped clavicles ence concerned with the nature and
A deformity in which the fingers are (collarbones), and can move the shoul- action of drugs) that deals with the use
permanently curled. It is caused by ders forwards so that they almost of drugs in patients, in hospitals and in
injury to the ulnar nerve, which controls touch. The sutures (fixed joints) of the the community. Clinical pharmacolo-
the muscles of the thumb and fingers. skull bones take longer than normal to gists are concerned with drug doses;
Treatment includes repairing the nerve fuse together. There may also be abnor- when and when not to give specific
by using splints to hold the fingers malities in the structure of the pelvis, drugs (indications and contraindica-
straight, or cutting a tendon in the fingers, teeth, and vertebrae (bones of tions); administration; and side effects.
wrist to allow the fingers to straighten. the spinal column).
clinical psychology
claw-toe clemastine The branch of psychology (the scientific
A deformity of unknown cause in An antihistamine drug that is used to study of mental processes) concerned
which the end of one or more affected relieve the symptoms of allergic condi- with the diagnosis and treatment of
toes bends downwards so that the toe tions such as urticaria (nettle rash) and emotional and behavioural problems.

178
 CLOSED FRACTURE

clinical trial fold of skin called the prepuce, or hood. planting them into the egg cells of
See trial, clinical. The clitoris swells and becomes more another individual. The eggs mature
sensitive during sexual stimulation. into living plants or animals that are all
Clinistix identical to the donor.
A brand-named product that detects glu- clobazam
cose (sugar) in urine and which can be A type of benzodiazepine drug used in clonic
used by people with diabetes mellitus to the treatment of anxiety and epilepsy. Relating to the abnormal muscle con- C
monitor their condition. Clinistix con- tractions known as clonus, which are
sists of test strips impregnated with a clobetasone sometimes a sign of a brain or spinal
chemical that reacts with glucose. A corticosteroid drug, used as a cream or cord disorder.
an ointment to treat inflammatory skin
Clinitest conditions, such as eczema. clonic convulsion
The brand name of a product that A form of seizure in which there are
detects glucose (sugar) in urine, which clofibrate uncontrolled, jerking movements of
some people with diabetes mellitus use A lipid-lowering drug that helps to the limbs and body (see clonus). Clonic
to monitor their condition. Clinitest reduce levels of cholesterol and trigly- convulsions are a feature of some types
consists of tablets containing a chemi- cerides in the blood. Clofibrate is of epilepsy.
cal that reacts with glucose. prescribed as a treatment for some
types of hyperlipidaemia. clonidine
clioquinol An antihypertensive drug that controls
An antibacterial drug and antifungal drug Clomid hypertension (high blood pressure) by
used as ear drops to treat infections of A brand name for clomifene, a drug that acting on the part of the brain that
the outer ear. Clioquinol is also inclu- is used to treat female infertility. regulates the size of blood vessels.
ded in some skin preparations. Clonidine is also used to control hot
clomifene flushes in menopausal women and to
clip A drug used to treat female infertility treat some cases of migraine. Possible
A small metal device used by surgeons caused by failure to ovulate. Minor side side effects of the drug include cons-
to hold a wound closed or to prevent effects may include hot flushes, head- tipation, drowsiness, dry mouth, and
leakage from a blood vessel. Specialized ache, nausea, breast tenderness, and dizziness. Caution should be taken if
plastic clips are used in female steriliza- blurred vision. More seriously, ovarian high doses of the drug are suddenly
tion operations (see sterilization, female) cysts occasionally develop, but they stopped because this can cause a dan-
to seal the fallopian tubes. shrink when the dose is reduced. The gerous rise in blood pressure.
drug may also cause multiple births.
clitoridectomy clonus
An operation to remove the clitoris (see clomipramine A series of rapid, abnormal muscle con-
circumcision, female). A tricyclic antidepressant drug, which is tractions. Clonus is a sign of damage to
used as a treatment for depression. Side nerve fibres that carry impulses from
clitoris effects include dry mouth, blurred the motor cortex in the cerebrum of the
A small, sensitive, erectile organ that is vision, and constipation. brain to a particular muscle. It may
part of the female genitalia. It is partly occur in the wrist, knee, ankle, or toe
enclosed in the labia and covered by a clonazepam in response to stretching of the muscles
A benzodiazepine drug used mainly as an in that area. It may also be a feature of
anticonvulsant drug to prevent and treat seizures (see clonic convulsion).
LOCATION OF CLITORIS
epileptic fits (see epilepsy). It also pre-
vents petit mal attacks in children. Side clopidogrel
The clitoris is a part of the external
genitals in females. It is located just effects include drowsiness, dizziness, An antiplatelet drug that is used to pre-
below the pubic bone, and is partly fatigue, and irritability. vent the formation of unwanted blood
enclosed within the labia. clots in individuals who are suffering
clone from atherosclerosis.
An exact copy. In medicine, the term
“clone” usually refers to duplicates of Clopixol
cells, genes, or organisms. The brand name of zuclopenthixol, an
Opening of Clitoris Clones of cells are all descended antipsychotic drug.
urethra from one original cell. In many types
of cancer, cells are thought to be closed-angle glaucoma
Labia
majora
derived from one abnormal cell. Clones An alternative term for acute glaucoma.
Vagina
of genes are copies of a single gene. In
research, several clones of a gene can closed fracture
Anus be made so the gene can be studied in A type of fracture, also known as a
detail. Clones of organisms are pro- simple fracture, in which the broken
duced by removing the nuclei from bone ends do not penetrate the over-
cells of a donor individual and trans- lying skin.

179
 CLOSTRIDIUM

Clostridium Clozaril lessen the dilation of the blood vessels

Any of a group of rod-shaped bacteria. A brand name for clozapine. and reduce the severity and frequency
Clostridia are found in soil and in the of cluster headaches.
gastrointestinal tracts of humans and clubbing
animals. They produce powerful toxins Thickening and broadening of the fin- CMV
and are responsible for potentially life- gertips and ends of the toes, which is The abbreviation for cytomegalovirus,
C threatening diseases such as botulism, usually accompanied by increased which is a type of herpes virus.
tetanus, and gangrene. curving of the nails. Clubbing is associ-
ated with certain chronic lung diseases, CNS
clot such as lung cancer, bronchiectasis, and The abbreviation for central nervous sys-
See blood clotting. fibrosing alveolitis; with some heart tem (the brain and spinal cord).
abnormalities; and, rarely, with the
clotrimazole inflammatory bowel diseases Crohn’s CNS stimulants
An antifungal drug that is used to treat disease and ulcerative colitis. Drugs that increase mental alertness
yeast and fungal infections, especially (see stimulant drugs).
candidiasis. club-foot
A deformity of the foot that is present coagulation, blood
clotting factor from birth (see talipes). The main mechanism by which blood
A circulating protein that is activated clots are formed. Coagulation involves a
during the blood clotting process. There clumping complex series of reactions in the
are a number of clotting factors, which The common name for agglutination, a blood plasma (see blood clotting).
are involved in a complex series of process in which tiny particles that the
chemical reactions leading to the for- body identifies as foreign (see antigen), coal tar
mation of a blood clot. such as the proteins on the surfaces of A thick, black, sticky substance that is
bacteria or foreign red blood cells, stick distilled from coal. Coal tar is a com-
clotting time together to form visible masses. This mon ingredient in many ointments
The time taken for blood to coagulate, process is an immune system reaction and medicinal shampoos that are pre-
which is measured in tests by the caused by antibodies (proteins manu- scribed for certain skin and scalp
observation of a blood sample under factured by the immune system; see disorders, such as psoriasis and some
laboratory conditions. (See also blood- antibody) called agglutinins. Particles of types of dermatitis and eczema.
clotting tests.) a particular antigen will only clump
together in the presence of the specific co-amilofruse
cloudy urine agglutinin to that antigen. A combined preparation that contains
An abnormality in the appearance of Looking for clumping can be used as the diuretic drugs amiloride and
urine, which may be caused by a urinary a means of determining people’s blood furosemide (frusemide).
tract infection or the presence of salts. groups. In blood typing, samples of a
(See also urine, abnormal.) person’s blood are mixed with anti- co-amoxiclav
bodies against the blood types A and B A penicillin drug containing a mixture of
clove oil to see if clumping occurs with either amoxicillin and clavulanic acid. It is a
An oil distilled from the dried flower- of these antibodies, neither, or both more powerful antibiotic than amoxi-
buds of EUGENIA CARYOPHYLLATA that is (see blood groups). In cross-matching, a cillin alone, so it is used to treat
used mainly as a flavouring in pharma- sample of a person’s blood is mixed infections caused by strains of bacteria
ceuticals. Clove oil is sometimes used with a sample of blood from a possible that are resistant to amoxicillin.
to relieve abdominal pain due to flatu- donor; if the red blood cells clump
lence and as a remedy for toothache. together, it shows that the two samples coarctation of the aorta
of blood are of incompatible types. In A congenital heart defect of unknown
cloxacillin addition, bacteria can be identified cause, in which there is narrowing in a
A penicillin-type antibiotic drug used using samples that contain agglutinins section of the aorta that supplies blood
to treat infections with staphylococcal to specific bacteria (as, for example, in to the lower body and legs. To compen-
bacteria (see penicillin drugs). the latex agglutination test). sate for this problem the heart has to
work harder than normal, thereby
clozapine cluster headaches causing hypertension (high blood pres-
A type of antipsychotic drug. Clozapine Brief but severe headaches that recur up sure) in the upper part of the body.
is used to treat schizophrenia in patients to several times a day over a period of a SYMPTOMS
who have not responded well to other few days or weeks. Cluster headaches Symptoms of coarctation of the aorta
forms of treatment, or in those who tend to affect one side of the head or usually appear in early childhood. They
have experienced severe side effects face, often in a characteristic pattern, include headache, weakness after exer-
from more conventional drugs. A per- and may also cause pain and watering cise, cold legs, and, rarely, breathing
son taking clozapine needs to have of the eye. The cause is uncertain, but difficulty and swelling of the legs due
regular blood tests because the drug they may be due to dilation of blood to heart failure. Associated abnormalities
may cause a serious decrease in the vessels in the brain, as in migraine. Beta- include a heart murmur, weak or absent
number of white blood cells. blocker drugs may be given in order to pulse in the groin, lack of synchroniza-

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 COCHLEAR IMPLANT

tion between the groin and wrist coccus

pulses, and blood pressure that is high- ANATOMY OF COCCYX The singular of cocci.
er in the arms than in the legs.
The coccyx consists of coccydynia
DIAGNOSIS AND TREATMENT
four fused bones at the
X-rays confirm the diagnosis. Surgery to base of the spine. With A pain in the region of the coccyx. Coc-
correct the defect is usually performed the sacrum, it forms the cydynia may result from a blow to the
before four years of age. back of the pelvis. base of the spine in a fall, prolonged C
pressure due to poor posture when
Coat’s disease Four
bones of sitting, or the use of the lithotomy pos-
A disease that causes a progressive dete- coccyx ition (lying on the back with hips
fused
rioration in vision. It is congenital together and knees bent) during childbirth. The
(present at birth) but usually begins in pain usually eases in time. Treatment
childhood, and affects boys more than may include heat, injections of a local
girls. The cause is unknown. anaesthetic, and manipulation.
In Coat’s disease, the capillaries (tiny
blood vessels) supplying the retina coccyx
become damaged and leak fluid (a A small, triangular bone, commonly
process called exudation). As a result, called the tailbone, made up of four
the retina does not function properly. tiny bones fused together at the base of
Usually, only one eye is affected. Vision the spine. Together with a larger bone
may be impaired in the centre of the called the sacrum, situated just above it,
visual field or around the edges. In the coccyx forms the back section of
some cases, a squint develops. There is the pelvis. There is very little movement
also a risk of retinal detachment. between the coccyx and sacrum, and
Diagnosis involves viewing the retina co-beneldopa later in life the two structures com-
through an ophthalmoscope, and by A preparation containing the drugs monly become fused together.
imaging the blood vessels using fluores- benserazide and levodopa; co-benel-
cein dye. Treatment may involve sealing dopa is used in the treatment of cochlea
the capillaries by phototherapy (treat- Parkinson’s disease. The spiral-shaped organ situated in the
ment with light rays) or cryotherapy labyrinth of the inner ear that enables
(treatment with cold). If given early cocaine hearing. A structure known as the organ
enough, it may stabilize the disease and A drug obtained from the leaves of the of Corti, inside the cochlea, can detect
may even improve vision. In some coca plant ERYTHROXYLON COCA. In the sound vibrations of different frequen-
cases, the disease stabilizes by itself. past, cocaine was used as a local anaes- cies and converts them into electrical
thetic (see anaesthesia, local) for minor impulses. These electrical impulses are
cobalamin surgical procedures, but it has largely then transmitted to the brain via the
A complex molecule that contains co- been replaced by other anaesthetics due vestibulocochlear nerve. Sound waves of
and is part of vitamin B12.
balt to its potential for abuse. different frequencies stimulate different
Cocaine affects the brain, producing areas inside the cochlea, enabling us to
cobalt euphoria and increased energy. These hear and differentiate between a wide
A metallic element. Cobalt is found in effects have led to its illicit use (see variety of sounds.
foods as a constituent of vitamin B12. A drug abuse). Regular inhalation of the
radioactive form is used in radiotherapy. drug can damage the lining of the nose cochlear implant
and may eventually cause perforation of A device that is used to treat profoundly
Cobb syndrome the septum (the tissue separating the deaf people who are not helped by
A very rare disorder in which spinal two sides of the nose). Continued use hearing aids. Unlike a hearing aid,
cord angiomas (noncancerous tumours of the drug can cause dependence (see which amplifies sounds, a cochlear
of the blood or lymph vessels) occur drug dependence), and, if high doses implant converts sounds into electrical
together with arteriovenous malforma- are taken, may result in psychosis, signals that are relayed to the cochlear
tions (abnormal connections between which can cause users to become vio- nerve deep in the inner ear (see coch-
arteries and veins) in the overlying lent. Overdose of cocaine can cause lear implant box, overleaf).
skin. It is congenital (present from seizures and cardiac arrest. The implant consists of tiny elec-
birth) but is almost never inherited. Crack, which is a purified form of trodes that are surgically implanted in
The symptoms usually appear in cocaine, produces a more rapid and the cochlea, and a receiver that is
childhood or adolescence; they include intense reaction; and deaths have occur- embedded in the skull just behind and
weakness, paralysis, loss of sensation, red as a result of the drug’s adverse above the ear. A microphone, sound
and loss of bowel and bladder control. effects on the heart. processor, and transmitter are worn
Treatment includes surgery to block the externally. A cochlear implant does not
blood flow to the abnormal vessels (see cocci restore normal hearing, but it enables
embolization) and to relieve pressure on Spherical bacteria, some of which cause patterns of sound to be detected. Com-
the spinal cord (see decompression, infections in humans (see staphylococcal bined with lip-reading, it may enable
spinal canal). infections; streptococcal infections). speech to be understood.

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 COCKAYNE’S SYNDROME

and children may also fail to grow or

COCHLEAR IMPLANT to gain weight, and may suffer from
muscle wasting, especially around the
Sounds picked up by the microphone are converted Receiver Transmitter buttocks. In adults, symptoms that
into electronic signals by the sound processor and include tiredness, breathlessness, abdo-
relayed to the external transmitter, which sends Skull bone minal pain, diarrhoea, vomiting, and
C them through the skin to the receiver. The waves
then travel along the wire to the electrodes in the swelling of the legs may develop over
cochlea, where sound is normally received. several months. In addition, a chronic,
Wire carrying distinctive rash called dermatitis herpeti-
Vestibulocochlear nerve electrical
signals formis may occur.
Microphone Electrode Damage to the intestinal lining and
malabsorption cause weight loss and
result in faeces that are bulky and foul-
Transmitter
smelling. The resulting vitamin and
mineral deficiencies can result in
Processor anaemia as well as skin problems. Some
affected people suffer damage to the in-
Wire from
microphone testinal lining but never develop
to processor symptoms of the disease.
DIAGNOSIS AND TREATMENT
Diagnosis may be made by blood tests
Wire connected but in most cases jejunal biopsies, in
Cochlea to processor Microphone
which tissue samples from the lining of
the jejunum (the central part of the
small intestine) are taken for examina-
Cockayne’s syndrome It may cause dizziness and drowsiness, tion, are also performed.
An autosomal recessive genetic disorder especially if taken with alcohol. If used Coeliac disease is treated by a life-
that causes premature aging and dete- for long periods, it may cause constipa- long gluten-free diet, which can relieve
rioration of the nervous system. The tion and be habit-forming. symptoms within weeks of its intro-
syndrome causes dwarfism (see short duction. Specially manufactured foods,
stature) and abnormally rapid aging cod-liver oil such as gluten-free flour and pasta, are
(see progeria). Affected people also A pale yellow oil obtained from the available. Without such treatment, there
have very thin skin that is extremely liver of fresh cod, which is a valuable may be a long-term risk of cancers
sensitive to the effects of sunlight. In source of vitamin A and vitamin D. developing in the small intestine.
addition, there may be visual problems
due to degeneration of the retina (see co-dydramol coenzyme
retinitis pigmentosa) or atrophy (wast- A compound analgesic drug (painkiller) A nonprotein chemical, occurring nat-
ing away) of the optic nerve; deafness; that contains paracetamol and dihydro- urally in the body, that plays a role in
and learning difficulties. The age at codeine. assisting the proper functioning of
which symptoms appear and the some types of enzyme (proteins that
course of the disease vary from one coeliac disease regulate chemical reactions in the
individual to another. A condition, sometimes called gluten- body). (See also NAD.)
There is no cure for the aging or the sensitive enteropathy, that results from
neurological symptoms, but an affected hypersensitivity to gluten, a protein Coffin–Siris syndrome
person can protect his or her skin from found in wheat, rye, and some other An autosomal genetic disorder character-
sun damage by avoiding exposure to cereals. Exposure to foods containing ized by absence or underdevelopment
ultraviolet light, or by applying a sun- gluten causes an abnormal immune of the tips of the little finger and little
block to protect areas of exposed skin response in which the lining of the toe. Other features include hirsutism
when outdoors in sunlight. small intestine is damaged. The condi- (excessive hair), hypotonia (lack of
tion leads to malabsorption and results muscle tone) and weak joints, and
co-codamol in vitamin and mineral deficiencies. learning difficulties.
A compound analgesic drug containing CAUSES AND SYMPTOMS
paracetamol and codeine. Coeliac disease tends to run in families, cognition
and varies in severity. The disorder may Mental processes by which knowledge
codeine first appear during infancy, or may not is acquired. Such cognitive processes
An opioid analgesic drug derived from develop until adulthood. include perception, problem-solving,
the opium poppy plant. Codeine is use- In babies, symptoms usually develop and reasoning.
ful for mild to moderate pain and may within six months of the introduction
be combined with other analgesics in of gluten into the diet. The baby may cognitive–behavioural therapy
painkilling preparations. It is also used become listless and irritable, develop A method of treating psychological dis-
as a cough remedy and as an anti- vomiting and diarrhoea, and become orders such as anxiety and depression,
diarrhoeal drug. dehydrated and seriously ill. Babies based on the idea that problems arise

182
 COLECTOMY

from a person’s faulty cognitions (erro- cold abscess and, as a result, develop gangrene. Less
neous ways of perceiving the world An abscess caused by infection with the serious forms of cold injury include
and oneself). In cognitive–behavioural tuberculosis bacterium. A cold abscess chilblains and chapped skin.
therapy, the patient is helped to identify does not usually produce redness and
negative or false cognitions and then heat, hence its name. cold remedies
encouraged to try out new thought Preparations used to relieve symptoms
strategies. For example, a patient may cold, common of colds (see cold, common). The main C
be asked to keep a diary of his or her A common viral infection that causes ingredient of cold remedies is usually a
thoughts and feelings, in order to iden- inflammation of the mucous mem- mild analgesic drug, such as paracetamol
tify triggers for distress, and may be branes lining the nose and throat. or aspirin, which helps to relieve aches
taught techniques for responding dif- CAUSES and pains. Other common ingredients
ferently to upsetting thoughts. There are at least 200 highly contagi- include antihistamine drugs and decon-
ous viruses that are known to cause the gestant drugs, designed to reduce nasal
cognitive dissonance common cold. These organisms are eas- congestion; caffeine, which acts as a
A state of mental or emotional tension ily transmitted in minute airborne mild stimulant; and vitamin C.
caused by inconsistency and disagree- droplets sprayed from the coughs or
ment among different aspects of a sneezes of infected people. In many cold sore
person’s thoughts, beliefs, values, and cases, cold viruses are also spread to the A small skin blister, usually around the
behaviour. (For example, a person may nose and throat by hand-to-hand con- mouth, commonly caused by a strain of
buy a well-made pair of shoes but find tact with an infected person, or by the herpes simplex virus called HSV1
that they are actually very uncomfort- handling objects that have become con- (herpes simplex virus type 1).
able.) People may try to reduce such taminated with the virus. CAUSES AND SYMPTOMS
tension by reinterpreting or rationaliz- SYMPTOMS AND TREATMENT The first attack of the virus may be
ing the situation. (For example, the The symptoms of a cold typically symptomless; alternatively, it may cause
person with the uncomfortable shoes include a stuffy or runny nose, sore a flulike illness with painful mouth and
may persuade himself or herself that throat, headache, and cough. They usu- lip ulcers, called gingivostomatis. The
the comfort of the shoes will improve ally intensify over 24–48 hours (unlike virus then lies dormant within nerve
with continued wear.) the symptoms of influenza, which tend cells, but may occasionally be reactivat-
to worsen rapidly over a few hours). ed and cause cold sores.
cogwheel rigidity Most colds clear up by themselves Reactivation of the virus may occur
A term that is sometimes used for a within a week. Affected people can take after exposure to hot sunshine or a cold
characteristic muscle stiffness seen in simple measures to cope with symp- wind, during a common cold or other
people with Parkinson’s disease. When toms; for example, mild analgesic drugs infection, or in women around the
the limbs of an affected person are pas- or cold remedies may help to relieve time of their menstrual periods. Pro-
sively moved, the muscles stretch in a aches and pains, and cough remedies longed attacks may occur in people
series of small jerks. can soothe a cough. Sometimes, how- whose immunity to infection has been
ever, infection spreads and may cause reduced due to illness or treatment
coil laryngitis, tracheitis, acute bronchitis, with immunosuppressant drugs.
The common name for any of the vari- sinusitis, or otitis media. In these cases, a In many cases, an outbreak of cold
ous types of intrauterine contraceptive bacterial infection may develop on top sores is preceded by tingling in the
device (see IUD; Mirena). of the viral infection, and antibiotic lips, followed by the formation of small
drugs may be needed to treat it. (Anti- blisters that enlarge, causing itching
coitus biotics are ineffective against viruses, and soreness. Within a few days the
Another term for sexual intercourse. so they will not cure colds.) blisters burst and become encrusted.
Most disappear within a week.
coitus interruptus cold injury TREATMENT
A method of contraception (see contra- Localized tissue damage caused by chil- The antiviral drug aciclovir, applied as a
ception, withdrawal method of) in which ling of part of the body. Cold injury is cream, may prevent cold sores if used at
the man withdraws his penis from the distinct from hypothermia, which refers the first sign of tingling.
woman’s vagina before ejaculation (the to chilling of the whole body.
discharge of semen) occurs. Coitus The most serious form of cold injury colecalciferol
interruptus is unreliable because sperm is frostbite. In this condition, an area of An alternative name for vitamin D3 (see
can be released before orgasm occurs, skin and flesh becomes frozen, hard, vitamin D).
and it may cause psychosexual dysfunc- and white as a result of exposure to
tion in men and women. very cold, dry air. Sometimes there is colectomy
restriction of the blood supply to the The surgical removal of part or all of
colchicine affected area. Another type of injury, the colon (the major part of the large
A drug extracted from the autumn cro- immersion foot, occurs when the legs intestine, which produces faeces).
cus (COLCHICUM AUTUMNALE). Colchicine and feet are kept cold and damp for WHY IT IS DONE
is used to treat acute attacks of gout and hours or days. The main risk of both Partial colectomy is usually carried out
to reduce their frequency. Side effects conditions is that the blood flow will to remove damaged or distorted sec-
include vomiting and diarrhoea. be slowed so much that the tissues die tions of colon. It may be performed to

183
 COLESTYRAMINE

treat severe cases of diverticular disease condition is thought to be due to mus- inflammation in the colon or rectum,
(in which abnormal pouches form in cle spasms in the intestines. such as diverticular disease or proctitis, or
the colon wall); to cut out a cancerous A baby that suffers an attack of colic with cancer (see colon, cancer of). In
tumour (see colon, cancer of); or to cries or screams incessantly, draws up addition, it may result from infection
remove a narrowed part of the intes- his or her legs towards the stomach, with various types of microorganism,
tine that is causing a blockage to the and may become red in the face and such as campylobacter and shigella bacte-
C passage of faeces. possibly also pass wind. The baby will ria, viruses, or amoebae. One form of
Total colectomy is performed to treat not respond to normal methods of colitis may be provoked by antibiotic
severe cases of ulcerative colitis, when comforting, such as feeding or cud- drugs; the drugs destroy bacteria that
the condition cannot be controlled by dling. Colic often tends to be worse in normally live in the intestine and allow
drugs. It may also be performed on the evenings; the symptoms may also CLOSTRIDIUM DIFFICILE, a bacterium that
individuals with familial polyposis (see be made worse by tiredness or stress. causes irritation, to proliferate.
polyposis, familial), an inherited condi- Colic can be very distressing, but it is DIAGNOSIS
tion in which large numbers of harmless. Usually, The condition first Investigations into colitis may include
growths develop in the colon. appears at the age of three to four examination of a sample of faeces for
HOW IT IS DONE weeks, and it clears up without treat- micro-organisms or for obvious or hid-
In a partial colectomy, the diseased sec- ment by the age of 12 weeks. Carers den blood (see faecal occult blood test);
tion of the colon is removed, and the should seek medical help, however, if sigmoidoscopy or colonoscopy (viewing
ends of the severed colon are joined. A additional symptoms, such as fever, of the inside of the colon); biopsy (tis-
temporary colostomy (which allows the develop, or if they are finding it diffi- sue sampling) of the inflamed areas or
discharge of faeces from the large cult to cope with the baby. ulcers; and a barium enema (see barium
intestine through an artificial opening X-ray examinations).
in the abdominal wall) may be needed colic, renal TREATMENT
until the rejoined colon has healed. See renal colic. If the cause is an infection, antibiotics
In a total colectomy, the whole of the may be needed. Crohn’s disease and
large intestine is removed, either with colic, uterine ulcerative colitis are treated with corti-
or without the rectum. If the rectum is Cramping abdominal pains that are costeroid and immunosuppressant drugs,
removed, an ileostomy (similar to a usually associated with menstruation. together with a special diet.
colostomy, but using the small intes- (See also dysmenorrhoea.)
tine) may be performed. collagen
RECOVERY coliform bacteria A tough, fibrous protein. Collagen is the
The colon usually functions normally A group of rod-shaped bacteria that body’s major structural protein, form-
after a partial colectomy. But in a total inhabit the intestine. Coliform bacteria ing an important part of tendons, bones,
colectomy, the large intestine’s ability include ESCHERICHIA and other genera and connective tissue.
to absorb water from faeces is reduced; that are sometimes associated with gas-
this can result in diarrhoea. Antidiar- trointestinal illnesses. collagen diseases
rhoeal drugs may therefore be required. See connective tissue diseases.
colistin
colestyramine One of the polymyxin group of antibiotic collapse
A lipid-lowering drug used to treat some drugs. Colistin is used in topical prepa- A nonmedical term for a state of pros-
types of hyperlipidaemia (very high lev- rations for eye and skin conditions. It tration or extreme exhaustion. The
els of fats in the blood). It is also used may also be given orally to destroy bac- word “collapse” may also be used to
to treat diarrhoea in disorders such as teria in the large intestine, in people describe a fainting fit or loss of con-
Crohn’s disease. who are particularly susceptible to sciousness. The medical term circulatory
infection. In addition, colistin may be collapse refers to a life-threatening con-
colic used in a nebulizer in order to treat lung dition in which the blood no longer
A term that means “pertaining to the infections. The drug is used only to circulates effectively.
colon”. The term “colic” also refers to a treat infections that are resistant to
severe, spasmodic form of abdominal other antibiotic drugs because it is collarbone
pain that occurs in waves of increasing toxic and may cause damage to kidney The common name for the clavicle.
intensity. (See also biliary colic; colic, and nerve tissue.
infantile; renal colic; colic, uterine.) collar, orthopaedic
colitis A soft foam or stiffened device that is
colic, biliary Inflammation of the colon. Colitis caus- worn around the neck to relieve pain
See biliary colic. es diarrhoea, usually containing blood or give additional support.
and mucus. Other symptoms may
colic, gallstone include abdominal pain and fever. Colles’ fracture
Another term for biliary colic. CAUSES A break in the radius (one of the bones
Colitis is a feature of the inflammatory of the forearm) just above the wrist, in
colic, infantile bowel disorders ulcerative colitis and which the wrist and hand are displaced
Episodes of irritability and excessive Crohn’s disease. It may also be associ- backwards, restricting movement and
crying in otherwise healthy infants. The ated with other conditions that cause causing swelling and severe pain. The

184
 COLON, CANCER OF

fracture is usually the result of putting spinning at a very high speed. In medi-
out a hand to lessen the impact of a cine, plasma proteins are separated from LOCATION OF COLON
fall. It is more common in elderly peo- blood and sometimes used in colloid
The colon is a segmented
ple, due to weakening of the bones by preparations to treat shock.
tube. It runs from the
aging or osteoporosis. The term “colloid” also refers to a caecum (where the large
The broken bones are manipulated material that contains protein and is and small intestines meet)
back into place and set in a cast. Heal- found in the thyroid gland. to the rectum, forming an C
ing of the bones takes up to six weeks. M-shaped loop within
Hand and wrist movements usually coloboma the abdomen.
return to normal, but there may be A rare birth defect in which a gap exists
minor wrist deformity. in the tissues of the eye. The gap may Transverse colon Small intestine
be in the eyelid or in part of the eye- Liver Stomach
Collet–Sicard syndrome ball, such as the iris, retina, or choroid. A
A condition resulting from damage to coloboma in the iris will be visible as a
the cranial nerves that control muscles in black notch, or as a gap stretching from
the tongue and throat. It is usually due the pupil to the edge of the iris.
to a head injury or to compression of the The condition results from incom-
nerves by a tumour. The syndrome plete development of the eyes while the
causes paralysis of muscles in the baby is still an embryo; this problem
tongue, palate, throat, larynx (voice- may, in turn, be linked to certain chro-
box), and neck on one side. There is no mosomal abnormalities. Coloboma may
cure, but the cause is treated if possible. range from minor to severe. In some
cases, it may cause blurred vision or
collodion decreased visual acuity.
A syrupy mixture of ether, alcohol, and
pyroxylin used in skin preparations for colon
minor cuts and abrasions. Collodion The major part of the large intestine. Appendix
acts by evaporating rapidly to leave a STRUCTURE
protective film over the area. The colon is a segmented tube, about Rectum Sigmoid
1.3 m long and 6.5 cm wide, that colon
colloid forms a large loop in the abdomen. It Ascending
colon Descending colon
A form of fluid that is similar to a sus- consists of four sections: the ascending,
pension (a fluid consisting of insoluble transverse, and descending colons, and
particles of a substance suspended in a the S-shaped sigmoid colon, which
liquid). Particles in a suspension are connects with the rectum. colon, cancer of
large and heavy enough to be separated The colon consists of four layers. It A malignant tumour of the colon (the
from the liquid in a centrifuge. A colloid has a tough outer membrane that pro- major part of the large intestine). Can-
has smaller, lighter particles that can tects it from damage. The next layer cers of the colon or of the rectum (the
only be separated out of the liquid by comprises muscles that contract and lower part of the colon), which are
relax rhythmically to move the intesti- generally referred to as colorectal can-
nal contents along (see peristalsis). cer, are among the most common
Ulna Inside the muscular layer is a sub- forms of cancer. They most often occur
mucous coat containing blood vessels in people over the age of 60.
and lymph vessels (see lymphatic sys- CAUSES
tem). The innermost layer produces A genetic basis has been found for
Radius
mucus, which helps to lubricate the some types of colon cancer. Up to one
passage of waste material. in three cases are associated with a
FUNCTIONS family history of colon disease. In par-
Lower end of The main functions of the colon are to ticular, an inherited disorder called
broken radius
displaced absorb water and mineral salts from familial adenomatous polyposis (in
backwards food residue and to concentrate the which large numbers of polyps develop
remaining waste products. The material in the colon) greatly increases the risk.
that remains after digestion enters the In the majority of cases, however, the
colon from the small intestine. As this precise cause is not known. Contribu-
substance passes through the colon, the tory factors include diet: eating a lot of
water and salts that it contains are meat and fatty foods and not enough
absorbed into the blood vessels in the fibre may increase the risk. The disease
submucous coat. The waste material also sometimes occurs in association
X-ray of Colles’ fracture becomes increasingly concentrated and with ulcerative colitis.
This X-ray clearly shows that the lower end of the
broken radius has been pushed back. This gives
is finally expelled from the rectum in SYMPTOMS
a classic “dinner fork” appearance when the wrist the form of faeces. (See also digestive The first symptoms of colon cancer
is viewed from the side. system; intestine, disorders of.) include an inexplicable change in

185
 COLON, DISORDERS OF

bowel movements (either constipation colon, disorders of colon, spastic

or diarrhoea), blood mixed in with the See intestine, disorders of. See irritable bowel syndrome.
faeces, and pain in the lower abdomen.
Sometimes, however, there are no colon, irritable Colorado tick fever
symptoms until the tumour has grown See irritable bowel syndrome. A viral illness transmitted by the bites
large enough to cause an obstruction of infected ticks. It occurs in the
C in the intestine (see intestine, obstruction colonization mountain areas of the western United
of) or perforate it (see perforation). The multiplication of foreign organ- States, usually in early summer. Symp-
DIAGNOSIS AND TREATMENT isms, such as bacteria, in a host body. toms appear 3–6 days after a tick bite;
Successful treatment of cancer of the (This process is not necessarily harm- they include flulike chills and fever,
colon depends, crucially, on an early ful.) The term “colonization” is also severe headache, nausea, and some-
diagnosis. Screening may be carried out used to refer to the development of times a red, raised rash. The illness
to detect early signs. This procedure cancer cells in an area to which they usually lasts for a few days, subsides,
includes a test to detect blood hidden have spread that is separate from the then returns for a further few days. The
in the faeces (see faecal occult blood primary tumour. virus can, how-ever, remain in the
test). If the test is positive, doctors may blood for several months.
perform sigmoidoscopy and colonoscopy colonoscopy Treatment involves removal of the
to view the inside of the colon. A biopsy The viewing of the inside of the colon tick as soon as possible and taking anal-
may be performed at the same time. using a flexible endoscope (fibre-optic gesic drugs (painkillers) if necessary.
In most cases, a partial colectomy is instrument) known as a colonoscope, Tick bites can be prevented by wearing
carried out. In this procedure, the dis- which is introduced through the anus clothing that covers the arms and legs
eased part of the colon is removed, and guided along the colon. Colonos- and tucking trouser legs into socks.
together with a surrounding area of copy is used to investigate symptoms (See also ticks and disease.)
healthy tissue, then the cut ends of the such as bleeding from the anus and to
colon are rejoined. Surgery may be detect physical abnormalities such as colorectal cancer
combined with radiotherapy or possibly inflammation (see colitis), growths (see A general term referring to cancer of
with chemotherapy. The chance of sur- polyps), and cancer. Instruments may be the colon (see colon, cancer of) and/or
vival depends on how far the tumour passed through the colonoscope to take of the rectum (see rectum, cancer of).
has spread, but colon cancer in its early biopsy specimens or remove polyps.
stages can be cured. (See also endoscopy.) colostomy
An operation in which part of the colon
is brought to the surface of the skin
PROCEDURE FOR COLOSTOMY through an incision in the abdominal
wall. The exposed part is formed into a
An incision is made in the abdominal
stoma, an artificial opening through
wall and part of the colon is pulled Large intestine
through. In a temporary colostomy, a which faeces are discharged into a bag
small loop is exposed, and an opening attached to the skin. A colostomy may
Possible sites
is made in it large enough for faeces to of colostomy
be either temporary or permanent.
pass through. If the rectum and anus openings A temporary colostomy may be per-
have been removed, the cut end of the formed at the same time as a partial
colon is brought to the skin surface. colectomy (removal of part of the
The edges of the opening or severed colon) to allow the remainder of the
end are stitched to the skin at the Small intestine
colon to heal without faeces passing
edges of the abdominal incision to through and contaminating it. The col-
create a stoma (artificial opening) ostomy is closed when the rejoined
through which faeces will be expelled.
colon has healed. A permanent colosto-
Navel Stoma my is needed if the rectum or anus has
been removed (for example, to treat
colon cancer) and normal defaecation
is therefore impossible.
colostrum
A thick, yellowish fluid that is pro-
duced by the breasts during the first
few days after childbirth, before being
replaced by breast milk. Colostrum
Open end of
contains less fat and sugar, but more
Position of the stoma colon brought minerals and protein, than breast milk.
A colostomy bag is attached over the stoma to Diseased part of through to It also has a high content of lymphocytes
rectum removed skin surface
collect faeces. After a bowel movement, it is (white blood cells) and immuno-
either replaced or emptied. Permanent colostomy globulins, which help to protect the
baby against infections.

186
 COLOUR VISION

colour blindness metre). Different wavelengths trigger light, but only the cones can distin-
See colour vision deficiency. nerve signals in the retina (the light- guish colour. There are three types of
sensitive layer of cells at the back of the cone: red-sensitive, blue-sensitive, and
colour vision eye); these signals pass to the brain and green-sensitive. Each of these types of
The ability to see and distinguish the are interpreted as violet, indigo, blue, cone responds more strongly to a par-
different parts of the colour spectrum, green, yellow, orange, and red. ticular part of the light spectrum. The
which consists of electromagnetic radi- RETINAL FUNCTION cones are most concentrated in a cen- C
ation (energy waves) with a range of As light falls on the retina, it strikes tral area of the retina called the fovea;
wavelengths between about 400 and light-sensitive cells called rods and for this reason, colour vision is most
700 nanometres (millionths of a milli- cones. The rods can detect all visible accurate for objects that are viewed

COLOUR VISION

Light, consisting of radiation of various wavelengths, is The impulses then travel through cells called bipolar cells to a
focused on the retina. At the back of the retina, light-sensitive layer called the ganglion cells, where some initial processing
rod and cone cells are stimulated to emit electrical impulses. occurs, before passing to the brain via the optic nerve.
Fovea Ganglion cells Bipolar cells Rods

Retina Optic nerve

Location of colour-sensitive cells
The rods and cones are located at the back of
the retina. Behind them is a darkly pigmented Light Nerve fibres Nerve impulses Cones Pigment cells
layer of cells, which reduces light scattering.
Colour vision depends on the cones, which Cells in the retina
are concentrated in an area called the fovea.
Light

Violet Blue Green Yellow Orange Red

Key
Blue-sensitive cones Maximum response to light wavelengths
Green-sensitive cones
Red-sensitive cones

Colour response of cones (right)

There are three classes of cone. One of these
(red-sensitive) responds best to light of long
wavelengths; another (blue-sensitive) to light
of short wavelengths; and the third (green-
sensitive) to intermediate wavelengths.
400 450 500 550 600 650 700 750
Wavelength (nanometres)

Response to white light Response to red light

White light White light consists of a mixture Red light Light with a long wavelength (red
of all wavelengths (colours), light) produces a strong response
and it therefore stimulates all from red-sensitive cones, a weak
three classes of cone to signal response from blue-sensitive
equally. This pattern of cones, and an intermediate
response is interpreted as response from green-sensitive
whiteness by the brain. cones. This pattern of signalling
is interpreted as the colour red by
the brain.
G R B Key G R B
G Green-sensitive
R Red-sensitive
B Blue-sensitive

187
 COLOUR VISION DEFICIENCY

directly. Colour vision is, therefore, of early cervical cancer (see cervix, can- combination drug
poor at the periphery of vision. cer of). Removal of tissue samples (see A preparation containing more than
When light hits a cone, it causes a biopsy) or treatment to remove any one active substance.
structural change in the pigment with- abnormal areas can be performed dur-
in the cone, which in turn causes the ing colposcopy, and this is usually done comedo
cone to emit an electrical signal. This under local anaesthetic. Another name for a blackhead.
C signal passes to the brain via the optic
nerve. Colour perception requires a coma commensal
minimum level of light; below this A state of unconsciousness and unres- A bacterium or other organism that nor-
level, everything is perceived only by ponsiveness to external stimuli (for mally lives in or on the body without
the rods and is seen as various shades example, pinching) or internal stimuli either harming or benefiting its host.
of grey. (See also colour vision deficiency; (such as a full bladder).
eye; perception; vision.) CAUSES comminuted fracture
Coma results from disturbance or dam- A type of fracture in which the bone
colour vision deficiency age to areas of the brain involved in shatters into more than two pieces. A
Any abnormality in colour vision that conscious activity or maintenance of severe blow, such as an impact occur-
causes a person to have difficulty in consciousness – in particular, parts of ring in a car accident, may result in a
distinguishing between certain colours. the cerebrum, upper parts of the brain- comminuted fracture.
TYPES stem, and central regions of the brain,
The most common type of colour especially the limbic system. commode
vision deficiency is the reduced ability Conditions that can produce coma A portable chair that contains a remov-
to discriminate between red and green. include severe head injury; disorders able toilet bowl in its seat.
Most cases of red–green colour vision such as stroke or cardiac arrest, in which
deficiency are the result of defects in part or all of the brain tissue is deprived common cold
the light-sensitive cells in the retina. of blood; or infectious disorders that See cold, common.
These defects are usually inherited, and affect the brain, such as meningitis and
tend to be sex-linked (see genetic disor- encephalitis. In addition, excessively communicable disease
ders); the majority of sufferers are high or low blood levels of certain sub- Any disease due to a microorganism or
male, while females are unaffected, but stances may result in coma; for parasite that can be transmitted from
they can pass on the disorder to their example, a person with diabetes mellitus one person to another. (See also conta-
children. Occasionally, defects may be may become comatose if his or her gious; infectious disease.)
acquired as a result of diseases of the blood level of glucose (sugar) rises or
retina or the optic nerve, or they are falls to an abnormal degree. compartment syndrome
caused by injury. There are two forms SYMPTOMS A painful cramp due to compression of
of red–green deficiency. A person with There are varying depths of coma. In a group of muscles within a confined
a severe green deficiency has difficulty less severe forms, the affected person space. It may occur when muscles are
in distinguishing between oranges, may make small movements and res- enlarged due to intensive sports train-
greens, browns, and pale reds. A severe pond to certain stimuli. In a deep ing or to an injury such as shin splints.
red deficiency causes all shades of red coma, the person does not make any Cramps induced by exercise usually
to appear dull. movements or respond to any stimu- disappear when the exercise is stopped.
A much rarer colour vision deficiency lus. However, even people in deep Severe cases may require fasciotomy to
exists in which blue cannot be distin- comas may show some automatic improve blood flow and prevent devel-
guished. This condition may be inher- responses, for example breathing opment of a permanent contracture.
ited, or it may be due to degeneration unaided and blinking. If the lower
of the retina or the optic nerve. Mono- brainstem is damaged, however, vital compensation
chromatism (the total absence of functions are impaired, and artificial The adjustment made by an organ to
colour vision) also exists, but this defi- ventilation and maintenance of the cir- make up for changes in body function
ciency is very rare. culation are required. or structure. An example of compensa-
OUTLOOK tion is the increased size of one kidney
Colpermin If brain damage is minor and rever- when the other has been removed.
A brand name for peppermint oil. This sible, the person may make a full
preparation is used to relieve the pain recovery, but deep coma due to severe complement
that results from muscle spasms in trauma may result in long-term neuro- A collection of proteins in the plasma
irritable bowel syndrome and diverticular logical problems such as muscle (the fluid part of blood) that helps to
disease. weakness or changes in behaviour. A destroy foreign cells and is an import-
person in a deep coma (a persistent veg- ant part of the immune system.
colposcopy etative state) may be kept alive for years
Viewing of the cervix (the neck of the provided the brainstem is still func- complementary medicine
uterus) and vagina using a magnifying tioning. Complete and irreversible loss A group of therapies, often described as
instrument called a colposcope. Col- of brainstem function leads to brain “alternative”, that are now increasingly
poscopy is carried out to detect areas of death (the permanent cessation of all used to complement or to act as an
precancerous tissue (see dysplasia) or brain functions). alternative to conventional medicine.

188
 CONDOM

Such treatments fall into three broad compress may be used to stop bleeding Anyone who has been concussed, how-
categories: touch and movement (as in from a wound or may be coated with ever briefly, should see a doctor as soon
acupuncture, massage, and reflexology); medication to help treat infection. as possible. Persistent symptoms, or
medicinal (as in naturopathy, Chinese new ones such as drowsiness, difficulty
medicine, and homeopathy); and psy- compression syndrome in breathing, repeated vomiting, or
chological (as in biofeedback, hypno- A collection of localized neurological visual disturbances, could signify brain
therapy, and meditation). symptoms, such as numbness, tingling, damage or an extradural haemorrhage, C
discomfort, and muscle weakness, that and medical advice should be sought
complete abortion is caused by pressure on a nerve. without delay. Repeated concussion
The expulsion from the uterus of an can cause punch-drunk syndrome. (See
embryo or a fetus together with its compulsive behaviour also head injury.)
membranes and placenta (see abortion). See obsessive–compulsive disorder.
conditioning
complete heart block computed tomography The formation of a specific physical or
See heart block. Another name for CT scanning. behavioural response to a particular
stimulus in the environment.
complex computer-aided diagnosis CLASSICAL CONDITIONING
A term used in medicine to mean a The use of computer technology in In classical conditioning, a stimulus
group or combination of related signs certain diagnostic tests and procedures. that consistently evokes a particular
and symptoms that form a syndrome It involves the use of probability-based response is paired repeatedly with a
(as in Eisenmenger complex), or a collec- computer systems that store informa- second stimulus that would not nor-
tion of substances of similar structure tion on thousands of cases of different mally produce the response. Eventually,
or function (as in vitamin B complex). In disorders, detailing the type, location, the second stimulus begins to produce
psychology, a complex (for example, duration, symptoms, medical history, the response whether or not the first
the Oedipus complex) denotes a group of and diagnosis. A patient’s symptoms stimulus is present. This phenomenon
unconscious ideas and memories that and medical history can be entered into was shown by the physiologist Ivan
have emotional importance. a computer, which then compares the Pavlov. He observed that dogs salivated
details with existing data and produces in anticipation of food (an uncondi-
compliance a list of the most likely diagnoses. tioned response to a stimulus). He then
The degree to which patients follow Such technology is not currently in devised a procedure in which a bell
medical advice. common use in hospitals, but is of was rung every time a dog was given
value for people who are isolated from food; once the procedure had been
complication medical services, such as oil-rig crews. repeated several times, the dog began
A condition resulting from a preceding Computers programmed to interpret to salivate every time it heard the bell
disorder or from its treatment. visual data, such as abnormal cells, have (a conditioned response to a stimulus)
potential use in certain types of blood even if no food was presented.
compos mentis test and cervical smear tests. Computers OPERANT CONDITIONING
Latin for “of sound mind’’. are also used in investigative proce- In operant conditioning, attempts are
dures such as CT scanning and MRI. made to modify behaviour by reward-
compound ing or punishing a subject (animal or
A term used in chemistry to describe a concealed haemorrhage human) every time the subject shows a
substance that contains two or more Internal loss of blood (see bleeding). particular response to a specific stimu-
chemically combined elements. In phar- lus. A response that is rewarded will be
macy, a compound is a preparation that conception reinforced and become more frequent,
contains a number of ingredients. The fertilization of a woman’s ovum while one that is punished will be
(egg) by a man’s sperm, followed by inhibited and become less frequent.
compound fracture implantation of the resulting blastocyst USE IN MEDICINE
A type of fracture, also known as an (the growing mass of fertilized cells) in Behavioural psychology (see behaviour
open fracture, in which a broken bone the lining of the uterus. This process therapy) is based on the idea that inap-
breaks through the overlying skin. In marks the beginning of pregnancy. (See propriate behaviour patterns in some
this type of fracture, there is a high also contraception; infertility.) psychological disorders are learned
risk of infection. through conditioning. It is thought that
concussion these patterns can be modified by the
compress Brief unconsciousness, usually following same process of conditioning.
A pad of lint or linen applied, under a violent blow to the head. The loss of
pressure, to an area of skin. Cold com- consciousness is due to a brief distur- condom
presses soaked in ice-cold water or bance of the electrical activity in the A barrier method of contraception in the
wrapped around ice help to reduce brain. Common symptoms following form of a thin latex rubber or plastic
pain, swelling, and bleeding under the concussion include confusion, inability sheath, which is placed over a man’s
skin after an injury (see ice pack). Hot to remember events that occurred just penis before sexual intercourse. Con-
compresses increase the circulation and prior to the injury, dizziness, blurred doms also provide some protection
help to bring boils to a head. A dry vision, and vomiting. against sexually transmitted infections.

189
 CONDOM, FEMALE

condom, female cone biopsy drugs, and certain physically based men-
A barrier method of contraception in A surgical procedure in which a conical tal disorders. Many of the conditions
the form of a sheath that is inserted or cylindrical section of tissue from the that cause chronic confusion (for exam-
into a woman’s vagina before sexual lower part of the cervix (neck of the ple, dementia) are progressive. Features
intercourse. Female condoms also offer uterus) is removed (see biopsy of the of such conditions include absent-
some protection against sexually trans- cervix box on p.159). A cone biopsy is mindedness, poor short-term memory,
C mitted infections. performed following an abnormal and a tendency to be repetitive.
result of a cervical smear test if the extent TREATMENT
conduct disorders of the precancerous or cancerous area If the underlying cause of confusion
Repetitive and persistent patterns of cannot be seen by colposcopy (inspec- can be treated, there may be marked
aggressive and/or antisocial behaviour, tion of the cervix with a viewing improvement. Sedative drugs can be of
such as vandalism, substance abuse, and instrument). (See also cervix, cancer of). benefit in acute confusion.
persistent lying, in children or adoles-
cents. (See also behavioural problems in confabulation congenital
children; adolescence.) The use of a fictional story to make up A term meaning “present at birth”.
for gaps in memory. The phenomenon Congenital abnormalities (sometimes
conduction occurs most commonly in chronic called birth defects) may be inherited.
The movement of particular forms of alcoholics who suffer from Wernicke– Alternatively, they may result from
energy, such as nerve impulses and Korsakoff syndrome. It may also occur in damage or infection occurring either in
sound waves, through a system. people with head injuries. the uterus or at the time of birth.
conductive deafness confidentiality congenital adrenal hyperplasia
Deafness caused by faulty conduction of The ethical principle that a doctor does See adrenal hyperplasia, congenital.
sound from the outer to the inner ear. not disclose any information given in
Causes include excess earwax or fluid confidence by a patient. congenital amputation
in the middle ear (see glue ear). The patient’s consent is necessary See amputation, congenital.
before a doctor supplies confidential
conduit information to an insurance company, congestion
A channel or tube that conveys fluid. an employer, or a lawyer. Doctors must, A term that usually refers to the accu-
Conduits may be created surgically to however, disclose information about mulation of excess blood, tissue fluid, or
redirect the flow of body fluids. The patients when required to do so by law, lymph in part of the body.
most common form of artificially con- or when they are faced with injuries or A major cause of congestion is an
structed conduit is an ileal conduit, disorders that indicate a serious crime. increased blood flow to an area due to
which is created from part of the small Doctors are also required to notify inflammation. Another possible cause is
intestine to divert urine out of the body health authorities about patients with reduced drainage of blood from an
when the bladder has had to be specified infectious diseases. affected area, as can occur in heart fail-
removed (see cystectomy). Treatment of young children is usu- ure, in venous disorders such as varicose
ally discussed with the parents, but an veins, and in lymphatic disorders. (See
condyle older child’s request for confidentiality also nasal congestion.)
A round projection on the end of a is generally respected if the doctor feels
bone that fits into a hollow on another that he or she is competent enough to congestive heart failure
bone to form a joint; an example of a understand the issues involved. See heart failure.
condyle is the elbow.
confluent conjoined twins
condyloma A term meaning “merging or running See twins, conjoined.
A warty skin growth that usually occur- together”. It is used, for example, in
ring in moist areas of the body, for relation to individual skin blemishes conjunctiva
example the genitals. The most com- that merge to form one abnormal area. The transparent membrane covering
mon type of condyloma is caused by the sclera (white of the eye) and lining
the human papillomavirus (see genital confusion the inside of the eyelids. Cells in the
warts). Condylomata are highly infec- An acute or chronic disorganized men- conjunctiva produce a fluid that lubri-
tious flattened growths that may tal state in which thought, memory, cates the lids and the cornea.
develop around the genitals in the sec- and reasoning are impaired.
ondary stage of syphilis. CAUSES AND SYMPTOMS conjunctival haemorrhage
Acute confusion can arise as a symp- An alternative term for subconjunctival
condyloma acuminatum tom of delirium, in which brain activity haemorrhage (bleeding in the white of
See warts, genital. is affected by fever, drugs, poisons, or the eye).
injury. People with acute confusion
cone may also have hallucinations and behave conjunctivitis
A type of light-sensitive cell located in in a violent manner. Chronic confusion Inflammation of the conjunctiva, caus-
the retina of the eye. Cones play a major is often associated with alcohol depen- ing redness, discomfort, and discharge
role in colour vision. dence, the long-term use of antianxiety from the affected eye.

190
 CONTACT LENSES

connective tissue diseases Occasionally, constipation is a symp-

LOCATION OF CONJUNCTIVA Certain autoimmune disorders (disorders tom of an underlying disorder. This is
in which the immune system attacks especially likely if it is part of a per-
This transparent membrane covers the body’s own tissues) that often sistent change in bowel habits in
the sclera (white of the eye) and
lines the inside of the eyelids.
affect blood vessels and produce sec- someone over the age of 40, or if it is
ondary damage to connective tissue. accompanied by other symptoms such
Sclera Conjunctiva Connective tissue diseases include as blood in the faeces, pain on moving C
rheumatoid arthritis, polyarteritis nodosa, the bowels, or weight loss. Conditions
systemic lupus erythematosus, systemic that may cause constipation include
sclerosis, and dermatomyositis. haemorrhoids, anal fissure, irritable bowel
syndrome, and narrowing of the colon
Conn’s syndrome due to disorders such as diverticular dis-
A disorder caused by the secretion of ease or cancer (see colon, cancer of).
excessive amounts of the hormone TREATMENT
aldosterone. The overproduction of this Self-help measures such as establishing
hormone is caused by a noncancerous a regular bowel routine, increasing the
tumour of one of the adrenal glands. amount of fibre in the diet, and drink-
(See also aldosteronism.) ing more fluids are usually beneficial.
Prolonged use of laxative drugs should
Cornea consciousness be avoided, because this can impair the
A state of alertness in which a person is normal functioning of the colon.
Lens Iris
fully aware of his or her thoughts, sur-
roundings, and intentions. constriction
A narrowed area in the body, or the
TYPES AND SYMPTOMS consent process of narrowing.
There are two common types: infective Also sometimes referred to as informed
conjunctivitis, caused by bacteria or consent, the legal term describing a consultant
viruses; and allergic conjunctivitis, an patient’s agreement to a doctor per- In the UK, a doctor, usually attached to
allergic response to substances such as forming an operation, arranging drug a certain hospital, who is a specialist in
cosmetics and pollen. Both types may treatment, or carrying out a diagnostic a particular branch of medicine and
have similar symptoms. In infective test. The patient’s consent is also need- who takes full responsibility for the
conjunctivitis, the discharge contains ed before a doctor supplies confidential patients in his or her care.
pus and may result in the eyelids being information to an insurance company,
stuck together on waking in the morn- an employer, or a lawyer. contact dermatitis, allergic
ings. In allergic conjunctivitis, the Consent is valid only if the patient A type of dermatitis caused by an aller-
discharge is clear and the eyelids are has been fully informed about the pur- gic skin reaction to a substance that is
often swollen and itchy. pose of that particular procedure, the harmless for most people. Common
Other forms of conjunctivitis that likely outcome, and any complications causes include nickel and rubber. (See
occur less commonly include neonatal and side effects. Consent cannot be also irritant dermatitis.)
ophthalmia (infective eye disease in given by young children or by people
newborns), keratoconjunctivitis (inflam- who are not considered to be com- contact lenses
mation of both the conjunctiva and the petent, but a relative may give or Thin, shell-like, transparent discs fitted
cornea), and trachoma (a serious form withhold consent on their behalf. over the cornea of the eye that are used
of chlamydial infection). to correct defective vision. Contact
TREATMENT constipation lenses are most commonly used for the
Bacterial infections are treated with The infrequent or difficult passing of correction of myopia (shortsightedness)
eyedrops or ointment containing an hard, dry faeces. Constipation may be and hypermetropia (longsightedness). In
antibiotic drug. Viral conjunctivitis often uncomfortable but in the short term is addition, noncorrective lenses are avail-
disappears without the need for treat- usually harmless. able for cosmetic use, for example to
ment. Allergic conjunctivitis may be CAUSES change eye colour.
treated with eyedrops that contain cro- The most common cause of constipa- TYPES
moglicate, an antihistamine, or a tion is insufficient fibre in the diet (see There are several types. Hard plastic
corticosteroid drug. fibre, dietary), because fibre assists the lenses give good vision; they are also
propulsion of waste matter through the long-lasting and durable, inexpensive,
connective tissue colon. Other common causes include and easy to maintain. Sometimes, how-
The material that supports, binds, or lack of regular bowel movements due ever, these lenses are difficult for the
separates the various structures of the to poor toilet-training in childhood or wearers to tolerate and may fall out.
body. Tendons and cartilage are made up repeatedly ignoring the urge to move Hard gas-permeable lenses are more
of connective tissue. This type of tissue the bowels. Constipation in elderly comfortable because they allow oxygen
also forms the matrix (basic substance) people may be due to immobility or to to pass through to the eye, but are less
of bone and the nonmuscular structures weakness of the muscles of the abdo- durable. Soft lenses are the most com-
of arteries and veins. men and the pelvic floor. fortable because of their high water

191
 CONTACT TRACING

content. Disposable soft lenses are for

single use only; extended-wear lenses CARE AND INSERTION OF CONTACT LENSES
are worn for up to a month.
The care of hard contact lenses may Soft contact lenses absorb any
Other types of contact lenses include
require the use of several chemical chemicals with which they come into
rigid scleral lenses, which cover the solutions. A cleaning solution is used contact, so the solutions used must be
whole of the front of the eye and are to remove deposits of mucus and weaker. Disinfection with a chemical or
C used to disguise disfigurement; bifocal protein from the lenses. A wetting heating system is needed to prevent
contact lenses; and toric contact lenses, solution is used before inserting a lens contamination and eye infection. Two
which have an uneven surface curva- in the eye. A further solution may also or three solutions may be necessary,
ture and can correct astigmatism. be used for storage; if used, a storage but intermittent cleaning with a third
PROBLEMS solution must be washed off before a system, such as an enzyme tablet or an
Hard plastic lenses may cause abrasion contact lens is inserted. oxidizing agent, may also be required.
of the cornea if worn for too long. Soft
lens wearers sometimes develop sensi-
tivity of the eyes and lids. Any type of
contact lens may cause redness of the Tear layer
eye. The most serious complication of
using lenses is infection, which can
occasionally cause permanent damage Cornea
to the cornea and affect vision; meticu-
Lens Contact Hard Soft
lous hygiene lowers the risk. lens lens lens
contact tracing
A service provided by clinics treating
sexually transmitted infections, in which
all contacts of a person diagnosed as 1andBefore touching lenses, wash your
hands thoroughly under running water
take care to rinse off all traces of
having a sexually transmitted infection soap. Remove the lens from its container;
are traced and then encouraged to be for a hard lens, you may prefer to do this
examined and treated. Contact tracing with a rubber sucker. Rinse the lens
is also used in cases of other infections, thoroughly in the wetting solution.
Do not use tapwater.
especially tuberculosis, meningitis, and
imported tropical diseases.
contagious
A term used to describe a disease that
can be transferred from person to per-
son by ordinary social contact. All Inverted
contagious diseases, such as the com- lens
mon cold or chickenpox, are infectious.
The term “contagious” does not apply
to the many infectious diseases, such as
typhoid, syphilis, or AIDS, which are
spread by other means.
continuous positive airway 2thatPlace the contact lens on the tip of your
index finger. If it is a soft lens, make sure
Keep both eyes open. Hold the upper lid of
3the lens
one eye open, and look straight ahead or at
pressure (CPAP) it has not turned inside out. If it has, you as you bring it up to your eye.
will see an out-turned rim.
A method of ventilation (mechanically
assisted breathing) in which the air
pressure inside a patient’s airways is
kept above atmospheric pressure.
continuous positive pressure
ventilation (CPPV)
A rarely used method of ventilation
(mechanically assisted breathing) in
which positive pressure is applied to
the airways to produce each inhalation.
contraception
4the lid.Place the contact lens on your eye, over the iris
and pupil. Look downwards and then release
If necessary, the lens may be centred by
The control of fertility to prevent preg- gently massaging the eyelid. The photograph on
the right shows a hard lens correctly positioned.
nancy. Contraception can be achieved
by a variety of methods. Some forms

192
 CONTRACEPTION

METHODS OF CONTRACEPTION

Forms of contraception include natural, barrier, hormonal, and postcoital methods.

Most are for use by women. Another option is sterilization, surgery that disrupts part
of the male or female reproductive system to render a person permanently infertile.
C

Condom
Female condom Male condom Hormone injection
The female condom is placed in the Condoms should be checked for A progestogen is injected by a doctor or nurse
vagina with the open end extending holes and air squeezed from the tip into a muscle in the woman’s arm or buttock.
just beyond the vaginal opening. Open end
to prevent bursting. They may be The hormone is released into her body over a
used with a spermicide. On with- period of 8 to 12 weeks, after which time the
drawal, the rim should be held to procedure is repeated.
Female condom stop the condom slipping off.

Diaphragm
plus
spermicide

IUD in position Diaphragm in position Hormonal implant

An IUD is a small piece of moulded A diaphragm is a rubber dome held A flexible rod containing a progestogen
plastic with strings attached. Some in place over the cervix by means of hormone is inserted into the woman’s arm,
contain copper or a progestogen. IUD a coiled metal spring in its rim. It under the skin, where it releases progestogen
The IUD is fitted in the uterus to physically prevents sperm from into the blood.
stop fertilized eggs implanting. reaching the cervix.
Days
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
Temperature method
98.4 36.9
This natural form of contraception
98.2 36.8 involves charting a woman’s Mini-pill
98.0
Temperature
36.7
temperature to see whether
rise ovulation has taken place. The
97.8 36.6 temperature should be taken at
97.6 36.5 the same time each day, on waking. Pill
Ovulation Ovulation precedes a temperature The pill
97.4 36.4
rise. A rise in temperature for Contraceptive pills contain oestrogen to prevent
97.2
Temperature
36.3 three days means the end of the ovulation, and/or a progestogen, which changes
97.0 fall 36.2
fertile time. the cervical mucus to prevent sperm penetration,
or alters the uterine lining to prevent implantation.

STERILIZATION

This procedure offers an almost Male sterilization Female

(vasectomy) sterilization
completely safe and reliable form The vas deferens A laparoscope
of birth control; it is usually (tube from a testis (viewing tube) is
irreversible. It does not affect sex to the urethra) on inserted, under
hormones, so a man produces each side is cut so anaesthetic, through
sperm-free semen and a woman sperm cannot enter the abdominal wall.
produces normal eggs that do not the urethra. An instrument is
reach the uterus. passed through it
to cut or seal the
fallopian tubes.

193
 CONTRACEPTION, BARRIER METHODS OF

prevent ovulation in the woman; others types of spermicide should be used occurred. The woman takes her temp-
stop sperm from meeting an ovum in the with rubber barrier devices. (See also erature each day using an ovulation
fallopian tube (preventing fertilization), the illustrated box on previous page.) thermometer. Sex is considered to be
or prevent a fertilized ovum from safe only after there has been a rise in
implanting in the uterus. contraception, emergency temperature lasting at least three days.
Some contraceptive methods involve Measures to avoid pregnancy following The cervical mucus method involves
C changes in sexual activity; such methods unprotected sexual intercourse. There are attempting to pinpoint the fertile per-
include total or periodic abstinence from two main methods: hormonal and phys- iod by charting the appearance and
intercourse (see contraception, natural ical. In the first, oral contraceptives (the amount of cervical mucus during the
methods of) and coitus interruptus, in “morning after” pill) should be taken in menstrual cycle. Certain recognized
which sexual intercourse is stopped a high dose as soon as possible after changes in the mucus occur before and
before ejaculation occurs. Other meth- unprotected sexual intercourse: prefer- often at ovulation. The symptothermal
ods, known as barrier methods (see ably within 12 hours, but no later than method is a combination of the temper-
contraception, barrier methods of), involve 72 hours afterwards. The pills contain a ature and mucus methods. (See also the
the use of condoms to prevent sperm high dose of the hormone progesterone. illustrated box on previous page.)
from coming into contact with eggs. In the physical method, an IUD is inserted
Hormonal methods, including the use by a doctor within five days of unpro- contraception, postcoital
of oral contraceptives, implants, and tected sex. Both methods are thought to See contraception, emergency.
injections (see contraceptives, injectable), work by preventing a fertilized egg
prevent conception by altering the hor- from implanting in the uterus. (See also contraception, withdrawal
mone balance in a woman’s body. Further the illustrated box on previous page.) method of
forms of contraception include the use of See coitus interruptus.
intrauterine devices (see IUDs); postcoital contraception, hormonal
methods (see contraception, emergency); or methods of contraceptive
sterilization of the male (see vasectomy) The use by women of synthetic pro- Any agent that reduces the likelihood of
or female (see sterilization, female). gestogen drugs, often combined with conception. (See also contraception.)
synthetic oestrogens, to prevent concep-
contraception, barrier methods of tion. The combined pill (see oral contraceptive implant
The use of a device and/or a chemical contraceptives), the best-known form of A hormonal method of contraception in
that will physically stop sperm from hormonal contraception, contains both which a long-acting progestogen drug is
reaching an ovum, thus preventing fertil- an oestrogen and a progestogen; it acts inserted under the skin inside the
ization and pregnancy. Barrier methods by suppressing ovulation (the release of upper arm. An implant consists of a
and spermicides (preparations that kill an egg from an ovary). Progestogen small, flexible rod that steadily releases
sperm), when used together correctly, drugs make cervical mucus thick and the drug into the bloodstream. It func-
can be highly effective in preventing impenetrable to sperm. They also cause tions continually for several years.
conception. Barrier methods of contra- thinning of the endometrium (lining of
ception also help to prevent the sexual the uterus), which reduces the chance contraceptives, injectable
transmission of diseases such as HIV, of a fertilized egg implanting success- A hormonal method of contraception in
genital herpes (see herpes, genital), and fully. Progestogens can be given as pills, which long-acting progestogen drugs are
viral hepatitis (see hepatitis, viral). as contraceptive implants under the skin, injected every two to three months.
The male condom, a latex sheath that or by injection (see contraceptives, inject- Injectable contraceptives are very effec-
covers the penis, is one of the most able), or they can be released into the tive, but they may cause menstrual
widely used barrier contraceptives. The uterus by some IUDs. (See also the illus- disturbances, weight gain, headaches, and
female condom (see condom, female), trated box on previous page.) nausea, especially in the first few months.
which lines the vagina, is similar to the
male condom but is larger. contraception, natural methods of contractions, uterine
Other barrier methods that are used Methods of avoiding conception that Rhythmic, squeezing muscular spasms
by women include the diaphragm and do not involve the use of any contra- that occur in the walls of the uterus
the cap. The diaphragm (see diaphragm, ceptive hormones or devices. These before and during childbirth in order to
contraceptive) is a hemispherical dome methods are based on attempts to pin- expel the baby from the uterus. Regular
of thin rubber with a metal spring in point a woman’s fertile period around contractions indicate the start of labour
the rim to hold it in place against the the time of ovulation, so that sexual and increase in strength and frequency
vaginal wall, blocking the entrance to intercourse can be avoided at this time. throughout the first stage. (See also
the cervix. It is used with a spermicide. The calendar method is based on the Braxton Hicks’ contractions.)
A cervical cap (see cap, cervical) is an assumption that ovulation takes place
alternative to the diaphragm. around 14 days before menstruation. contracture
Spermicides, in the form of aerosol Due to its high failure rate, it has been A deformity that is caused by shrinkage
foams, creams, gels, and pessaries, are largely superseded by other methods. of tissue in an area of skin, muscle, or
placed in the vagina as close as possible The temperature method is based on a tendon and that may restrict the
to the cervix shortly before sexual the normal rise of a woman’s body movement of a joint. Skin contractures
intercourse. Although some condoms temperature in the second half of the commonly occur as a result of scarring
are precoated with spermicide, not all menstrual cycle, after ovulation has following extensive burns or other

194
 CORN

injuries. Other types of contracture are contusion COPD

caused by inflammation and shrinkage Bruising to the skin and underlying tis- The abbreviation for chronic obstruc-
of connective tissues; examples of these sues from a “blunt” injury such as an tive pulmonary disease (see pulmonary
include Dupuytren’s contracture and Volk- abrasion (graze) or an impact. disease, chronic obstructive).
mann’s contracture.
convalescence copper
contraindication The period of recovery following an A metallic element that is an essential C
Factors in a patient’s condition that illness or a surgical operation during part of several enzymes (substances that
would make it unwise to pursue a cer- which the patient gradually regains regulate chemical reactions in the
tain line of treatment. strength before returning to their nor- body). Copper is required by the body
mal activities. in only minute amounts (see trace ele-
contrast enema ments). An excess in the body may
A contrast medium (opaque substance), convergent squint occur as a result of the rare inherited
which is introduced through the anus, A type of squint in which the abnormal disorder Wilson’s disease.
that enables the colon and rectum to be eye is directed too far inwards towards
seen in outline on an X-ray. (See also the other eye. co-proxamol
barium X-ray examinations.) An analgesic drug (painkiller) contain-
conversion disorder ing paracetamol and the weak opioid
contrast medium A psychological disorder, formerly analgesic drug dextropropoxyphene.
A substance that is opaque to X-rays and called hysteria, in which repressed Co-proxamol is used to relieve mild to
is introduced into hollow or fluid-filled emotions appear to be unconsciously moderate pain that has not responded
parts of the body to render them visible converted into physical symptoms such to paracetamol or other nonopioid
on X-ray film. Barium is one of the as blindness, loss of speech, or par- analgesics alone. Side effects include
most commonly used contrast media alysis. Conversion disorder is generally dizziness, drowsiness, constipation, and
(see barium X-ray examinations). treated by psychotherapy. nausea. The drug may be habit-forming
if taken over a long period.
controlled drug convulsion
One of a number of drugs that are subject See seizure. cordotomy
to restricted use because of their potential A surgical procedure in which certain
for abuse. Controlled drugs include opi- convulsion, febrile bundles of nerve fibres within the
ates such as cocaine and morphine, Twitching or jerking of the limbs with spinal cord are severed. Cordotomy is
amphetamine drugs, and barbiturate drugs. loss of consciousness that occurs in a carried out to relieve persistent, severe
child after a rapid rise in body temper- pain that has not responded to other
controlled trial ature. Febrile convulsions are common treatment. It is most frequently per-
A scientific method of testing the effec- and usually affect children between the formed to treat pain occurring in the
tiveness of new treatments or of ages of six months and five years. lower trunk and legs, especially in peo-
comparing different treatments. CAUSES ple who have cancer.
In a typical controlled drug trial, two The convulsions are due to immaturity
comparable groups of patients with the of the temperature-lowering mechan- cord, spermatic
same illness are given courses of appar- ism in the brain; the mechanism allows See spermatic cord.
ently identical treatment. Only one the child’s body temperature to rise too
group, however, actually receives the rapidly in response to infections such cord, testicular
new treatment; the second group as measles or influenza. See spermatic cord.
(known as the control group) is given a TREATMENT AND PREVENTION
placebo (a harmless substance contain- Treatment involves lowering the tem- cord, umbilical
ing no active ingredients). Alternatively, perature by sponging the child’s face See umbilical cord.
the control group may be given an and body with tepid water and using a
established drug that is already known fan. Seizures can often be prevented in cord, vocal
to be effective. After a predetermined susceptible children by giving paraceta- See vocal cords.
period, the two groups are assessed mol at the first signs of fever.
medically. If the patients on the new OUTLOOK corn
treatment show a greater improvement Most children who have one or more A small area of thickened skin on a toe
than those on the placebo (or those on febrile convulsions suffer no long-term or other part of the foot. A corn is
an existing treatment), this result proves effects. However, there is a very small caused by the pressure of a tight-fitting
that the drug has a beneficial effect. risk of developing epilepsy, which is in- shoe. The dead skin cells form a hard
Controlled trials must be conducted creased in children with a pre-existing plug that extends down into the skin
“blind’’ (meaning that the patients do abnormality of the brain or nervous tissues. Pressure on this plug can cause
not know which treatment they are system, or children with a family his- pain. If a corn is painful, a spongy ring
receiving). In a “double-blind’’ trial, tory of epilepsy. or corn pad can be placed over it to
neither the patients nor the doctors relieve the pressure. If the corn persists,
who assess them know who is receiv- Cooley’s anaemia the area of thickened skin can be
ing which treatment. See thalassaemia. removed by a chiropodist.

195
 CORNEA

fluid from the cornea, thus keeping the corneal graft

tissues transparent. The surgical transplantation of donor
Epidermis
(outer layer For the cornea to stay healthy, it must corneal tissue to replace a damaged
of skin) be kept moist and clean. It is kept moist cornea. In most grafts, tissue is taken
by a film of tears, which are produced from a human donor after death. The
Plug of
by the lacrimal gland and by the mucus- success rate of corneal grafts is gener-
C dead skin
cells and fluid-secreting cells in the eyelids ally high, because the cornea has no
and conjunctiva. Further protection is blood vessels; this reduces access for
Dermis
provided by the eyelids, which blink or white blood cells, which could other-
(inner layer close to keep out debris. In addition, wise cause rejection of the donor tissue.
of skin) the cornea is very sensitive, and imme-
Nerve diately registers the presence of any corneal transplant
injury or foreign body. See corneal graft.

Subcutaneous corneal abrasion corneal ulcer

fat
A scratch or defect in the epithelium A break, erosion, or open sore in the
Cross-section of a corn
A plug of dead skin cells extends through the (outer layer) of the cornea caused by a cornea. It usually affects the outer layer
epidermis into the dermis, which has a nerve small, sharp particle in the eye (see eye, of the cornea, but in some cases may
supply. Pressure on the plug can cause pain. foreign body in) or by an injury. Corneal penetrate down to the middle layer.
abrasions usually heal quickly but may Corneal ulcers are commonly caused
cornea cause severe pain and photophobia. by a corneal abrasion. They may also be
The transparent, thin-walled surface Treatment of a corneal abrasion due to chemical damage, or infection
that forms the front of the eyeball. The includes covering the eye with a patch with bacteria, fungi, or viruses (partic-
cornea has two main functions. It helps and analgesics to relieve pain. If the cil- ularly herpes virus). Eye conditions such
to focus light rays on to the retina at the iary muscles go into spasm, eyedrops as keratoconjunctivitis sicca and eyelid
back of the eye, and protects the front containing cycloplegic drugs may be deformities such as entropion or ectropi-
of the eye from debris and injury. used to paralyse the ciliary muscle. on increase the risk of an ulcer.
The cornea is joined at its circumfer- Antibiotic eyedrops are usually given to Ulcers are revealed by introducing
ence to the sclera (white of the eye); prevent bacterial infection (which can fluorescein dye into the eye. Infections
the black pupil and the coloured iris are lead to a corneal ulcer). and predisposing eye conditions are
visible beneath it. There are five layers.
The outermost layer (the epithelium)
protects the eye and absorbs oxygen DISORDERS OF THE CORNEA
and nutrients from tears. The central
Various injuries or conditions can affect Congenital defects
layer (the stroma) is by far the thickest
the sensitive cornea. Rare congenital defects include
and gives the cornea its form. The inner
microcornea (a cornea that is smaller
layer (the endothelium) expels excess
Injury than normal) or megalocornea
A corneal abrasion (scratch) can become (one that is bigger than normal) and
LOCATION OF CORNEA infected and progress to a corneal ulcer. buphthalmos, or “ox-eye’’, in which
Penetrating corneal injuries can cause the entire eyeball is distended as a
The cornea is a transparent, thin- scarring, which may lead to im- result of glaucoma (raised fluid
walled dome forming the front of the pairment of vision. Chemical injuries pressure in the eyeball).
eyeball, over the iris. It consists of can result from contact with a corrosive
five layers of differing thickness. substance such as an acid or alkali. Degeneration
Retina Iris In actinic keratopathy, the outer layer Degenerative conditions of the cornea
of the cornea is damaged by ultraviolet include calcium deposition, thinning,
light. In exposure keratopathy, damage and spontaneous ulceration. Such
occurs as a result of reduced protection conditions occur mainly in elderly
from the tear film and blink reflex. people, and are more common in
previously damaged eyes.
Infection
The cornea can be infected by viruses, Other disorders
bacteria, or fungi. Some infections can Other disorders include: keratomalacia,
cause ulceration, the herpes simplex which may result from vitamin A
virus being especially dangerous. deficiency; keratoconjunctivitis sicca
(dry eye); corneal dystrophies, such
Inflammation as keratoconus, in which the cornea
True inflammation of the cornea (called becomes thinner and cone-shaped;
Lens
keratitis) is uncommon because the and oedema, in which fluid builds up
Cornea
cornea contains no blood vessels. inside the cornea and impairs vision.

196
 CORSET

treated according to their cause. A coronary artery disease ing sufficient oxygen from reaching a
superficial, noninfectious ulcer usually Narrowing of the coronary arteries, section of the heart muscle. In most
heals quickly; if it fails to do so, it may which supply blood to the heart, lead- cases, the thrombus forms in a blood
be treated with a “bandage’’ contact ing to damage or malfunction of the vessel that has already been narrowed
lens or with tarsorrhaphy (temporary heart. The most common heart disor- by atherosclerosis. Sudden blockage of a
sealing of the eyelids). ders due to coronary artery disease are coronary artery will cause a myocardial
angina pectoris (chest pain due to insuf- infarction (heart attack). C
coronary ficient oxygen reaching the heart) and
Any structure that encircles another like myocardial infarction (heart attack). coroner
a crown. The term is usually used to CAUSES A public officer appointed to inquire into
refer to the coronary arteries, which sur- The usual cause is atherosclerosis, in a cause of death when it is unknown or
round the heart and supply it with which fatty plaques develop on artery when unnatural causes are suspected.
blood It is also sometimes used as a linings. An affected vessel can become
nonmedical term for a heart attack (see totally blocked if a blood clot forms or cor pulmonale
myocardial infarction). lodges in the narrowed area. Enlargement of, and strain upon, the
Atherosclerosis has many interrelated right side of the heart, that is caused
coronary artery causes, including smoking, a high-fat by one of several chronic lung diseases.
Either of the two main arteries that sup- diet, lack of exercise, being overweight, Damage to the lungs leads to pulmonary
ply the heart tissues with oxygen-rich and raised blood cholesterol levels. hypertension (abnormally high blood
blood. These vessels, known as the left Other risk factors include a genetic pressure in the arteries that supply the
and right main coronary arteries, arise predisposition and diseases such as dia- lungs). The resulting “back pressure” of
directly from the aorta (the main artery betes mellitus and hypertension. blood puts strain on the heart, and may
in the body). The term “coronary SYMPTOMS eventually cause right-sided heart failure
artery” is also applied to any of the In its early stages, coronary artery dis- with oedema.
arteries that branch off from the main ease often produces no symptoms. The
coronary arteries, such as the left cir- first sign is frequently the chest pain of corpus callosum
cumflex artery and the left anterior angina, or an actual heart attack. The band of nerve fibres that forms a
descending artery. Blockage of a coron- The disease may also cause arrhyth- connection between the two hemi-
ary artery as a result of atherosclerosis mias (abnormalities in the heartbeat); spheres of the brain.
(an accumulation of fatty deposits in in severe cases, arrhythmia can cause
the artery) can lead to myocardial infarc- cardiac arrest (in which the heart stops corpus cavernosum
tion. (See also coronary artery disease.) beating). In elderly people, it may lead One of two cylindrical bodies of erec-
to heart failure, in which the heart grad- tile tissue that is found in both the
coronary artery bypass ually becomes less and less efficient. clitoris and the penis. The spongy struc-
A major heart operation that is carried TREATMENT ture of the corpus cavernosum allows
out in order to bypass coronary arteries Drugs are given to help the heart to the tissue to become rigid when it
that have become narrowed or blocked function more efficiently and to relieve becomes filled with blood.
(usually as a result of atherosclerosis). symptoms. These include glyceryl tri-
The procedure involves using addition- nitrate and other nitrate drugs; calcium corpuscle
al blood vessels (such as a mammary channel blockers; beta-blockers; potassium Any minute body or cell, particularly
artery or a vein from the leg) to channel activators; and vasodilator drugs. red and white blood cells or certain
improve blood flow to the heart mus- If drug treatment fails to relieve the types of nerve ending.
cle. A coronary artery bypass is symptoms of coronary artery disease,
performed if symptoms of coronary or if there is extensive narrowing of corpus luteum
artery disease have not been relieved by the coronary arteries, blood flow may A small tissue mass in the ovary that
drugs, or if balloon angioplasty (a sur- be improved by balloon angioplasty or develops from a ruptured egg follicle
gical procedure used to widen blocked coronary artery bypass surgery. after ovulation (the release of an egg).
arteries) is inappropriate or has failed. The corpus luteum secretes the female
Before surgery, sites of blockage are coronary care unit sex hormone progesterone, which caus-
identified using an imaging procedure A specialist ward for the care of acutely es the lining of the uterus to thicken in
called angiography. Usually, a heart–lung ill patients who may have suffered a preparation for implantation of a fertil-
machine is needed to maintain the cir- myocardial infarction (heart attack) or ized egg. If fertilization does not occur,
culation during the operation, although another serious cardiovascular disorder. the corpus luteum shrinks and dies.
sometimes minimally invasive surgery may
be used to bypass the artery, thereby coronary heart disease corrosive oesophagitis
avoiding the need to stop the heart. An alternative name for coronary artery A type of oesophagitis that is caused by
The long-term outlook is good disease. swallowing caustic chemicals.
following a coronary artery bypass.
However, the grafted vessels may also coronary thrombosis corset
eventually become blocked by athero- A condition in which a thrombus A device that is worn around the trunk
sclerosis. (See also Coronary artery bypass (blood clot) narrows or blocks one to relieve back pain and treat spinal
box, overleaf.) of the coronary arteries, thereby prevent- injuries or deformities.

197
 CORTEX

CORONARY ARTERY BYPASS

This procedure is now the most common and successful

major heart operation in the Western world. Each year some WHY IT IS DONE
10,000 people in the UK undergo the operation, which can
relieve them from dependence on drug treatment for heart Narrowed coronary arteries are unable to supply the heart
C disease and restore them to active life. muscle with a sufficient amount of blood, and, as a result,
the heart muscle becomes starved of oxygen. This may cause
Site of incision HOW IT IS DONE angina (chest pain) or damage to the heart tissue. By joining
Coronary artery bypass lengths of a vein (taken from the leg during the operation) to
is a major procedure, the aorta and to a point below the blockages, the narrowed
requiring two surgeons or blocked sections of coronary artery can be bypassed.
and lasting up to five Before the operation After the operation
hours.
Diseased coronary artery Bypass
The first surgeon makes an
1 incision down the centre of
the patient’s chest. The heart
is then exposed by opening
the pericardium.

Affected area

Simultaneously, several
2 incisions are made in the leg,
and a length of vein removed.
First surgeon prepares
heart for bypass
Coronary arteries

Second surgeon
removes vein
Anaesthetist from leg

Before any incisions are made

3patient
in the coronary arteries, the
is connected to a heart-lung
machine. This takes over the
function of the heart and lungs
while the surgeon repairs the heart.

Heart-lung machine

Oxygenated
blood from
heart-lung
machine
Aorta
Superior
vena cava
The section of the vein taken
4the aorta
from the leg is then sewn to
and to a point below the
(tied off)
Bypass

blockage. If several arteries are Deoxygenated Wire

blocked, they can be bypassed by blood to suture
using other sections from the same heart-lung
machine
leg vein, or an arterial graft may be
taken from the chest. Coronary
Inferior arteries
vena cava

5bloodThe heart-lung machine is

disconnected, allowing the
to flow back into the
(tied off)

6andFinally, the breastbone is wired

together, and the pericardium
coronary arteries. Pericardium chest are sewn up.

198
 COSMETIC DENTISTRY

cortex treatment card and inform a doctor of Corynebacterium

The outer layer of certain organs, such the fact before undergoing any other A genus of gram-positive (see Gram’s
as the brain or kidneys. form of medical treatment. stain), rod-shaped bacteria. Corynebac-
teria cause disease, including diphtheria
corticosteroid drugs corticosteroid hormone in humans and various types of infec-
COMMON DRUGS Any of a variety of hormones that is tion in domestic animals and birds.
•Beclometasone •Cortisone produced by the cortex of the adrenal C
•Dexamethasone •Fludrocortisone glands. There are two main groups of coryza
•Hydrocortisone •Prednisolone corticosteroid hormone: glucocorticoids A term for the nasal symptoms of the
•Prednisone•Triamcinolone (such as hydrocortisone, cortisone, and common cold (see cold, common).
corticosterone) and mineralocorticoids
A group of drugs that are chemically (such as aldosterone). (See also corticos- COSHH Regulations
similar to corticosteroid hormones, which teroid drugs; steroid hormones.) The abbreviation for the Control of
are produced by the adrenal glands. Substances Hazardous to Health Regu-
WHY THEY ARE USED corticotropin lations, which is one of the major
Corticosteroid drugs are used as hor- An alternative name for ACTH (adreno- legal provisions in the UK regarding
mone replacement therapy in Addison’s corticotrophic hormone). the use of dangerous chemicals in
disease and when the adrenal glands or the workplace.
pituitary gland have been destroyed by Corti, organ of
disease or have been removed. They are See organ of Corti. cosmesis
also used to treat inflammatory intes- A term used for any procedures that are
tinal disorders, such as ulcerative colitis cortisol carried out to improve a person’s
and Crohn’s disease, and as an urgent An alternative name for hydrocortisone, appearance or to correct a disfiguring
treatment for the inflammation in the a corticosteroid hormone that is pro- physical defect, such as cosmetic surgery,
artery supplying the retina that occurs duced by the adrenal glands. cosmetic dentistry, or the use of make-up
in temporal arteritis. Other uses of corti- to cover physical flaws.
costeroid drugs include the treatment cortisone
of autoimmune diseases such as systemic A corticosteroid hormone that is produced cosmetic dentistry
lupus erythematosus and rheumatoid synthetically. Cortisone is used as Procedures to improve the appearance
arthritis, and the treatment of asthma, a replacement hormone in the treat- of the teeth or prevent further damage
eczema, and allergic rhinitis. ment of Addison’s disease. Side effects of to the teeth and/or gums. Cosmetic
Corticosteroid drugs are also used to the hormone include peptic ulcer and dentistry procedures include: fitting an
prevent organ rejection following trans- bleeding in the stomach. orthodontic appliance to correct teeth
plant surgery and in the treatment of
some types of cancer, such as lymphoma
or leukaemia. In addition, injections HOW CORTICOSTEROIDS WORK
of corticosteroids may be administered
to relieve pain in disorders such as ten- When given as hormone replacement
therapy (such as in Addison’s disease),
nis elbow and arthritis. Inflamed
corticosteroids supplement or replace skin
POSSIBLE ADVERSE EFFECTS natural hormones. Large doses have an
Side effects are uncommon when cor- anti-inflammatory effect (right) because
ticosteroid drugs are used in the form they reduce the body’s production of Dilated
blood
of cream or taken by inhaler. However, prostaglandin (natural chemicals that vessels
tablets taken in high doses for long cause inflammation in damaged tissues
periods may cause diabetes mellitus, such as an arthritic joint). They also
Increase in
hypertension, osteoporosis, oedema, pep- suppress the immune system by reducing white blood
tic ulcer, Cushing’s syndrome, inhibited release and activity of white cells. cells
growth in children, and, in rare cases,
cataract or psychosis. High doses of the Corticosteroids
drugs also impair the immune system,
increasing the risk of serious infections
such as septicaemia and tuberculosis; and Reduced
inflammation
chickenpox can be life-threatening in
Inflamed
people taking corticosteroids. joint
Long-term treatment suppresses pro- Blood vessels
duction of corticosteroid hormones by return to
normal
the adrenal glands, and sudden with-
drawal may lead to adrenal failure,
which can be life-threatening. For this Fewer white
reason, anyone who is taking cortico- blood cells
steroids, or who has recently taken
them, should always carry a steroid

199
 COSMETIC SURGERY

that are out of alignment or an incor- cough CAUSES

rect bite (see malocclusion); fitting a A reflex action that helps to clear the Many disorders can cause haemoptysis.
crown; bonding to treat chipped or airways of sputum, a foreign body, or The most common are infections, such
stained teeth; and bleaching of dis- any other irritant or blockage. A cough as pneumonia or bronchitis; and conges-
coloured teeth. is described as “productive” when it tion and rupture of blood vessels in the
brings up mucus or sputum and “un- lungs due to heart failure, mitral stenosis,
C cosmetic surgery productive” or “dry” when it does not. or pulmonary embolism. A cancerous
Any operation performed to improve CAUSES tumour can also produce haemoptysis
appearance rather than to cure or treat Many coughs are due to irritation of by eroding the wall of a blood vessel.
disease. Cosmetic surgery techniques the airways by dust, smoke (see cough, DIAGNOSIS AND TREATMENT
include the removal of skin blemishes smoker’s), or a viral infection of the Investigations into coughing up blood
or dermabrasion; rhinoplasty to alter the upper respiratory tract (see cold, com- include chest X-ray, and, in some cases,
shape or size of the nose; face-lifts; mon; laryngitis; pharyngitis; tracheitis). bronchoscopy. In about a third of cases,
mammoplasty to reduce or enlarge the Coughing is also a feature of bronchitis, no underlying cause is found. Treat-
breasts; body contour surgery to remove asthma, pneumonia, and lung cancer. ment depends on the cause.
excess body fat and tissue; hair trans- TREATMENT
plants; blepharoplasty to remove excess Over-the-counter cough remedies are cough remedies
skin on the eyelids; and mentoplasty to available, but, in general, they just ease Over-the-counter medications used for
alter the size or shape of the chin. symptoms. More specific treatment is treating a cough. There are various
As with any surgical procedure, all directed at the underlying disorder. preparations, but the effectiveness of
forms of cosmetic surgery carry the most is unproven. Expectorant cough
risk of side effects from the anaesthetic, coughing up blood remedies are purported to encourage
and of complications arising from the A symptom, also called haemoptysis, expulsion of sputum by making it less
operation itself. caused by the rupture of a blood vessel viscous (sticky). Cough suppressants,
in the airway, lung, nose, or throat. which control the coughing reflex,
costal The coughed-up blood may appear include some antihistamine drugs and
A term meaning “relating to the ribs”. as bright-red or rusty-brown streaks, codeine.They may be helpful in control-
clots in the sputum, a pinkish froth, or, ling coughing at night that prevents
costalgia more rarely, blood alone. In all cases, sleep; however, they cause drowsiness
Pain that occurs around the chest as a medical assessment is needed. and often cause constipation as well.
result of damage to a rib or to one of
the intercostal nerves beneath the ribs.
Damage to an intercostal nerve most TYPES OF COSMETIC SURGERY
commonly results from an attack of the There is a range of cosmetic surgery procedures for various parts of the body. The
viral infection herpes zoster (shingles). sites of some of the more commonly performed operations are shown below. The
The pain is difficult to treat and has a procedures vary in the permanency of their results and in the likelihood of
tendency to persist. achieving a satisfactory appearance.

Costen’s syndrome Hair transplant Rhinoplasty

Transplantation of hair- Alteration of the shape
A term that is sometimes used to bearing skin from the or size of the nose
describe facial pain due to temporo- back or sides of the head
to bald areas
mandibular joint disorders.

costosternal
A combined term sometimes used to Blepharoplasty Dermabrasion
describe the junction of the ribs and Removal of excess skin Removal of the upper
on the eyelids skin layers to improve
the sternum (breastbone). the appearance of skin
blemishes
cot death
See sudden infant death syndrome.
Face-lift Mentoplasty
co-trimoxazole Removal of excess facial
skin and tightening of
Alteration of the shape
or size of the chin
An antibacterial drug that is a combina- the remainder to reduce
wrinkles and jowls
tion of trimethoprim and sulfamethox-
azole. Because of rare but potentially
serious side effects, co-trimoxazole is
now used to treat certain infections
only in circumstances in which they Mammoplasty Body contour surgery
Breast reduction by Removal of excess
cannot be treated with other drugs. Its removal of excess tissue tissue and fat to alter
main use is for the prevention and treat- or breast enlargement by body shape
insertion of implants
ment of pneumocystis pneumonia in
people with AIDS.

200
 CRANDALL’S SYNDROME

cough, smoker’s femur is reduced, resulting in shorten- Cradle cap is harmless as long as the
A recurrent cough that is due to smok- ing of the leg, pain and stiffness in the skin does not become infected. It can
ing. The cough is usually triggered by hip, and a limp. The most common be treated by daily use of a simple
the accumulation of thick sputum in cause is a fracture to the neck of the shampoo. Alternatively, warm olive oil
the airways as a result of inflammation femur or, during adolescence, injury to may be rubbed into the baby’s scalp
caused by tobacco smoke. Giving up the developing part of the head of the and left on overnight to loosen and
smoking will usually stop the cough, femur. Coxa vara can also occur if the soften the scales, which can be washed C
but it may take time. In general, the bone tissue in the neck of the femur is off the following day. A mild ointment
longer a person has been smoking, the soft, a condition that may be congenital that contains an antifungal drug and a
longer it takes for the cough to clear. or the result of a bone disorder such as corticosteroid drug may be prescribed if
Smokers who have a persistent cough rickets or Paget’s disease. Treatment may the skin becomes inflamed.
should seek medical advice, particularly include surgery (see osteotomy).
if the cough changes, because smoking
is associated with lung cancer. COX-2 inhibitor drugs
A group of nonsteroidal anti-inflammatory
counselling drugs (NSAIDs) that are less likely to
Advice and psychological support from cause stomach irritation than the other
health professionals to help people to NSAIDs. One example of a COX-2 inhi-
deal with personal difficulties. Coun- bitor drug is celecoxib.
selling is used to address problems at
school, work, or in the family; provide coxsackievirus
advice on medical problems and sexual One of a group of viruses responsible
and marital problems; help people to for a broad range of diseases. There are
Appearance of cradle cap
deal with addictions; and give support two main types of coxsackievirus: A Thick, yellow, scaly patches occur on the scalp of
during life crises. Types of counselling and B. The best known of the type A babies, most commonly between the age of 3 and
include genetic counselling, trauma couns- infections is hand, foot, and mouth dis- 9 months. It is not clear why cradle cap occurs.
elling, and sex therapy. ease, which is a common childhood
In most cases counselling is a one- disorder characterized by blistering of cramp
to-one activity, but it may also be skin around the mouth, hands, and A painful spasm in a muscle that is
carried out in small groups. (See also feet. Type B viruses can cause serious caused by excessive and prolonged
child guidance; family therapy; marriage illnesses such as meningitis, pericarditis, contraction of the muscle fibres. The
guidance; psychotherapy.) and pneumonia. affected muscle may feel hard and ten-
der. Cramps often occur as a result of
Cowden’s disease CPAP increased muscular activity, which
An autosomal dominant genetic dis- The abbreviation for continuous positive causes a build-up of lactic acid and
order, also called multiple hamartoma airway pressure. other chemicals in the muscles, and
syndrome, in which non-cancerous leads to small areas of muscle-fibre
growths develop in tissues, including CPPV damage. Repetitive movements, such as
the skin, mouth, and intestines. Skin The abbreviation for continuous positive writing (see cramp, writer’s) or sitting
growths may include flat- topped, pressure ventilation. or lying in an awkward position may
flesh-coloured lesions on the face. Mul- also result in cramps. In addition,
tiple polyps may grow in the intestines. crab lice cramps may follow profuse sweating
People with Cowden’s disease are also See pubic lice. because loss of sodium salts disrupts
at increased risk of developing certain muscle cell activity.
cancers, particularly thyroid cancer, col- crack Massaging or stretching the muscles
orectal cancer, and, in women, breast A popular term for a highly potent, involved may bring relief. A drug con-
and ovarian cancer. There is no specific fast-acting form of cocaine. taining calcium or quinine may be given
treatment for the condition, but affected for recurrent night cramps. Recurrent,
individuals are carefully monitored in cracked heel sudden pain in a muscle not associated
order that early signs of these cancers See heel, cracked. with hardness of the muscle may be
can be detected. caused by peripheral vascular disease.
cradle cap
cowpox A skin condition, common in babies cramp, writer’s
An infection caused by the vaccinia and most prevalent between the age of Painful spasm in the hand muscles fol-
virus, which usually affects cows. This 3 and 9 months, in which thick, yellow lowing repetitive movements, which
virus was used in the past to confer scales occur in patches over the scalp. makes writing or typing impossible.
immunity against smallpox. Cradle cap, which is a form of sebor-
rhoeic dermatitis, may also occur on the Crandall’s syndrome
coxa vara face, neck, behind the ears, and in A rare congenital disorder that runs in
A deformity of the hip in which the the nappy area. The reason why cradle families and is characterized by twist-
angle between the neck and head of the cap occurs is not clear, but the condi- ed, brittle hairs, sensorineural deafness,
femur (thigh-bone) and the shaft of the tion is not due to poor hygiene. and hypogonadism (underdevelopment

201
 CRANIAL NERVES

of the ovaries or testes). The condition nerve (producing head and shoulder aches, vomiting, and defective vision. If
is associated with deficiencies of lutein- movements), and hypoglossal nerve (pro- the tumour develops in childhood, the
izing hormone and growth hormone. ducing tongue movements). child’s growth may be stunted and sex-
Some cranial nerves have both senso- ual development may not occur.
cranial nerves ry and motor functions. They are the Craniopharyngiomas are usually sur-
Twelve pairs of nerves that emerge from facial nerve (facial expressions, taste, gically removed. If left untreated, they
C the underside of the brain. Each of the and the secretion of saliva and tears), may cause permanent brain damage.
cranial nerves has a number as well as the trigeminal nerve (facial sensation and
a name; the numbers are used to indi- jaw movements), and the glossopharyn- craniosynostosis
cate the sequence in which the nerves geal nerve (taste and swallowing). The The premature closure of one or more
emerge from the brain. vagus nerve has branches to all the main of the joints (sutures) between the skull
Certain cranial nerves primarily send digestive organs, as well as to the heart bones in infants. If all of the joints are
sensory information from the ears, and the lungs. It is a major component involved, the growing brain may be
nose, and eyes to the brain. These of the parasympathetic nervous system, compressed and there is a risk of brain
nerves are the vestibulocochlear nerve which is concerned with maintaining damage due to the increased pressure
(hearing and balance), olfactory nerve automatic body functions such as inside the skull. If the abnormality is
(smell), and optic nerve (vision). Other breathing, the heartbeat, and digestion. localized, the head may be deformed.
cranial nerves carry impulses that move Craniosynostosis may occur before
the muscles in the head and neck. They craniopharyngioma birth and may be associated with other
are the oculomotor nerve, the trochlear A rare, non-hormone-secreting tumour birth defects. It may also occur in an
nerve, and the abducent nerve (producing of the pituitary gland. Symptoms of a otherwise healthy baby, or in a baby
eye movements), the spinal accessory craniopharyngioma may include head- with a disorder such as rickets.

CRANIAL NERVES

All but two of the cranial nerve pairs connect with nuclei in ears, nose, and eyes to the brain. Others carry impulses that
the brainstem. The olfactory and optic nerves, in contrast, move the tongue, eyes, and facial (and other) muscles, or
link directly with parts of the cerebrum. The nerves emerge stimulate glands such as the salivary glands. A few nerves
through openings in the cranium (skull); many then divide have both sensory and motor functions. The 10th, or vagus
into branches. nerve, is one of the most important parts of the
Certain cranial nerves are principally concerned with parasympathetic nervous system, and has branches to the
transmitting sensory information from organs such as the main digestive organs, the heart, and the lungs.

1 8
Olfactory nerve Vestibulo-
Smell cochlear nerve
Hearing and
balance

2 9
Optic nerve Glossopharyn-
Vision geal nerve
Taste and throat
sensations

3, 4, 6 10
Oculomotor, Vagus nerve
trochlear, and Breathing,
abducent circulation,
nerves and digestion
Eye movements

5 11
Trigeminal Spinal
nerve accessory nerve
Facial sensation Movements of
and jaw neck and back
movements muscles

7 12
Facial nerve Hypoglossal
Facial nerve
expressions Tongue
and taste movements

202
 CREUTZFELDT–JAKOB DISEASE

If the brain has been compressed, an

operation may be performed to sepa- PROCEDURE FOR CRANIOTOMY
rate the fused skull bones.
Before the operation, all or part of Burr holes
A series of burr
craniotomy the patient’s scalp is shaved. After a
holes is made. The
general anaesthetic has been given,
The temporary removal of a section of layers of skin, muscle, and membrane
holes must be very
the skull to enable doctors to perform are cut away from the skull at the
close together if the
bone is thick.
C
an operation on the brain. A craniotomy planned operation site and the bone
may be carried out to take a sample of is cut with a saw (see below). The “lid”
tissue for analysis, remove a tumour, or of bone is then either folded back on
drain an abscess or blood clot. a “hinge” of muscle or removed
completely. The dura (the outermost Burr
cranium of the three membranes that surround Skull
The part of the skull around the brain. the brain) is then opened to reveal the
Dura
inner membranes and the brain.
C-reactive protein
Brain
A protein produced by the body in res-
ponse to inflammation. The blood level
of this protein is measured to evaluate
treatment of inflammatory conditions.
Brain
cream
A thick, semi-solid preparation with
moisturizing properties, used to apply
medications to the skin.
creatine kinase
An enzyme (a protein that alters the rate
of a chemical reaction in the body)
Skin hinged
found in muscle. After damage to mus- back Flap of skull
cle cells, including those of the heart hinged back
muscle, creatine kinase leaks into the
blood. Increased levels of the enzyme Gigli’s saw
can be detected by diagnostic tests (see The bone between the burr holes is cut using
muscle enzymes). Different types of cre- Gigli’s saw, which is passed between the burr
Burr hole Gigli’s saw holes using a malleable saw guide.
atine kinase exist in different types of
muscle. If blood tests show a raised
level of the form found in heart mus-
cle, this may indicate that a myocardial crepitation difficulties, and coarse facial features.
infarction (heart attack) has occurred. A crackling sound in the lungs (heard Cretinism occurs when the thyroid gland
Raised levels of the form found in through a stethoscope) due to a build- produces insufficient amounts of, or
skeletal muscles may indicate a range of up of fluid. (See also auscultation.) fails to produce any, of the thyroid
disorders, from muscle injury to dis- hormone thyroxine at birth. However,
eases such as muscular dystrophy. crepitus provided that the condition is recog-
A grating sound or sensation caused by nized early, replacement therapy with
creatinine rough surfaces inside the body rubbing thyroxine can effect a cure. (See also
A waste product from chemical pro- together. Crepitus may be felt or heard hypothyroidism.)
cesses in the muscles. The kidneys filter when the ends of a broken bone rub
it from the blood for excretion in urine. against each other, or when cartilage on Creutzfeldt–Jakob disease
the surfaces of a joint has worn away A rare, progressive degenerative disease
creatinine clearance due to osteoarthritis. Faint crepitus may of the brain. Creutzfeldt–Jakob disease
A type of kidney function test in which be heard in the lung due to abnormali- (CJD) is thought to be caused by infec-
the level of creatinine in the blood and ties such as inflammation in pneumonia. tion with a prion (a type of infectious
the urine is measured. The blood level The term also describes the crackling protein). A similar agent causes scrapie
is measured, then the urine is collected sound made when an air pocket under in sheep and bovine spongiform enceph-
and tested over 24 hours to measure the skin (see emphysema, surgical), or an alopathy (BSE) in cattle.
the level of creatinine being excreted. area of gas gangrene, is pressed. TYPES
The two levels are compared; if there is One form of CJD largely affects middle-
a high level of creatinine in the blood cretinism aged or elderly people, and appears to
but a low level in the urine, it shows A congenital condition in infants that have no obvious cause. A second form
that the kidneys are not effectively is characterized by stunted growth, occurs in younger people. and this is
clearing creatinine from the body. failure of normal development, learning associated with contamination during

203
 CRI DU CHAT SYNDROME

brain surgery or transplants from crisis intervention About three in ten affected people
infected people, or with treatment The provision of immediate advice or develop a fistula (abnormal passage-
using infected human growth hormone help, by agencies such as social services way). Internal fistulas may form
or gonadotrophins. departments, to people with acute per- between loops of intestine. External fis-
A third form, new variant (nv) CJD, sonal or sociomedical problems. tulas, from the intestine to the skin of
was first identified in 1995 and affects the abdomen or around the anus, may
C people in their teens and 20s. It is critical cause leakage of faeces (see faecal fistula).
thought to be acquired by eating beef A term used to mean “seriously ill” or Abscesses (pus-filled pockets of infec-
infected with BSE. This form causes to describe a crucial state of illness tion) form in about one in five people.
pathological changes in the brain that from which a patient may not recover. Many abscesses occur around the anus,
are similar to the changes found in cat- but some occur within the abdomen.
tle suffering from BSE. Crohn’s disease Complications in other parts of the
SYMPTOMS A chronic inflammatory disease that body may include inflammation of var-
Symptoms are broadly similar for all can affect any part of the gastrointesti- ious parts of the eye, severe arthritis
forms of the disease. Slowly progressive nal tract from the mouth to the anus. affecting various joints of the body,
dementia (deterioration in brain func- Crohn’s disease can occur at any age, ankylosing spondylitis (an inflammation
tion) and myoclonus (sudden muscular but people in their mid-twenties are of the spine), skin disorders, liver dis-
contractions) occur; coordination dim- most likely to be affected. ease, and gallstones.
inishes; the intellect and personality The most common site of inflamma- DIAGNOSIS
deteriorate; and blindness may develop. tion is the terminal ileum (the end of A physical examination may reveal ten-
As the disease progresses, speech is lost the small intestine where it joins the der abdominal swellings that indicate
and the body becomes rigid. large intestine). The wall of the intes- thickening of the intestinal walls. Sig-
OUTLOOK tine becomes extremely thick due to moidoscopy (examination of the lower,
There is no treatment, and death usu- continued chronic inflammation, and or sigmoid, colon and the rectum with
ally occurs within two to three years. deep, penetrating ulcers may form. The a viewing instrument) may confirm the
disease tends to be patchy; areas of the diagnosis. X-rays using barium follow-
cri du chat syndrome intestine that lie between the diseased through or barium enemas (see barium
A rare congenital condition that causes parts may appear to be normal, but are X-ray examinations) will show thickened
severe learning difficulties, abnormal usually mildly affected. loops of intestine with deep fissures.
facial appearance, low birth weight, CAUSES It may be difficult to differentiate
and short stature. It is characterized by The cause is unknown, but genetic and between Crohn’s disease when it is
a cat-like cry in infancy. Cri du chat environmental factors seem to be affecting the colon and ulcerative colitis,
syndrome is caused by a chromosomal involved. It is possible that the disease an inflammatory bowel disease limited
abnormality. There is no treatment. (See is caused by an abnormal immune to the large intestine. However, colon-
also genetic counselling.) response to an antigen (foreign pro- oscopy (examination of the colon using
tein). Smoking increases the risk, and a flexible viewing instrument) and
Crigler–Najjar syndrome worsens the condition once developed. biopsy (the removal of a sample of tis-
A rare genetic disorder in which there is The risk of developing Crohn’s dis- sue for microscopic examination) can
an absence or lack of the liver enzyme ease is higher in people who have a confirm the diagnosis.
that breaks down bilirubin (the yellow- close relative with the disorder. TREATMENT
ish pigment in the digestive juice bile) SYMPTOMS The aim of treatment is to bring about
for excretion. The condition appears in In young people, the ileum is usually long-term remission of the disease. It
early childhood. involved. The disease causes spasms of may involve high doses of corticosteroid
Children with Crigler–Najjar syn- abdominal pain, diarrhoea and chronic drugs, which are given either orally or
drome have jaundice (yellowing of the sickness, loss of appetite, anaemia, and intravenously; the immunosuppressant
skin and whites of the eyes, due to a weight loss. The ability of the small drugs azathioprine or mercaptopurine;
buildup of bilirubin in the blood). In intestine to absorb nutrients from food metronidazole; and also enteral feeding,
some children, the liver enzyme is is reduced. In elderly people, it is more in which easily digestible food in liq-
completely absent, and the condition is common for the disease to affect the uid form is given through a tube
fatal by about two years of age. Some rectum and cause rectal bleeding. directly into the intestines. Once the
other children may just have insuffi- Crohn’s disease can also affect the disease is in remission, normal feeding
cient amounts of the enzyme, and may colon (the major part of the large intes- can be resumed and the dose of
live into adulthood. A liver transplant tine), causing bloody diarrhoea. In rare corticosteroids reduced. Aminosalicy-
may be the only effective treatment for cases, it also affects the mouth, oeso- late drugs, such as sulfasalazine or
the syndrome. phagus, stomach, and duodenum (the mesalazine, may be given.
upper part of the small intestine). Surgical treatment to remove dam-
crisis Complications may affect the intes- aged sections of the intestine is avoided
A term for a turning point in the tines or may develop elsewhere in the whenever possible because the disease
course of a disease (either the onset of body. The thickening of the intestinal may recur in other parts. Many patients
recovery or deterioration). The word is wall may narrow the inside of the do need surgery at some stage, how-
also used to describe a distressing and intestine so much that an obstruction ever, to treat problems including
difficult episode in life. occurs (see intestine, obstruction of). perforation or blockage of the intestine.

204
 CROWNING

OUTLOOK croup crown

Some people in whom the disease is A common disorder in infants and The name for the top of the head. The
localized remain in normal health young children, in which narrowing word is also used of the visible part of a
indefinitely and seem to be cured. and inflammation of the airways causes tooth. (See also crown, dental; crowning.)
hoarseness, stridor (a grunting noise
cromoglicate during breathing), and a barking cough. crown, dental
See sodium cromoglicate. Croup may be caused by a viral or An artificial replacement for the crown C
bacterial infection affecting the larynx, of a decayed, discoloured, or broken
crossbite epiglottis, or trachea. Most cases are due tooth. A crown made from porcelain is
A type of malocclusion (an abnormal to a viral infection and are generally usually used on front teeth, but back
relationship between the upper and mild. Other causes include diphtheria, teeth need the greater strength of a
lower teeth) in which some or all of allergy, spasm due to insufficient calci- crown made from gold or porcelain
the lower front teeth overlap the upper um levels in the blood, and inhalation fused to metal.
front teeth. A molar crossbite, in which of a foreign body. A crown may be fitted by filing the
the upper and lower back teeth overlap, Humidifying the air can help to tooth to form a peg and cementing
can also occur. ease breathing. In some cases, cortico- the crown over the top of it. For a badly
steroid drugs administered through a decayed or weakened tooth, it may be
cross-eye nebulizer, and oxygen, may be pre- necessary to remove the natural crown,
A type of strabismus (squint) in which scribed. If the infection is bacterial, it perform root-canal treatment, then fit
one of the eyes turns inwards relative is treated with antibiotic drugs. the artificial crown on to a post that is
to the other, or in which both eyes turn cemented in the root canal. For details
inwards towards each other. Crouzon’s syndrome on how crowns are fitted, see the illus-
An autosomal dominant genetic disorder trated box below.
cross-matching that causes facial deformities. Affected
A procedure to determine compati- people have these features: eyes that crown–heel length
bility between the blood of a person protrude (see exophthalmos) and are A routine measurement of the length of
who requires a blood transfusion and spaced widely apart; a squint; an abnor- a newborn baby, taken from the crown
that of a donor. Red blood cells from mally tall skull; a large, beaked nose; of the head to the heels.
one person are combined with serum and an underdeveloped upper jaw,
(the clear fluid that separates from which makes the lower jaw look as if it crowning
blood when it clots) from the other. is protruding. The popular name given to the phase in
Clumping of red blood cells indicates the second stage of labour (see child-
the presence of antibodies, showing that crowding, dental birth) when the baby’s head first appears
the blood is not compatible. See overcrowding, dental. at the mother’s vaginal opening.

HOW CROWNS ARE FITTED

The tooth is filed down to form a peg over which the replacement is fitted. An
impression of the peg and the natural tooth is taken and a replica is made. POST CROWNS
Using this replica as a model, the artificial crown is constructed.
If the natural tooth is badly decayed
or has been weakened, its crown is
removed and a post crown is fitted.
Root canal

Tooth root
1thatThis tooth is
so decayed
a retaining
peg cannot be
Damaged
tooth
fashioned.
Cast full Porcelain fused Porcelain Three-quarter
crown to metal crown jacket crown crown The tooth’s
2is completely
natural crown

removed.
Root canal filled
Tooth trimmed

Gold
post
in root
3rootAcemented
gold post is
into the
canal and the
The damaged area of the The artificial crown, a
A cracked or broken tooth,
1heavily
or one that has been
filled, can be replaced
2 tooth is removed and the
remaining part is shaped to
3 hollow shell, is fitted over
the shaped tooth and then
canal

Crown
crown is then cemented
over the post.
by a crown. receive the crown. cemented in place.

205
 CRUCIATE LIGAMENT

cruciate ligament cervix, the liver, and the intestines. It CSF

One of the two ligaments in the knee may be used in eye operations, for The abbreviation for cerebrospinal fluid.
that pass over each other to form a example in cataract surgery and treat-
cross. The ligaments form connections ment for retinal detachment. It is also CS spray
between the femur and tibia inside the commonly used for removing warts, A noxious powder, also known as CS
knee joint and prevent overbending skin tags, some birthmarks, and some gas or tear gas, that is used in aerosol
C and overstraightening at the knee. skin cancers, and to treat haemorrhoids. form as a means of riot control. CS
spray causes severe irritation of the
crush syndrome cryotherapy eyes, airways, and skin, and sometimes
Damage to a large amount of muscle The use of cold or freezing tempera- nausea and vomiting. Its effects are
(usually as a result of a serious acci- tures or substances in treatment. (See short-lived, usually lasting for only a
dent), which causes kidney failure. The also cryosurgery.) few minutes.
damaged muscles release proteins into
the bloodstream, temporarily impair- cryptococcosis CT scanning
ing kidney function. As a result, some A rare infectious disorder caused by A diagnostic technique in which the
substances normally excreted in the inhaling the fungus CRYPTOCOCCUS NEOFOR- combined use of a computer and a
urine build up to toxic levels in the MANS, which is found especially in soil machine emitting X-rays produces cross-
blood. If left untreated, crush syn- contaminated with pigeon faeces. The sectional images of the body tissues.
drome may be fatal, but dialysis allows most serious form that the infection A CT (computed tomography) scan-
the kidneys time to recover. can take is meningitis. Another form of ner is a machine that is shaped like a
infection causes growths in the lungs, doughnut that rotates around the
crutch palsy resulting in chest pain and a cough, or patient’s body. The machine contains
Weakness or paralysis of muscles in the on the skin, causing a rash of ulcers. one or more X-ray sources and, on the
wrist, fingers, and thumb in people who Most cases of cryptococcosis occur in opposite side, some X-ray detectors.
walk with a crutch under the armpit. people with reduced immunity, such as Unlike a conventional X-ray image,
Crutch palsy is due to pressure on the those with AIDS. which shows only a few levels of tissue
nerves supplying these muscles. It does Cryptococcal meningitis is diagnosed density, the X-ray detector can register
not occur if elbow crutches are used. from a sample of spinal fluid. A combi- hundreds of levels of density. It sends
nation of the antifungal drugs ampho- this information to a computer, which
crying in infants tericin B and flucytosine is usually pre- processes the data and shows the results
A normal response in babies to needs scribed to treat the infection. Most as an image on a monitor. CT images
or discomforts, such as hunger or cases in which only the lungs are usually show the body as “slices”, in
thirst. Most healthy babies stop crying infected need no treatment. which the different tissues can be seen
when their needs are attended to. In a in detail. In some machines, this infor-
few cases, persistent crying may be due cryptophthalmus mation can be used to produce a
to a physical cause such as intolerance A birth defect in which the opening three-dimensional reconstruction of
of cow’s milk or an illness (such as an between the upper and lower eyelids is the area scanned.
ear or throat infection, or a viral fever). absent. (See also Fraser’s syndrome.) CT scanning has revolutionized the
diagnosis and treatment of tumours, ab-
cryo- cryptorchidism scesses, and haemorrhages in the brain,
A prefix meaning “ice cold”. It is used A developmental disorder of male as well as head injuries and strokes. The
of medical procedures that involve the infants in which the testes fail to procedure is also used to locate and
use of freezing or low temperatures. descend normally into the scrotum (see show tumours, to investigate a wide
testis, undescended). range of diseases, and to aid needle
cryopreservation biopsy in organs of the trunk.
The preservation of living cells or tissue cryptosporidiosis Newer types of CT scanners use a
samples by freezing. The technique is A type of diarrhoeal infection caused spiral technique: the scanner rotates
used to store human eggs for in vitro fer- by protozoa, which may be spread from around the body as the patient is
tilization, sperm for artificial insemination, person to person or be transmitted moved slowly forwards on a bed, caus-
or plasma and blood obtained from from domestic animals to people. The ing the X-ray beams to follow a spiral
people with rare blood groups. disease causes watery diarrhoea and course. Images can be made of hollow
sometimes fever and abdominal pain. It organs such as the colon (a procedure
cryosurgery is most common in children but also known as “virtual colonoscopy”). For
The use of temperatures below freezing occurs in people with AIDS. some procedures, injected or swal-
to destroy tissue, or the use of cold In most cases, rehydration therapy is lowed contrast media (chemicals that
during surgical procedures to produce the only treatment needed. In people are opaque to X-rays) may be used to
adhesion between an instrument and an whose immune system is suppressed, make certain tissues more easily visible.
area of body tissue. however, the infection may be much The images produced during CT
Cryosurgery causes only minimal more severe. Such people may need to scanning can be stored digitally or on
scarring. It is used to treat cancerous be admitted to hospital for treatment conventional X-ray film. (For details of
tumours in sites where heavy scarring with intravenous fluids and antidiar- the procedure, see Performing a CT scan
can block vital openings, such as in the rhoeal drugs. box, opposite.)

206
 CURLING’S ULCER

PERFORMING A CT SCAN

CT scanning combines the use of a

computer and X-rays emitted by a 1andThe patient lies on a table that can be
moved up or down to allow easy transfer
accurate positioning within the machine.
rotating machine to produce cross-
sectional images. Before the scan is The table then slides the patient into the centre
carried out, a contrast medium may be
of the machine. C
injected to make blood vessels, organs, A central sliding cradle
in the table moves the
or abnormalities show up more clearly; patient, at a controllable
for scans of the intestines, a drink of rate, into the machine
contrast medium may be given to
highlight loops of intestine.

The machine can be tilted in any

direction to allow precise areas
to be X-rayed
Nasal Eye
cavity

Brain
tissue

Ear
cavity

Ear Skull

The scanner rotates around the patient. As Detectors in the scanner record the amount
2beams,
it does so, it sends a great number of X-ray
each of low dosage and lasting only a
3information
of X-rays absorbed by different tissues. This
is sent to a computer, which converts
fraction of a second, through the patient’s body it into an image (such as the section through
at different angles. the head, above) for a radiologist to interpret.

cuff cupping curettage

A body structure that consists of mus- An ancient procedure in which the The use of a surgical instrument called
cle and tendon fibres and encircles a practitioner draws blood to the skin a curette to scrape abnormal tissue, or
joint. (See also rotator cuff.) surface by applying a heated vessel to samples for analysis, from the lining of
the skin. It produces an inflammatory a body cavity or from the skin.
culture response thought to relieve bronchitis,
A growth of bacteria or other microor- asthma, and musculoskeletal pains. curettage, dental
ganisms, cells, or tissues cultivated The scraping of a cavity or other dental
artificially in the laboratory. curare surface with a curette (a narrow, spoon-
Microorganisms are collected from An extract from the bark and juices shaped instrument). Dental curettage is
the site of an infection and cultured in of various trees that has been used for one method used to remove the lining
order to produce adequate amounts so centuries by South American Indians as of periodontal pockets and diseased tis-
that tests to identify them can be per- an arrow poison. Curare kills by pro- sue from root surfaces in periodontitis.
formed. Cells from a fetus may be ducing muscle paralysis. Synthetic This enables the healthy underlying tis-
cultured to diagnose disorders prena- compounds that are related to curare sue to reattach itself to the root surface.
tally. Healthy cells may be cultured for are sometimes used to produce paraly-
the study of chromosomes (see chro- sis during surgery. curette
mosome analysis). Some types of tissue, A spoon-shaped surgical instrument
such as skin, may be cultured to pro- cure used for scraping away material or tis-
duce larger amounts that can then be The process of restoration to normal sue from an organ, cavity, or surface.
used for grafting. Other tissues are cul- health after an illness. The word “cure”
tivated to provide a medium in which usually means the disappearance of a Curling’s ulcer
viruses can be grown and identified in disease rather than simply a halt in its A type of stress ulcer that occurs speci-
the laboratory; viruses will only multi- progress. A treatment that ends an ill- fically in people who have suffered
ply within living cells. ness may also be called a cure. extensive skin burns.

207
 CUSHING’S SYNDROME

Cushing’s syndrome cutdown cyclophosphamide

A hormonal disorder caused by an Creation of a small skin incision in An anticancer drug used in the treatment
abnormally high level of corticosteroid order to gain access to a vein, to take of Hodgkin’s disease and leukaemia. It is
hormones in the blood. Cushing’s syn- blood or to give intravenous fluid. This also used as an immunosuppressant and
drome is characterized by a reddened, procedure is sometimes needed when a to treat connective tissue diseases.
moon-shaped face, wasting of the vein cannot be identified through the
C limbs, thickening of the trunk, and a skin, in conditions such as shock. cycloplegia
humped upper back. Other symptoms Paralysis of the ciliary muscle of the eye,
include acne; stretch marks on the skin; cuticle which makes accommodation difficult. In
bruising; osteoporosis (loss of bone The outermost layer of skin. The term some circumstances, cycloplegia may be
density); susceptibility to infection and commonly refers to the thin flap of induced by cycloplegic drugs to facili-
peptic ulcers; and, in women, increased skin at the base of a nail, and also to the tate eye examinations.
hairiness. Mental changes frequently outer layer of a hair shaft.
also occur, causing depression, insomnia, cyclosporin
paranoia, or, euphoria. Oedema, hyperten- CVA An alternative spelling for ciclosporin.
sion, and diabetes mellitus may develop. The abbreviation for cerebrovascular
In children, growth may be suppressed. accident. cyclothymia
The excess of hormones is most A personality characteristic typified by
commonly due to prolonged treatment CVP marked changes of mood from cheer-
with corticosteroid drugs. Such cases of The abbreviation for central venous pres- ful, energetic, and sociable to gloomy,
Cushing’s syndrome are usually mild. sure (the pressure within the right listless, and withdrawn. Mood swings
In other cases, high hormone levels are atrium of the heart). may last for days or months and may
due to overactivity of the adrenal glands follow a regular pattern.
because of an adrenal tumour, or due to CVS
a pituitary tumour affecting production The abbreviation for chorionic villus sam- Cymalon
of ACTH (adrenocortocotrophic hor- pling, and
for cardiovascular system. A brand name for an over-the-counter
mone), which in turn stimulates the preparation containing sodium bicarb-
adrenal glands. cyanide onate, sodium carbonate, citric acid,
Cushing’s syndrome due to cortico- Any of a group of salts of hydrocyanic and sodium citrate. This preparation is
steroid drugs usually disappears when acid. Most of these substances are ex- commonly used to relieve the symp-
the dose of the drug is gradually tremely poisonous, and their inhalation toms of cystitis.
reduced. In cases of Cushing’s syn- or ingestion can rapidly lead to breath-
drome that are caused by an adrenal lessness and paralysis, followed by cyproterone acetate
gland tumour, the tumour will be unconsciousness and death. Certain A drug that blocks the action of andro-
removed surgically. If the cause of the cyanides are eye irritants and are used gen hormones. It is used to treat prostate
disease is a pituitary tumour, it may be in tear gases. cancer (see prostate, cancer of) and oc-
removed surgically or shrunk by irradi- casionally to reduce male sex drive.
ation and drug treatment. In both of cyanocobalamin Side effects include weight gain and an
these cases, surgery is followed by hor- An alternative name for vitamin B12. increased risk of blood clots.
mone replacement therapy.
cyanosis cyst
cushion A bluish coloration of the skin or An abnormal but usually harmless lump
Any soft body structure resembling a mucous membranes caused by an or swelling filled with fluid or semi-
pad or cushion, such as a bursa. abnormally high level of deoxygenated solid material. Cysts occur in body
haemoglobin in the blood. Cyanosis organs or tissues. There are various
cusp confined to the hands and feet is not types, including sebaceous cysts, dermoid
A tapering point, such as on a tooth. serious; it is usually due to slow blood cysts, ovarian cysts, breast cysts, Baker’s
The term also refers to the flaps of the flow, often as a result of exposure to cysts, and cysts that form around para-
heart valves. cold. A blue tinge to the lips and sites in diseases such as hydatid disease
tongue, however, could be caused by a or amoebiasis. Cysts may need to be
cusp, dental serious heart or lung disorder such as removed surgically if they disrupt the
One of the protrusions found on the chronic obstructive pulmonary disease function of body tissues.
grinding surface of a tooth. or heart failure.
cyst-/cysto-
cutaneous cyclopenthiazide Relating to the bladder, as in cystitis
Relating to the skin. A thiazide diuretic drug used to reduce (inflammation of the bladder).
oedema associated with heart failure,
cutaneous anthrax kidney disorders, cirrhosis of the liver, cystectomy
See anthrax. and to treat hypertension. Side effects of The surgical removal of part or all of
this drug include lethargy, loss of the bladder. The procedure is used for
cutaneous horn appetite, leg cramps, dizziness, rash, treating bladder cancer (see bladder
See horn, cutaneous. and impotence. tumours). Radical cystectomy (in which

208
 CYSTINOSIS

all of the bladder is removed) is fol- cystic fibrosis The defective gene causes a biochemical
lowed by the construction of an A serious and potentially fatal genetic abnormality in which the faulty move-
alternative channel for urine, usually disorder, characterized by a tendency to ment of ions across cell membranes
ending in a stoma in the lower abdomen develop chronic lung infections com- affects mucus formation. As a result, the
(see urinary diversion). In men, the bined with an inability to absorb fats mucus-forming glands in several organs
prostate gland and seminal vesicles are and other nutrients from food. The do not function properly. Most serious-
also removed, usually resulting in impo- main characteristic feature of cystic ly, the glands in the lining of the C
tence. In women, the uterus, ovaries, and fibrosis (CF) is the secretion of sticky, bronchial tubes produce thick mucus,
fallopian tubes are removed. After radical viscous mucus in the nose, throat, air- which predisposes the person to chron-
cystectomy, the patient has to wear an ways, and intestines. ic lung infections. Another serious
external pouch to collect urine. CAUSES malfunction is poor or absent secretion
CF is caused by an inherited defect in a of pancreatic enzymes, which are
cysticercosis gene. The defect is recessive, which involved in the breakdown and absorp-
An infection, which is rare in devel- means that one faulty gene must be tion of fats in the intestine. The sweat
oped countries, caused by the larvae of inherited from each parent before any glands are also affected and excrete
the pork tapeworm. The disease is char- abnormality appears. People with only excessive amounts of salt.
acterized by the presence of cysts in the one defective gene have no symptoms SYMPTOMS AND COMPLICATIONS
muscles and brain, which are formed but are “carriers” and can pass the gene The course and severity of CF vary. Typi-
by the worms during their larval stage. on to their children. cally, a child passes unformed, pale, oily,
foul-smelling faeces and may fail to
thrive. Often, growth is stunted and the
HOW CYSTECTOMY IS DONE child has recurrent respiratory infections.
Without prompt treatment, pneumonia,
Radical cystectomy is a major bronchitis, and bronchiectasis may devel-
procedure performed under general
op, causing lung damage. Most males
anaesthesia. An incision is made in
abdomen, and the ureters are cut and some females are infertile. Excessive
and tied. The bladder and other lower salt loss from sweating may lead to heat-
abdominal organs are removed. The Ureters stroke and collapse.
stoma is then formed from part of the usually DIAGNOSIS AND TREATMENT
cut here
small intestine. After the operation, Early diagnosis, confirmed by simple
the patient is given intravenous sweat and blood tests, improves the out-
Line of
infusions of fluids, salt, and glucose incision look for children with CF. Prompt
until the intestines are functioning treatment with intensive physiotherapy
normally again. and antibiotics helps to reduce the seve-
Men Women rity and frequency of lung infections.
In men, In women, In addition, lung function may be im-
the prostate the uterus,
gland and fallopian tubes,
proved by treatment with dornase alfa, a
the bladder ovaries, and genetically engineered version of a
are removed part of the human enzyme, which is administered
vagina (as well
as the bladder) by nebulizer. Pancreatin and a diet rich in
Bladder are removed proteins and calories are given to bring
about weight gain and encourage more
Prostate gland Bladder Uterus normal faeces. Supervision of the treat-
ment is best carried out from a special
Large intestine Large intestine Kidney Ureter centre that is staffed by paediatricians,
nurses, and physiotherapists who have
particular knowledge of the disease.
OUTLOOK
The highly specialized treatment now
available for people with CF maximizes
Piece of small their chances of a reasonable quality of
intestine with
blood supply life. About 9 in 10 children survive into
intact their teens; many live well into their
40s. Progressive respiratory failure is
the usual cause of death, but in some
Formation of the stoma cases a heart-lung transplant may be
A short section of small intestine, with its blood
vessels, is detached from the remainder of the
Stoma considered.
intestines. The two ureters are joined to this Urine expulsion
loop of intestine. One end of the loop is then Urine produced by the kidneys is channelled via cystinosis
sealed, and the other inserted through the the ureters and intestinal loop to the stoma, A rare genetic disorder in which the
abdominal wall to form the stoma. where it leaves the body.
amino acid cystine accumulates in cells
throughout the body.

209
 CYSTINURIA

The juvenile form of cystinosis be- rare; it usually occurs when an cystocele
comes apparent in the first year of life, obstruction, such as an enlarged pro- A swelling in the front of the vagina
at which time cystine deposits damage state gland (see prostate, enlarged), that forms where the bladder pushes
the eyes, resulting in impaired vision. compresses the urethra. Cystitis in against weakened tissues in the vaginal
The deposits also lead to potentially children is often associated with a wall. A cystocele may be associated
fatal kidney failure. structural abnormality of the ureters, with a prolapsed uterus (see uterus,
C In the adult form, which is less which allows reflux (backward flow) of prolapse of). Occasionally, a cystocele
severe, the main symptoms are eye urine towards the kidneys. may pull the urethra out of position,
problems, including extreme sensitivity The use of catheters (see catheteriza- causing stress incontinence or incom-
to light (see photophobia). The kidneys tion, urinary) also carries the risk of plete emptying of the bladder, which
are much less likely to be affected in infection. People with diabetes mellitus may lead to infection of the retained
adults than in children. are especially susceptible to urinary urine (see cystitis).
tract infections because they have high- Pelvic floor exercises may help to
cystinuria er-than-normal levels of glucose in relieve symptoms. Surgery may be per-
An inherited disorder (see metabolism, their urine which encourages the formed to lift and tighten the tissues at
inborn errors of) in which the kidneys growth of bacteria. the front of the vagina.
are unable effectively to process certain SYMPTOMS
amino acids (the chemical compounds The main symptoms are a frequent urge cystometry
that make up proteins). Cystinuria is to pass urine and a burning pain on uri- A procedure that is used to assess the
inherited in an autosomal recessive nating. The urine may be foul-smelling function of the bladder and also to
manner (see genetic disorders) and or may contain blood.There may also be investigate urinary incontinence or poor
occurs in around one in 1,000 births. fever and chills, and lower abdominal bladder emptying; it is also used to
Under normal circumstances, blood discomfort. However, in children there detect abnormalities of the nerves sup-
is filtered as it passes through the kid- are frequently no symptoms relating to plying the bladder. In this procedure, a
neys; a wide range of substances is the urinary tract, and they may have catheter is inserted into the bladder,
removed, then useful compounds, such only generalized symptoms, such as then the internal pressure is measured
as amino acids, are reabsorbed. In fever and vomiting. as the bladder is filled and then emp-
cystinuria, this process does not work TREATMENT tied. (See urodynamics.)
effectively. As a result, high levels of Symptoms of mild cystitis may be
four amino acids, particularly cystine, relieved by drinking 0.5 litre of fluid cystoscopy
occur in the urine. This excess cystine every four hours, which helps to flush The examination of the urethra and
can result in the development of a rare out the bladder. Any bacterial infection bladder using a cystoscope inserted up
form of kidney stones (see renal calculi) is treated with antibiotic drugs to prevent the urethra. A cystoscope is a viewing
in both adults and children. bacteria from spreading upwards to the instrument, which can be rigid or flex-
Cystinuria is usually detected in peo- kidneys and causing pyelonephritis ible, sometimes with a camera at the
ple who have symptoms of kidney (infection of the kidneys). tip (see endoscopy).
stones, or in those who have passed
stones that, on analysis, are found to
contain cystine. The diagnosis can be PROCEDURE FOR CYSTOSCOPY
confirmed by urine tests that measure Cystoscopy involves passing a viewing instrument (cystoscope) up the urethra and
the levels of amino acids. Treatment into the bladder under local or general anaesthesia. There is no risk of damage to
involves drinking large amounts of flu- the genital organs or urinary tract, although the patient may feel some discomfort
ids regularly in order to dilute the when passing urine for the first few days afterwards.
urine and reduce the concentration of
cystine. If the levels of cysteine remain
Bladder
high, the drug penicillamine may be stone
required to help prevent the formation
of new stones.
cystitis
Inflammation of the lining of the blad-
der that is usually the result of a
bacterial infection.
View through
CAUSES
cystoscope
Cystitis is more common in women
than men because the urethra is short,
so it is relatively easier for the bacteria CYSTOSCOPE
that cause the disorder to pass into the Eyepiece
bladder. A bladder calculus (stone), a
bladder tumour, or a urethral stricture can
Sheath Forceps
obstruct urine flow and increase the
risk of infection. In men, cystitis is

210
 CYTOTOXIC DRUGS

CYTOLOGY METHODS

Cells for examination are obtained in several ways, depending Improvements in collection techniques have made it possible
on the part of the body being investigated. Cells from body to take cells from previously inaccessible sites. If a cytologist
surfaces may be collected by scraping or swabs; those from can make a diagnosis from cells removed in these ways, the
internal structures may be obtained by biopsy or aspiration. patient may be spared an exploratory operation.
C

Cells from the cervix Cells from the respiratory Cells from body fluids Aspiration biopsy
The vagina is held open with a tract or oesophagus These cells are obtained either by In this procedure, a very fine
speculum. Cells are scraped from the These cells are usually obtained by passing the fluid through a filter or needle is passed into a suspected
surface of the cervix with a spatula using an endoscope fitted with a centrifugation (spinning the fluid tumour and a biopsy sample of
(above) or a special brush. small brush or suction tube. rapidly to separate out the cells). cells is withdrawn.

Cystoscopy is used to inspect the blad- -cyte ions the fetus in the uterus are obtained
der for calculi (stones), bladder tumours, A suffix denoting a cell. For example, a by means of amniocentesis or chorionic
sites of bleeding and infection, and, in leukocyte is a white blood cell; an ery- villus sampling.
children, to investigate vesicoureteric throcyte is a red blood cell.
reflux. Cystoscopy is also used to take cytomegalovirus
urine samples from the ureters so that cyto- One of the most common herpes virus-
doctors can look for infection or A prefix that means “related to a cell”, es. Cytomegalovirus (CMV) infection
tumour cells. Radiopaque dye may be as in cytology, the study of cells. causes infected cells to appear enlarged.
injected into the ureters by means The virus may produce an illness that is
of the cystoscope during the X-ray cytokine similar to glandular fever (see mono-
procedure of retrograde pyelography A protein released by cells in response nucleosis, infectious), but usually there
(see urography). to the presence of harmful organisms are no symptoms. Individuals with
Certain treatments can also be per- such as viruses. Cytokines (such as inter- impaired immunity are more seriously
formed through the cystoscope. These ferons) bind to other cells, activating the infected. CMV in a pregnant woman
include the removal of bladder tum- immune response (see immune system). can cause birth defects and brain dam-
ours or calculi and the insertion of age in the baby.
stents (narrow tubes) into a ureter to cytology
relieve an obstruction. The study of cells. The main use of cytopathology
cytology is to detect abnormal cells; it The microscopic study of cells in health
cystostomy is widely used to screen for cancer (as and disease. (See also cytology.)
The surgical creation of a hole in the in the cervical smear test) or to confirm a
bladder. Cystostomy is usually carried diagnosis of cancer, and is increasingly cytoplasm
out to drain urine in cases where the used in antenatal screening to detect The jellylike substance that contains
introduction of a catheter (flexible certain fetal abnormalities. Examination the internal structures of a cell. Cyto-
tube) would be either inadvisable or of cells from body fluids helps doctors plasm is 90 per cent water, but it also
simply impossible. to determine the cause of conditions also contains enzymes, amino acids,
such as pleural effusion (fluid in the and other chemicals that are required
cystourethrography, micturating pleural cavity around the lungs) and for cell function.
An X-ray procedure that is used for ascites (abnormal accumulation of fluid
studying the bladder during the passing in the abdominal cavity); for example cytotoxic drugs
of urine. Micturating cystourethro- the tests can identify whether cancer or A group of anticancer drugs that kill or
graphy is most commonly used in infection is present. damage abnormal cells. Cytotoxic drugs
young children to detect abnormal Cells are collected by procedures may also damage or kill healthy cells,
reflux of urine (backflow of urine up such as scraping or fine-needle aspira- especially those that multiply rapidly,
the ureters) as the bladder empties. tion biopsy. For antenatal tests, cells such as the cells in hair follicles or
(See urodynamics.) from the fluid that surrounds and cush- those in the intestinal lining.

211
 DACRYOCYSTITIS

dander

D
sickle cell anaemia. Less commonly, the
condition can be associated with tuber- Minute scales that are shed from an
culosis or syphilis infection. animal’s skin, hair, or feathers. Dander
from humans and pets floats in the air
Daktacort or settles on surfaces, making up a
A brand name for a cream containing a large proportion of household dust.
combination of synthetic hydrocortisone Some people are allergic to animal dan-
(a corticosteroid drug) and miconazole der and develop the symptoms of
D (an antifungal drug). Daktacort is used
to treat inflamed skin conditions, such
allergic rhinitis (hay fever) or of asthma
if they inhale the scales.
as eczema and dermatitis, where a fungal
dacryocystitis infection is also suspected. dandruff
Inflammation of the tear sac, usually A harmless condition in which dead
resulting from the blockage of the tear Daktarin skin is shed from the scalp, often pro-
duct. The condition sometimes occurs A brand name for miconazole, an anti- ducing white flakes. The usual cause is
in infants if the tear duct has not devel- fungal drug used in the treatment of a rash called seborrhoeic dermatitis. Fre-
oped normally. In adults, it may follow athlete’s foot and other common fungal quent use of an antidandruff shampoo
inflammation in the nose or an injury. skin infections. Daktarin gel is used to usually controls dandruff.
The cause is often unknown. treat oral thrush (see candidiasis).
Symptoms include pain, redness, and danthron
swelling between the inner corner of Dalacin See dantron.
the eyelids and the nose. Infection may A brand name for clindamycin, an anti-
occur and cause a discharge. biotic that may be applied to the skin to dantrolene
The obstruction may be cleared by treat severe acne or as a vaginal cream A muscle-relaxant drug used to relieve
flushing the tear duct with saline. Anti- in the treatment of bacterial vaginal muscle spasm caused by spinal injury,
biotic eye-drops or ointment are given infections. Due to its toxic side effects, stroke, or neurological disorders such as
for infection. In infants, massaging the Dalacin is given as tablets or by injec- cerebral palsy. The drug does not cure
tear sac may clear a blockage. Surgery tion only for serious infections, when the underlying disorder, but it often
to drain the tear sac (dacryocystorhino- other antibiotics cannot be used. improves mobility.
stomy) is occasionally necessary.
danazol dantron
A drug used for treating endometriosis A stimulant laxative drug used to treat
(a condition in which fragments of the constipation in the terminally ill. Con-
uterine lining occur elsewhere in the stipation is common in these patients
pelvic cavity), noncancerous breast dis- as a side effect of treatment with opioid
ease, and menorrhagia (heavy periods). analgesic drugs (painkillers). Dantron
Danazol suppresses the release of may colour the urine red.
gonadotrophin hormones (pituitary hor-
mones that stimulate activity in the dapsone
ovaries), which in turn reduces the An antibacterial drug used to treat Han-
Tear production of the hormone oestrogen. sen’s disease (leprosy) and dermatitis
gland
This action usually prevents ovulation herpetiformis. Combined with pyrimeth-
and causes irregularity or absence of amine, dapsone is also used to prevent
menstrual periods. malaria. The drug may cause nausea,
Tear Possible adverse effects include nau- vomiting, and, rarely, damage to the
canal
sea, rash, and weight gain. Pregnancy liver, red blood cells, and nerves.
should be avoided while taking danazol.
Tear
sac
Darier’s disease
D and C A rare, progressive skin disorder, also
An abbreviation for dilatation and cur- known as keratosis follicularis, that is
Blocked
tear ettage, a gynaecological procedure in inherited as an autosomal dominant
duct which the cervix (neck of the uterus) is genetic trait (see genetic disorders). The
dilated, then the endometrium (lining of disease is characterized by the develop-
the uterus) is scraped away and a sample ment of a number of greasy, pigmented
Mechanism of dacryocystitis
Inflammation of the tear sac may occur when the is removed for analysis. D and C was papules (raised spots) on the scalp, the
duct through which tears drain away from the tear once used to diagnose disorders of the face and neck, behind the ears, and
sac becomes blocked. uterus, but has largely been replaced by along the middle of the back.
hysteroscopy, an endoscopic technique
dactylitis for viewing the uterus lining or taking daydreaming
Inflammation of the fingers or toes. a biopsy (tissue sample) from the lining. The conjuring up of pleasant or excit-
Dactylitis sometimes occurs in people Endometrial biopsies can also be taken ing images or situations in one’s mind
who have the inherited blood disorder using a small vacuum suction device. during waking hours.

212
 DEAFNESS

day surgery infections. The cochlea and labyrinth TREATMENT

Surgical treatment carried out in a hos- also degenerate naturally with old age, The treatment depends on the exact
pital or clinic without an overnight resulting in presbyacusis. Sensorineural cause of the deafness. Removal of
stay. The proportion of all operations deafness due to damage to the acoustic excess earwax remedies conductive
performed on a day-surgery basis has nerve may be the result of an acoustic deafness in many cases. Otosclerosis
risen substantially in recent years. Mod- neuroma (a noncancerous tumour that is generally treated by an operation
ern anaesthetics and surgical techniques, develops on the nerve). known as stapedectomy, in which the
in particular minimally invasive surgery, SYMPTOMS AND SIGNS stapes is replaced with an artificial sub-
allow a swifter recovery than in the
past, so that patients can often return
A baby who is congenitally deaf fails to
respond to sounds, and, although cry-
stitute. Glue ear may also be treated by
surgery (see myringotomy) and by the
D
home within a few hours of surgery. ing is often normal, he or she does not insertion of a grommet (a small tube
babble or make the usual baby noises that allows fluid to drain away from
DDAVP that lead to speech. In an adult who has the middle ear).
A brand name for desmopressin, which started to become deaf, sounds heard Many children who are born deaf
is a synthetic form of ADH (antidiuret- are not only quieter than before, but can learn to communicate effectively,
ic hormone). may be distorted and less clear. often by using sign language. Cochlear
Deafness may be accompanied by tin- implants (electrodes implanted in the
DDT nitus (noises in the ear) and vertigo inner ear that can receive sound sig-
The abbreviation for the insecticide (dizziness and loss of balance). Some- nals) may help profoundly deaf adults
dichlorodiphenyltrichloroethane. DDT times deafness can lead to confusion and children, but they are not suitable
was once widely used in the fight and sometimes to depression. for everyone. People who have sensori-
against diseases transmitted by insects, DIAGNOSIS neural deafness usually need hearing-
particularly in hot climates. However, Examination of the ear with an otoscope (a aids to increase the volume of sound
some insects have developed resistance viewing instrument with a light attached) reaching the inner ear. Lip-reading is
to the toxic effects of DDT, and this can show if the outer-ear canal is blocked invaluable for people who have diffi-
resistance can be passed on to their off- by wax, or if the eardrum is inflamed, per- culty hearing, whatever the type and
spring. (See also pesticides.) forated, or has fluid behind it. severity of their deafness. Other aids,
After a physical examination, hearing such as an amplifier for the earpiece of
deafness tests may be performed; these tests can a telephone, are available to help deaf
Complete or partial loss of hearing in determine whether deafness is con- people perform everyday tasks. (See
one or both ears. There are two types ductive or sensorineural. also ear; hearing.)
of deafness: conductive deafness, which
is caused by faulty propagation of
sound from the outer to the inner ear; DEAFNESS
and sensorineural deafness, in which
Earwax Ménière’s disease Drug Acoustic
there is a failure in the transmission of toxicity neuroma
sounds to the brain.
CAUSES Otosclerosis
The most common cause of conductive
deafness in adults is earwax. Otosclerosis, Perforated
eardrum
a condition in which the stapes (a small
bone in the middle ear) loses its normal
mobility, is a less common cause. In
children, conductive deafness is usually
due to otitis media (middle-ear infection)
or glue ear (accumulation of sticky fluid
in the middle ear). In rare cases, deaf-
ness results from a ruptured eardrum
(see eardrum, perforated).
Sensorineural deafness may be pres-
ent from birth. This type of deafness
may result from a birth injury or damage
resulting from maternal infection with Glue ear
rubella in early pregnancy. Damage to the
Barotrauma Occupational
inner ear may also occur soon after birth deafness
as the result of severe neonatal jaundice. Some possible causes of deafness
In later life, sensorineural deafness The part of the ear affected in each case is shown. Some of
can be due to damage to the cochlea the problems (e.g. earwax, which affects the outer ear, and
and/or labyrinth of the inner ear. It glue ear, which affects the middle ear) cause conductive
may result from prolonged exposure to deafness; others (e.g. drug toxicity and Ménière’s disease,
which affect the inner ear) cause sensorineural deafness.
loud noise, or be caused by Ménière’s
disease, certain drugs, or some viral

213
 DEATH

death death, sudden infant The word can also be used with regard
Permanent cessation of all vital func- When a baby is put to bed and later to mental illness, as in depression, when
tions. The classic indicators of death are found dead for no identifiable reason. an individual may lose his or her usual
the permanent cessation of heart and See sudden infant death syndrome (SIDS). compensation mechanisms (strategies
lung function, and, in almost all cases, by which a person makes up for real or
these remain the criteria by which debility imagined deficiencies) and suddenly
death is certified. Brain death is the Generalized weakness and lack of energy. deteriorate.
irreversible cessation of all functions It may be due to a physical disorder
D of the entire brain, including the brain- (such as anaemia) or to a psychological decomposition
stem (the part of the brain that controls disorder (such as depression). The gradual breakdown of organic
involuntary actions such as breathing). matter (such as food or dead tissue)
The diagnosis of death under normal debridement into other chemical compounds by way
circumstances, when the individual is Surgical removal of foreign material of bacterial and/or fungal action, heat,
not on a ventilator, is based on the and/or dead, damaged, or infected tis- or other processes.
absence of breathing, absence of heart- sue from a wound or burn in order to
beat, and on the pupils being fixed expose healthy tissue. Such treatment decompression sickness
wide open and unresponsive to light. promotes the healthy healing of badly A hazard of divers and of others who
When an individual has been placed damaged skin, muscle, and other tis- work in or breathe compressed air or
on a ventilator machine, the criteria sues in the body. other mixtures of gases. Decompression
for diagnosing brain death are based sickness is also called “the bends”. It
on clear evidence of irreversible dam- decalcification, dental results from gas bubbles forming in the
age to the brain; persistent deep coma; The dissolving of minerals in a tooth. tissues and impeding the flow of blood.
no attempts at breathing when the Dental decalcification is the first stage CAUSE
patient is taken off the ventilator; and of tooth decay. It is caused by bacteria At depth, divers accumulate inert gas in
complete lack of brainstem function. in plaque acting on the refined carbo- their tissues from the high-pressure gas
(See also death, sudden; mortality.) hydrates (mainly sugars) in food to mixture they breathe (see scuba-diving
produce acid, which, after prolonged medicine). Problems can usually be
death rate or repeated exposure, causes changes to avoided by allowing the excess gas in
See mortality. occur on the surface of the tooth. If the their tissues to escape slowly into the
decalcification penetrates the enamel lungs during controlled slow ascent or
death rattle layer, it spreads into the dentine and release of pressure. If the ascent is too
A noisy form of breathing resulting permits bacteria to enter the inner rapid and the pressure falls too quickly,
from the retention of sputum (mucous pulp. (See also caries, dental.) gas can no longer be held within the
material) in the airways of a dying per- tissues and is released as bubbles.
son who is no longer able to swallow it decay, dental SYMPTOMS
or cough it up. Although unpleasant for See caries, dental. Bubbles of gas may block blood vessels,
the person’s companions, it does not causing symptoms such as skin itching
appear to cause distress to him or her. decerebrate
The state of being without a function- Pressure
death, sudden ing cerebrum, the main controlling part increased
Unexpected death in a person who pre- of the brain. This situation occurs if the (descent)
viously seemed to be healthy. The most brainstem is severed, which effectively
common cause of sudden death in isolates the cerebrum.
adults is cardiac arrest (cessation of the
heartbeat). Cardiomyopathy (disease of decidua
the heart muscle) may cause sudden The lining of the uterus (womb) during
death at any age, and its presence may the course of pregnancy. The surface Inert gas dissolved in tissue
fluids and blood
have been unsuspected. Sudden death layers of the decidua are shed from the
may also occur as a result of stroke or in body during childbirth. Pressure
people with unsuspected myocarditis reduced
(inflammation of the heart muscle) or deciduous teeth (ascent)
pneumonia. Less common causes of a See primary teeth.
sudden death include anaphylactic shock
(a severe allergic reaction), a severe decompensation
attack of asthma, and suicide. The loss of an organ’s ability to meet
In infants, death without warning is the requirements of the body. The term
termed sudden infant death syndrome “decompensation” is usually used to Bubbles form Bubble blocking
in blood vessels blood vessel
(SIDS), or cot death. describe lessening function in an organ and tissues
The sudden death of a person of any that has been progressively damaged by
How decompression sickness occurs
age must be reported to the coroner, disease. For example, if the heart On ascent, pressure is reduced rapidly and the
who decides whether there should be decompensates, it becomes unable to gas may form bubbles that may, in turn, cause
an autopsy (postmortem examination). maintain an adequate circulation. symptoms. Divers avoid this by ascending slowly.

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 DEFENCE MECHANISMS

and mottling and severe pain in and tebrae. Any of these conditions can taken for longer than five days, they be-
around the larger joints. Symptoms of cause weakness or paralysis of the come ineffective; if they are stopped at
nervous system impairment (such as limbs and loss of bladder control. this stage, symptoms may be worse than
leg weakness or visual disturbances) To treat major disc prolapses and at the start of treatment. Therefore, they
are particularly serious, as is a painful, tumours, a laminectomy (removal of the should not be used continuously for more
tight feeling across the chest. bony arches of one or more vertebrae) than five days without medical advice.
TREATMENT to expose the affected part of the cord Decongestants may be unsuitable for peo-
Divers with decompression sickness are or nerve roots may be performed. ple with certain medical conditions and
immediately placed inside a recom-
pression chamber. Pressure within the
Recovery after treatment depends on
the severity and duration of the pres-
must be avoided in people taking MAOIs. D
chamber is raised, causing the bubbles sure, the success of the surgery in decubitus
within the tissues to redissolve. Subse- relieving the pressure, and whether The position of reclining or lying down,
quently, the pressure in the chamber is any damage is sustained by the nerves as in a decubitus ulcer (see bedsore).
slowly reduced, allowing the excess gas during the operation.
to escape safely via the lungs. decubitus ulcer
OUTLOOK decongestant drugs See bedsore.
If treated promptly by recompression, Drugs used to relieve nasal congestion,
most divers with the “bends” make a commonly in people who have upper decussation
full recovery. In serious, untreated cases, respiratory tract infections. The drugs are A point at which two or more struc-
however, there may be long-term com- thought to work by narrowing the blood tures in the body cross over each other
plications such as partial paralysis. vessels in the membranes lining the nose. to the opposite side. An example is the
Repeated episodes may lead to degen- This action reduces swelling, inflamma- point at which nerve fibres intercross
erative disorders of the bones or joints. tion, and the amount of mucus that is in the central nervous system.
produced by the nasal lining. Common
decompression, spinal canal decongestants include ephedrine, oxy- deep vein thrombosis
Surgery to relieve pressure on the metazoline, and phenylephrine. Small See thrombosis, deep vein.
spinal cord or a nerve root emerging amounts of these drugs are found in
from it (see microdiscectomy). Pressure many over-the-counter cold remedies. defaecation
may have various causes, including a There is little objective evidence that The expulsion of waste material as fae-
disc prolapse (“slipped” disc); a tumour decongestants effectively relieve respi- cesfrom the body through the anus.
or abscess of the spinal cord; or a ratory disorders. Taken by mouth, they
tumour, abscess, or fracture of the ver- may cause tremor and palpitations, and, defence mechanisms
Techniques used by the mind to lessen
unpleasant or unwelcome emotions,
THE ACTION OF DECONGESTANTS impulses, experiences, or events, and to
avoid external or internal conflict.
Decongestants work by narrowing blood vessels in the membranes that line the
TYPES
nose. This action reduces swelling, inflammation, and the amount of mucus
The principal defence mechanism is
produced by the nasal lining.
repression, which is the suppression of
unacceptable thoughts. Other types of
Enlarged Constricted defence mechanism include displace-
blood blood vessel ment, rationalization, projection, reaction
vessels Swollen
nasal
formation, and isolation.
lining Less mucus In displacement, dangerous thoughts
or feelings are redirected at a harmless
Reduced
swelling object; for example, someone who is
angry at another person may kick the
furniture instead of hitting that person.
Rationalization involves reinterpreting
thoughts or actions in a more accept-
able way; for example, a person may
criticize someone else but claim “It’s
Mucus for your own good”. In projection, a
person attributes his or her own faults
to someone else, for example by think-
Nasal
passage ing “that person hates me” when in
Congested nasal lining Effect of decongestants fact he or she hates that person. In reac-
When blood vessels enlarge in response to Chemicals stimulate constriction of the blood tion formation, an unacceptable feeling
infection or irritation, increased amounts of vessels in the nasal lining, which reduces is hidden by actions that suggest the
fluid pass into the lining, which swells and swelling, mucus production, and nasal opposite; for example, someone may
produces more mucus. congestion.
disguise hatred for another person by
showing great concern for that person.

215
 DEFIBRILLATION

In the mechanism of isolation, unpleas- of a part of the body can lead to defor- form depressed, white scars. Lesions
ant memories (for example, of being mity through stiffening and contracture may then form in arteries supplying
assaulted) are retained but the feelings of unused muscles or tendons. other parts of the body, such as the
that go with them are hidden, so that a Many deformities can be corrected intestine and the nervous system. This
person may recall such an event appar- by means of orthopaedic techniques, development may cause severe or even
ently without emotion. plastic surgery, or specific exercises. life-threatening problems, such as stroke
from lesions that have formed in the
defibrillation degeneration brain and perforation of the intestine by
D Administration of one or more brief
electric shocks to the heart, usually via
Physical and/or chemical changes in
cells, tissues, or organs that reduce
lesions that penetrate through the intes-
tine wall (see peritonitis).
two metal plates, or paddles, placed on their efficiency. Degeneration is a fea-
the chest over the heart. It is performed ture of aging and may also be due to dehiscence
to return the heart’s rhythm to normal disease processes. Other known causes The splitting open of a partly healed
in some types of arrhythmia (irregular include injury, reduced blood supply, wound. The term is most commonly
or rapid heartbeat), such as atrial fibrilla- poisoning (by alcohol, for example), or used to refer to the splitting open of a
tion or ventricular fibrillation. a diet deficient in a specific vitamin. surgical incision that has been closed
Defibrillation can be carried out as (See also degenerative disorders.) with sutures or clips.
an emergency procedure to treat ven-
tricular fibrillation, which is a cause degenerative disorders dehydration
of cardiac arrest and most commonly A term covering a wide range of condi- A condition in which a person’s water
occurs after a heart attack (see myocar- tions in which there is progressive content is at a dangerously low level.
dial infarction). It can also be used as impairment in the structure and func- Water accounts for about 60 per cent of
a planned treatment, in which case it tion of a body system, organ, or tissue. a man’s body weight and about 50 per
is performed under a brief general The number of specialized cells or cent of a woman’s. The total content of
anaesthesia. Breathing may be main- structures in the organ affected is usu- water (and mineral salts and other sub-
tained by artificial means for the ally reduced, and cells are replaced by stances that are dissolved in the body’s
duration of the procedure. connective tissue or scar tissue. In many fluids) must be kept within fairly nar-
cases, the cause of the disease is poorly row limits to enable the healthy
deficiency anaemia understood, but degenerative disorders functioning of cells and tissues.
A type of anaemia. See anaemia, iron- are the subjects of intensive research. CAUSES
deficiency; pernicious anaemia. Degenerative nervous system disor- Dehydration occurs due to inadequate
ders include Alzheimer’s disease, motor intake of fluids or excessive fluid loss.
defluoridation neuron disease, Huntington’s disease, and The latter may occur as a result of
The removal of excess fluoride from Parkinson’s disease. Degenerative disor- severe or prolonged vomiting or diar-
drinking water, often using domestic ders of the eye include Leber’s optic rhoea, or in people who have poorly
water filters, to prevent fluorosis (mot- atrophy and senile macular degeneration. controlled diabetes mellitus, diabetes insip-
tling of tooth enamel) in consumers. Degenerative disorders of the joints idus, and certain types of kidney failure.
(See also fluoridation; fluoride.) include osteoarthritis. Muscle degenera- Children are particularly susceptible to
tion occurs in muscular dystrophies. dehydration due to diarrhoea.
defoliant poisoning Some degree of hardening of the arter- SYMPTOMS
The toxic effects of plant poisons that ies seems to be a feature of normal aging, The symptoms of severe dehydration
cause leaves to drop off. Defoliants are but in certain people degenerative are extreme thirst; dry lips and tongue;
poisonous if they are swallowed. Widely changes in the muscle coat of the arteries an increase in heart rate and breath-
used defoliant poisons include sodium are unusually severe, and calcium deposits ing rate; dizziness; confusion; lethargy;
chlorate, potassium chlorate, phenoxy may be seen on X-rays (as in Monckeberg’s and eventual coma. The skin looks dry
herbicides, and paraquat. sclerosis, a type of arteriosclerosis). and loses its elasticity. Any urine passed
In most cases, there is little that can is small in quantity and dark-coloured.
deformity be done to slow the progress of the dis- If there is also salt depletion (for exam-
Any malformation or distortion of part ease, but it is often possible to relieve ple, due to heavy sweating), there may
of the body. Deformities may be con- symptoms with drug treatment (for be headaches, cramps, and pallor.
genital (present from birth), or they example, in Parkinson’s disease). TREATMENT
may be acquired as a result of injury, Drinking bottled mineral water helps
disorder, or disuse. Degos syndrome to maintain the intake of salts. In cases
Most congenital deformities are rela- A rare disorder that affects the linings of persistent vomiting and diarrhoea,
tively rare. Among the more common of small and medium-sized arteries rehydration therapy is required; salt and
are club-foot (talipes) and cleft lip and throughout the body, particularly in the glucose rehydration mixtures are avail-
palate. Injuries that can cause deformity skin, intestine, and nervous system, able from chemists.
include burns, torn muscles, and bro- causing the vessels to become blocked. In severe cases of dehydration, fluids
ken bones. Disorders that may cause The cause is unknown. may be given intravenously, and the
deformity include certain nerve prob- The disease typically produces multi- water/salt balance is carefully moni-
lems, some deficiencies, such as rickets, ple small skin lesions that initially tored by means of blood tests and is
and Paget’s disease of the bone. Disuse appear as red, raised spots and then adjusted as necessary.

216
 DELTOID

déjà vu girls; or a long-term illness, such as withdrawal or abstinence from alcohol.

French for “already seen”. A sense of Crohn’s disease. Certain lifestyle factors, Early symptoms include restlessness,
having already experienced an event such as excessive exercise or an inade- agitation, trembling, and sleeplessness.
that is happening at the moment. Fre- quate diet, may also delay puberty. The person may then develop a rapid
quent occurrence may sometimes be a Treatment depends on the underly- heartbeat, fever, and dilation of the
symptom of temporal lobe epilepsy. ing cause. If delayed puberty runs in pupils. Sweating, confusion, hallucina-
the child’s family, no action may be tions, and convulsions may also occur.
Dejerine–Roussy syndrome needed. In some cases, however, condi- Treatment consists of rest, rehydra-
A rare neurological disorder, also called
thalamic syndrome or central pain syn-
tions causing delayed puberty may also
lead to infertility, so the child may need
tion, and sedation. Vitamin injections,
particularly of thiamine (see vitamin B
D
drome, that results from damage to the further investigations in the future if he complex), may be given, as some symp-
thalamus, the part of the brain that pro- or she wishes to have children. toms are linked to thiamine deficiency.
cesses sensory information.
The main symptom is severe pain, delayed shock delivery
possibly accompanied by other abnor- A common term for severe mental or The expulsion or extraction of a baby
malities such as loss of sensation or a physical reactions that may occur some from the mother’s uterus. In most
“crawling” feeling in the skin. time after a traumatic event (see post- cases, the baby lies lengthwise in the
traumatic stress disorder; shock; stress.) uterus with its head facing downwards;
delayed allergy it is delivered head first through the
A type of hypersensitivity reaction that, Delhi belly vaginal opening by a combination of
unlike most forms of allergy, does not A popular name for gastroenteritis and uterine contractions and the mother’s
develop immediately on exposure to a infective diarrhoea caused by ingesting pushing (see childbirth). If the baby is
particular allergen (a normally harmless contaminated food or water. lying in an abnormal position (see
substance that causes a reaction in peo- breech delivery; malpresentation), if uter-
ple who have become sensitized to it). delinquency ine contractions are weak, or if the
Delayed allergies, also called type IV Criminal behaviour in a young person baby’s head is large in relation to the
hypersensitivity reactions, may result who is below the official age at size of the mother’s pelvis, a forceps
from bacterial, viral, fungal, or proto- which he or she can be prosecuted. delivery or vacuum extraction may be
zoal infections or from vaccination with The term is often extended to include required. If a vaginal delivery is impos-
a live virus vaccine. Examples of such behaviour such as drug abuse, playing sible or dangerous to the mother or the
delayed allergic reactions include con- truant, or running away from home. baby, a caesarean section is necessary.
tact dermatitis and the body’s response Delinquency that occurs in juveniles is
to infection in tuberculosis. probably a result of a combination of deltoid
social, psychological, and biological fac- The triangular muscle of the shoulder
delayed dentition tors. Child guidance or family therapy may region that forms the rounded flesh of
The late eruption of teeth. The term be recommended. Persistent offenders the outer part of the upper arm, and
“delayed dentition” may refer to the may be sent to special schools, taken
eruption of the first deciduous teeth into care, or made wards of court.
(see primary teeth) after the end of the LOCATION OF THE DELTOID
13th month of life or to the eruption delirium
of the first permanent teeth after the sev- A state of acute mental confusion, com- The deltoid muscle of the shoulder
enth year of life. Delayed dentition is a monly brought on by physical illness. region forms the rounded, outer part
of the upper arm and is attached to
feature of various conditions that result Symptoms vary according to personal- the scapula and clavicle.
in generally restricted growth (see short ity, environment, and the severity of
stature), such as hypothyroidism. illness. They may include failure to
understand events or remember what
delayed puberty has been happening, physical restless- Scapula
(shoulder-
Onset of puberty (sexual maturation) ness, mood swings, hallucinations, and blade)
after the age of 14. In most cases, the panic. Fever and disturbances of body
child is simply developing at a slower chemistry are often contributory factors.
Clavicle
rate than normal, a tendency that often Children and older people are most (collarbone)
runs in families, but in some cases susceptible to delirium, particularly as
Deltoid
there may be an underlying disorder. a result of infection, following surgery, muscle
One possible underlying cause of or when there is a pre-existing brain
delayed puberty is underproduction of disturbance (such as dementia in an
sex hormones. Rarely, the condition elderly person). Drugs, poisons, and
results from a problem with the hypo- alcohol are common precipitants.
thalamus or the pituitary gland, which Humerus
are responsible for secreting sex hor- delirium tremens (upper-arm
bone)
mones; a genetic abnormality affecting A state of confusion accompanied by
sexual development, such as Klinefelter’s trembling and vivid hallucinations. It
syndrome in boys or Turner’s syndrome in usually arises in chronic alcoholics after

217
 DELUSION

passes up and over the shoulder joint. CAUSES AND TYPES as donepezil may halt the deterioration
The wide end of the muscle is attached Dementia is caused by damage to brain in mental function, or may even restore
to the scapula (shoulderblade) and the tissue. It is most commonly due to Alz- function to the level the person experi-
clavicle (collarbone). The muscle fibres heimer’s disease, which causes changes enced six months previously. Regardless
meet to form the apex of the triangle, in the structure and chemistry of the of treatment, however, Alzheimer’s dis-
which is attached to the humerus (the brain. The second most common form ease is progressive, and usually leads to
upper-arm bone) at a position about is multi-infarct dementia. In this condi- death within 10 years of onset.
halfway down its length. tion, narrowed or blocked arteries in
D The central, strongest part of the del- the brain deprive the tissue of blood dementia praecox
toid muscle raises the arm sideways. The and oxygen; repeated small strokes An outdated term formerly used to des-
front and back parts of the muscle are (episodes of tissue damage due to a cribe severe schizophrenia, especially that
used to twist the arm. lack of blood) occur, causing deteriora- affecting adolescents or young adults.
tion that develops gradually and in
delusion stages. Other, rare forms of dementia demineralization
A fixed, irrational idea not shared by include Lewy body dementia (in which Excessive loss of the minerals calcium
others and not responding to reasoned small, spherical structures called Lewy and phosphate from bone. Generalized
argument. The central idea in a para- bodies appear in the brain tissue); AIDS- demineralization can occur as a result
noid delusion involves persecution or related dementia; and deterioration that of immobility following an illness or
jealousy; for instance, a person may occurs as a result of progressive brain injury, or may be due to a bone disease
falsely believe that he or she is being disorders such as Parkinson’s disease. such as osteomalacia. Patchy demineral-
poisoned or that a partner is persistently SYMPTOMS ization can be due to bone metastases
unfaithful (see paranoia). The main symptoms of dementia are (cancerous tumours that have spread
Persistent delusions are an indication progressive memory loss, disorienta- from elsewhere in the body); this con-
of serious mental illness, particularly tion, and confusion. The affected dition causes areas of bone to weaken,
schizophrenia and manic–depressive illness. person may not remember recent increasing the risk of fractures.
(See also hallucination; illusion.) events, he or she may become easily
lost in a familiar neighbourhood, and De Morgan’s spots
demand pacemaker may be confused over days and dates. See Campbell de Morgan’s spots.
A permanent artificial cardiac pacemaker These symptoms may come on gradu-
(a device that sends electrical impulses ally and they may be hardly noticeable De Morsier’s syndrome
to the heart to maintain a regular heart- at first; in addition, the person may Also called septo-optic dysplasia, a rare
beat) that discharges impulses only cover up any problems by confabulation disorder that results from the abnormal
when the heart rate is abnormal. Such a (making up explanations in order to fill development of the optic disc in the eye,
pacemaker may be set to function only the gaps in his or her memory). the pituitary gland, and parts of the
if the heart rate slows, or alternatively to Sudden outbursts or embarrassing brain. De Morsier’s syndrome causes
override an abnormally rapid rate. (See behaviour may be the first obvious eye problems, including blindness in
also fixed-rate pacemaker.) signs of dementia. Unpleasant person- one or both eyes, abnormal eye move-
ality traits may be magnified; families ments such as nystagmus, squint, and
demasculinization of those affected may have to endure dilation of the pupils (rather than the
The loss, in a male, of normal male sec- accusations, unreasonable demands, or normal contraction) in response to
ondary sexual characteristics (see sexual even assault. Paranoia, depression, and light. Other symptoms of the syndrome
characteristics, secondary). This includes delusions may occur as the disease pro- include seizures, hypotonia (poor muscle
reduced facial hair growth, along with gresses. Irritability or anxiety gives way tone), and hormonal problems, com-
testicular atrophy (wasting away of the to indifference towards all feelings and monly a deficiency in growth hormone
testes) and shrinkage of the prostate events. Personal care and hygiene are leading to short stature.
gland. Demasculinization may occur in neglected, and speech becomes inco- Treatment aims to relieve symptoms
a range of conditions in which the herent. Affected people may eventually such as hormonal deficiencies, and to
testes are damaged or diseased. It may need total nursing care. provide rehabilitation for affected people
also result from disorders such as TREATMENT who have impaired vision.
cirrhosis and kidney failure, which inter- The management of the most common
fere with the processing in the body Alzheimer-type illness is based on the demyelination
of the female sex hormone oestrogen. treatment of symptoms. The affected Breakdown of the fatty sheaths that sur-
(See also feminization; intersex; masculin- person should be kept clean and well- round and electrically insulate nerve
ization; sex determination.) nourished, in comfortable surroundings fibres. The sheaths provide nutrients
and with good nursing care. Sedative to the nerve fibres and are vital to the
dementia drugs may be given to reduce restless- passage of electrical impulses along
A condition characterized by a gener- ness or paranoid beliefs. These measures them. Demyelination “short-circuits” the
alized deterioration in brain function. can help to ease distress for both the functioning of the nerve, which causes
Dementia most commonly affects the patient and their family. loss of sensation, coordination, and
elderly; about 1 in 20 people over the For some people with mild to mod- power in specific areas of the body.
age of 65, and up to 1 in 5 people over erate Alzheimer’s disease, drug treatment The affected nerves may be within the
the age of 80, have the disorder. with acetylcholinesterase inhibitors such central nervous system (CNS), compris-

218
 DENTAL EMERGENCIES

Cell body dengue density

A tropical disease caused by a virus The “compactness” of a substance,
spread by the mosquito AEDES AEGYPTI. defined as its mass per unit volume.
Nucleus
The symptoms include fever, headache, In radiology, the term relates to the
rash, and joint and muscle pains, which amount of radiation absorbed by the
often subside after about three days. structure being X-rayed. Bone absorbs
There is no specific treatment for radiation well and appears white on X-
dengue. Prevention involves protection ray film. A lung, which contains mostly
Myelin Myelin
against mosquito bites (see insect bites). air, absorbs little radiation and is dark
on the film.The same is true for CT scan-
D
sheath sheath
densitometry ning and MRI. (See also specific gravity.)
Axon Axon An imaging technique that uses low-
dose X-rays to measure bone density, as dental emergencies
Degeneration determined by the concentration of Injuries or disorders of the teeth and
of sheath calcified material within bone tissue. gums that require immediate treatment
Muscle Densitometry is used to diagnose and because of severe pain and/or because
fibres assess the severity of osteoporosis (wast- delay could lead to poor healing or to
ing away of bone tissue), especially in complications. A tooth that has become
Mechanism of demyelination
The fatty myelin sheaths that surround and insulate the spine and the femur (thigh bone), dislodged by injury can be reimplanted
nerve fibres break down, causing the affected and to assess its response to treatment. (see reimplantation, dental) into the gum
nerves to “short-circuit”. During the procedure, X-rays are successfully if this is done without
passed through the body. A computer delay, usually within 30 minutes of the
ing the brain and the spinal cord, or assesses the amount of X-rays absorbed injury. A partly dislodged tooth should
may be part of the peripheral nervous by the body and uses this information be manipulated back into the socket in
system, which links the CNS to sense to calculate the bone density. the gum immediately.
receptors, muscles, glands, and other
organs throughout the body.
Patches of demyelination are visible SCOPE OF DENTAL EXAMINATION
on MRI scans of the brain in people
who have multiple sclerosis, a disease A dental examination includes an
Dental assistant
assessment of the condition of the
with symptoms that include blurred
teeth, of the gums, of the mouth, and X-ray viewing
vision, muscle weakness, and loss of of the bone that supports the teeth. screen
coordination. The cause of the demy- Light
elination in multiple sclerosis is not
known. In many cases of the disease,
episodes of demyelination alternate Dentist

with periods of partial or complete

recovery of nerve function.
In the rare disorder encephalomyelitis,
there is inflammation of nerve cells in
the CNS and sometimes also areas of Rinsing
demyelination along the nerves. bowl

dendritic ulcer
A type of corneal ulcer (affecting the
transparent dome that forms the front
of the eyeball) with threadlike exten-
sions that branch out from the centre.
Dendritic ulcers are commonly due to
infection with herpes simplex virus.
denervation
The loss of the nerve supply to an area Constructing a Instruments used
dental record The dentist uses a mirror
of skin, a muscle, an organ, or another During the dental to see the backs of the
body part. Nerves may be damaged by examination, the teeth and into the back
injury or by disease, or as a result of dentist checks for the of the mouth; a metal
surgery. A denervated area loses all presence or absence instrument is used to
of individual teeth. probe for dental cavities
sensation, and its functioning may be Any abnormalities and or chipped teeth.
impaired; for example, muscles may all fillings are recorded Mirror
become paralysed. In some cases, the (by the dentist’s
Probe
assistant).
affected nerves may regrow, but often
the damage is permanent.

219
 DENTAL EXAMINATION

TYPES OF DENTAL X-RAY

There are three types of X-ray. Each of

the different types is useful for
revealing particular dental problems.

D
Bite-wing X-rays
These X-rays show the crowns of the teeth.
They are useful for detecting areas of decay
between teeth and changes in bone that are
caused by periodontal (gum) disease. The
film is in a holder with a central tab on to
which the patient bites.
Periapical X-rays
These X-rays give detailed pictures of whole
teeth and the surrounding gums and bone. Panoramic X-rays
They show unerupted or impacted teeth, root These X-rays show all the teeth and surrounding
fractures, abscesses, cysts, tumours, and the structures on one large film. They are invaluable
characteristic bone patterns of some skeletal for finding unerupted or impacted teeth, cysts,
diseases. The film, in a protective casing, is jaw fractures, or tumours. Pictures are recorded
placed in the patient’s mouth and is held in continuously on to film as the camera swings
position behind the teeth to be X-rayed. around from one side of the jaw to the other.

Other dental emergencies include a dental floss the teeth and can detect areas of decay
broken tooth (see fracture, dental); severe A fine thread or tape, usually made of and changes in bone due to periodontal
toothache, which may be due to an nylon, that is used to remove plaque disease. Panoramic X-rays show all the
abscess (see abscess, dental); Vincent’s (see plaque, dental) and food particles teeth and the surrounding structures on
disease (see gingivitis, acute ulcerative), from hard-to-reach areas between the one large film. They can show unerupt-
which causes ulceration, and bleeding teeth and around the line of the gums ed or impacted teeth, as well as cysts,
of the gums; and eruption of wisdom (see flossing). Floss may be waxed or jaw fractures, or tumours.
teeth that cut into the tongue. unwaxed, and some types contain fluo- The amount of radiation received
ride. Flossing should be carried out from dental X-rays is extremely small;
dental examination regularly, in addition to toothbrushing. however, routine dental X-rays should
An examination of the mouth, gums, be avoided during pregnancy.
and teeth by a dentist as a routine dental impaction
check or during the assessment of a See impaction, dental. dentifrice
suspected problem. A paste, powder, or gel used with a
Routine examinations are recommend- dental X-ray toothbrush to clean the teeth. Denti-
ed so that tooth decay (see caries, dental), An image of the teeth and jaws that frice usually contains a mild abrasive,
gum disease (see gingivitis), or mouth can- provides information for the detection, along with detergents, colourings and
cer can be detected and treated at an early diagnosis, and treatment of conditions flavourings, binding and moistening
stage, before they cause serious damage. that can threaten oral and general health. agents, and thickening agents. It also
During the examination, the dentist uses a The part to be imaged is placed between usually has fluoride added, and, some-
metal instrument to probe for dental cavi- a tube emitting X-rays and a photograph- times, desensitizing agents.
ties, chipped teeth, or fillings. (See the ic film. Because X-rays are unable to pass
illustrated box on p.219.) Dental X-rays are easily through hard tissue, a shadow of dentigerous cyst
sometimes carried out to detect prob- the teeth and bone is seen on the film. A fluid-filled cyst (lump or swelling)
lems, for example with the jaw, that may There are three types of dental X-ray: surrounding the crown of an unerupted
not be visible. The dentist also checks the periapical X-ray, bite-wing X-ray, and tooth (see eruption of teeth). This type of
bite, that is how well the upper and the panoramic X-ray. cyst may produce swelling or resorp-
lower teeth come together. Regular exam- Periapical X-rays are taken using X-ray tion (loss of substance) of the adjacent
inations in children enable a dentist to film held behind the teeth. They give tooth roots. Treatment is by extraction
monitor the replacement of primary teeth detailed images of whole teeth and the of the affected tooth and by surgical
by permanent, or secondary, teeth. Refer- surrounding tissues. They can show removal of the cyst.
ral for orthodontic treatment may be made. unerupted or impacted teeth, root frac-
tures, abscesses, cysts, and tumours, and dentine
dental extraction can help diagnose some skeletal diseases. The hard tissue that surrounds the pulp
See extraction, dental. Bite-wing X-rays show the crowns of of a tooth (see teeth).

220
 DEPO-PROVERA

dentistry dependence antianxiety drugs or antidepressant drugs,

The science or profession concerned Psychological or physical reliance on may sometimes be effective in relieving
with the teeth and their supporting persons or drugs. An infant is dependent associated symptoms.
structures. Most dentists work in general on its parents, but, as he or she grows,
dental practice; others practise a spe- this dependence normally wanes. Some depersonalization
cialized branch of dentistry. adults never become fully independent A state of feeling unreal, in which an
Dentists in general practice under- (see dependent personality). individual has a sense of detachment
take all aspects of dental care. They may Alcohol and drugs may induce phys- from self and surroundings. Deperson-
refer patients to a consultant in one of
the specialized branches of dentistry,
ical or emotional dependence in users;
a person who has a dependency may
alization is frequently accompanied
by derealization, in which the world is
D
such as orthodontics (correction of the develop physical symptoms, such as experienced as unreal. It is rarely seri-
alignment of teeth), prosthetics (fitting sweating or abdominal pains, or become ous and usually comes on suddenly and
of bridgework and dentures), endo- distressed if deprived of the drug. (See may last for moments or for hours.
dontics (treatment of diseases of the also alcohol dependence; drug dependence.) Depersonalization most often occurs in
tooth pulp), and periodontics (treatment people who have anxiety disorders.
of disorders affecting the tissues sup- dependent oedema Other causes include certain drugs and
porting the teeth). A form of oedema (the accumulation of temporal lobe epilepsy.
Dental hygienists carry out scaling fluid in body tissues) that mainly
(removal of hard deposits on the teeth) affects the lower parts of the body. It depilatory
and demonstrate methods to keep the may be a feature of congestive heart fail- A chemical hair remover, such as barium
teeth and gums healthy. ure. Oedema affecting the ankles may sulphide, supplied as a cream and applied
have various possible causes, such as for cosmetic reasons or to treat hirsu-
dentition immobility, varicose veins, and pregnancy. tism (excessive hairiness in women).
The arrangement, number, and type of
teeth in the mouth. In young children, dependent personality Depixol
primary dentition comprises 20 teeth A personality disorder characterized by A brand name for flupentixol, an
(incisors, canines, and molars). These an inability to function without signifi- antipsychotic drug used in the treatment
teeth are replaced between the ages of 6 cant guidance from others, feelings of of schizophrenia and other related ill-
and 13 years by the secondary (perma- helplessness when alone or when close nesses. The drug may be given either
nent) dentition. Secondary dentition relationships end, and a fear of separa- orally or by injection. Possible adverse
comprises 32 teeth (incisors, canines, tion. Other features of a dependent effects include an increased risk of
premolars, and molars). Often, the third personality include difficulty in making parkinsonism (a set of neuromuscular
molars (wisdom teeth) do not erupt decisions, low self-esteem, and hyper- symptoms including tremors, muscle
until the age of 18–25, or even older in sensitivity to criticism. rigidity, and slow movements).
some cases; sometimes, they fail to Dependent personality disorder is
erupt at all. (See also eruption of teeth.) of unknown cause and normally first Depo-provera
manifests itself in early adulthood. A brand name for medroxyprogesterone,
denture There is no specific treatment for the a long-acting progestogen drug that is
An appliance that replaces missing condition, but psychotherapy may grad- given by depot injection as a contraceptive.
natural teeth. A denture consists of a ually help sufferers to make their own It is similar to progesterone hormone, a
metal and/or acrylic (hard plastic) base choices. Medication, for example with natural female sex hormone.
that is mounted with acrylic teeth. The
artificial teeth are matched to the per-
son’s original teeth. Denture baseplates, TYPES OF DENTURES
which are created from impressions
Partial dentures
taken from the upper and lower gums, Partial dentures are used when only some of the teeth are missing. They fill unsightly gaps,
fit the mouth accurately. make chewing easier, maintain clear speech, and keep the remaining teeth in the correct
position. Teeth on either side of a gap may tip (making cleaning more difficult) or drift (placing
deodorant unnatural stress on the tissues of the mouth). Partial dentures are held in place by metal clasps
that grip adjacent teeth or by clasps combined with metal rests (extensions of the denture plate
A substance that removes unpleasant that rest on the surface of the tooth).
odours, especially body odours.
deossification Full dentures
Full dentures are needed when there are no teeth left in the mouth. They stay in place by resting
The loss or removal of bone tissue, as in on the gum ridges and, in the case of upper dentures, by suction. Fitting is sometimes delayed
osteoporosis. (See also ossification.) after extraction of teeth to allow the gums to shrink and change shape as they heal.

deoxygenation Immediate dentures

In respiration, the release of oxygen from Immediate dentures are fitted immediately after extraction of teeth. They protect the gum and
red blood cells to supply other tissues. control bleeding from extraction sites. Since a toothless period is avoided, they are particularly
useful for replacing front teeth. However, they can be expensive and require follow-up visits so
that they continue to fit comfortably. They may also need replacing within a short time.
deoxyribonucleic acid
See DNA; nucleic acids.

221
 DEPOT INJECTION

depot injection and impaired concentration. Movement Antidepressant drugs may be very effec-
An intramuscular injection of a drug and thinking become slower; alterna- tive, with up to seven in ten affected
that gives a slow, steady release of its tively, the opposite occurs, and the people responding well to the first
active chemicals into the bloodstream. person may become extremely anxious. drug that is offered. Antidepressants are
Release of the drug is slowed by the Severely depressed people may have not addictive. Many drugs, however, do
inclusion of substances such as oil or thoughts of committing suicide and not start to take effect until about two
wax, and can be made to last for hours, feelings of worthlessness. Hallucinations weeks into treatment, and all types
days, or weeks. or delusions may occur in extreme cases. need to be continued after the symp-
D A depot injection can be useful for
patients who may not take their medi-
CAUSES
Often, there is no single obvious cause,
toms of depression have cleared.
ECT (electroconvulsive therapy) is
cation correctly. It also prevents the and a combination of factors may be infrequently used in the UK, but it
necessity of giving a series of injections involved. Depression may be triggered is still considered to be an effective
over a short period. Drugs that may be by physical illnesses (such as a viral treatment for people suffering from
given by depot injection include hor- infection), by hormonal disorders (such life-threatening depression. ECT may
monal contraceptives (see contraception, as hypothyroidism), or by the hormonal be life-saving, but it can cause mild,
hormonal methods of), corticosteroid drugs, changes that occur following childbirth temporary memory impairment.
and antipsychotic drugs. Side effects may (see postnatal depression). Certain drugs, OUTLOOK
arise due to the uneven release of the such as oral contraceptives, may con- Depression is often a recurrent disor-
drug into the bloodstream. tribute to the condition. Inheritance der; up to three-quarters of people who
may play a part in manic–depressive ill- have needed hospital treatment for
depressed skull fracture ness. Some people become depressed in depression will have another episode
A fracture in which a part of a skull the winter (see seasonal affective disorder within 10 years. However, long-term
bone is pushed inwards towards the syndrome), probably in response to the antidepressant medication and psycho-
brain (see skull, fracture of). A depressed long hours of darkness. logical therapies can greatly reduce the
skull fracture usually results from a Aside from these causes, there are risk of recurrence.
high-energy blow to a small surface social and psychological factors that Despite the effectiveness of drug
area of the skull. may play a role. Depression may also treatment, suicide remains a serious
be related to the number of disturbing risk; nearly half of all deaths in people
depression changes or events in a person’s life. with recurrent depression are due to
Feelings of sadness, hopelessness, and a INCIDENCE suicide. This risk can, however, be
loss of interest in life, combined with Depression is the most common serious substantially reduced by maintenance
a sense of reduced emotional well- psychiatric illness. The World Health treatment with antidepressive drugs.
being. Most people experience these Organization ranks it fourth in the ten
feelings occasionally, usually as a nor- leading causes of disease worldwide. De Quervain’s disease
mal response to an upsetting event; for One person in six is estimated to suffer An inflammatory condition that affects
example, it is natural to feel depressed some degree of depression in their life- one of the tendons of the muscles that
when a close relative dies. When a per- time, and one person in 20 develops are used to move the thumb. In de
son’s behaviour and physical state are clinical depressive illness. Quervain’s disease, the sheath (cover-
also affected, however, this is an indica- Depression is particularly common in ing) of this tendon becomes so in-
tion that the symptom is part of a people over 50, and appears to be more flamed and thickened that the tendon
depressive illness. common in women; twice as many can no longer move through the sheath
Depression that occurs without any women as men seek help for the condi- smoothly, and thumb movements are
apparent cause, deepens, and persists tion. This difference may result from painful. The inflammation is often
may occur as part of a variety of psy- the fact that women are more prepared caused by overuse of the thumb.
chiatric illnesses. Some people who to seek help for their symptoms, while Treatment is with rest, nonsteroidal
suffer from depression are eventually men may be more likely to express their anti-inflammatory drugs (NSAIDs), and
diagnosed as having manic–depressive discontent in the form of problems corticosteroid drug injections into the
illness (also known as bipolar affective such as alcohol abuse and violence. affected tendon sheath, which may be
disorder) a condition characterized by TREATMENT helpful in relieving the inflammation,
episodes of depression alternating with There are three main forms of treat- but in severe cases surgery is needed to
mania (periods of overly excitable ment for depression, depending on the loosen the sheath.
mood and uncontrolled behaviour). type and severity of the illness.
SYMPTOMS Treatment usually includes a form of De Quervain’s thyroiditis
Symptoms vary with the severity of the psychotherapy, given either individually A form of thyroiditis (inflammation of
condition. In a person suffering from or in a group. This form of treatment is the thyroid gland) that is uncommon
mild depression, the main symptoms most useful for people whose personal- and is caused by a viral infection; the
are anxiety and a variable mood; the ity and life experiences are the main condition often follows a viral infec-
person may also have fits of crying that causes of their illness. Types of therapy tion of the nose and throat.
occur for no apparent reason. More range from counselling to help deal with The thyroid gland, which is situated
severe depression may cause loss of practical problems to more structured in the front of the neck, may become
appetite, difficulty in sleeping, tired- approaches such as cognitive–behavioural painful and swollen; this swelling is
ness, loss of interest in social activities, therapy or psychoanalysis. sometimes accompanied by fever. There

222
 DERMOID CYST

is a temporary rise in thyroid hormone Abnormal sensation in a dermatome

levels (hyperthyroidism) lasting for a few signifies damage to a particular nerve
weeks, as damage to the thyroid gland root, commonly due to a disc prolapse
causes it to release its hormone stores. (“slipped” disc).
This is followed by insufficient levels
(hypothyroidism) when the stores then dermatome, surgical
become depleted. A surgical instrument for cutting vary-
Aspirin is used to treat the inflam- ing thicknesses of skin for use in skin
mation, with a short course of the
corticosteroid drug prednisolone given
grafting procedures. D
in more severe cases. Thyroid function dermatomyositis
usually returns to normal once the ill- A rare autoimmune disorder in which the
Contact dermatitis
ness has been treated. An allergic reaction to the metal (often nickel) muscles and skin become inflamed. In
in a ring has produced a red, inflamed area of most cases the cause is unknown, but
Dercum’s disease skin around the finger. in some instances the disease is linked
Also called adiposis dolorosa, a disor- to an underlying cancer.
der characterized by the accumulation topical corticosteroids. A patch test (see Dermatomyositis causes a skin rash
of localized, symmetrical fat deposits skin tests) may be performed in order that may first appear on the bridge of
under the skin, mainly on the forearms to identify the cause. the nose and cheeks, followed by a pur-
and thighs. The swellings are uncom- PHOTODERMATITIS ple discoloration on the eyelids and
fortable or painful. Other symptoms of This form of dermatitis occurs in peo- sometimes a red rash over the knees,
the disease include muscle weakness ple whose skin is abnormally sensitive knuckles, and elbows. Muscles become
and headaches. The disease may cause to light. A cluster of spots or blisters weak, stiff, and painful, particularly
death from heart failure. Dercum’s dis- occurs on any part of the body exposed those in the shoulders and pelvis;
ease mainly affects middle-aged women to the sun (see photosensitivity). affected people may find that they can-
and is thought to be an autosomal not raise their hands above their head,
dominant genetic disorder. dermatitis artefacta or cannot raise themselves from a
Any self-induced damage to the skin. It squatting position. Calcium may be
derealization may range from scratches to extensive deposited in the muscles, particularly
Feeling that the world has become mutilation that produces severe ulcers in affected children.
unreal. It usually occurs together with or other lesions. When given a medical The diagnosis is made by medical
depersonalization and may be caused by examination, the affected person may examinations, blood tests, and biopsy of
fatigue, hallucinogenic drugs, or disor- vigorously deny having any part in caus- muscle tissue. Treatment is with cor-
dered brain function. ing the problem. Psychiatric assessment ticosteroids and/or immunosuppressant
and treatment is required to control the drugs and physiotherapy. In about half of
dermabrasion behaviour. (See also factitious disorder.) all cases, full recovery occurs after a
Removal of the surface layer of the skin few years. The remainder have persis-
by high-speed sanding to improve the dermatitis herpetiformis tent muscle weakness. In some cases,
appearance of scars, such as from acne, A chronic skin disease in which clus- the disease eventually affects the lungs
or to remove tattoos. ters of tiny, red, intensely itchy blisters and other organs and may be fatal.
occur in a symmetrical pattern, most
dermatitis commonly on the back, elbows, knees, dermatophyte infections
Inflammation of the skin, sometimes buttocks, and scalp. It usually develops A group of common fungal infections
due to an allergy. Dermatitis is the same in adult life and is believed to be related affecting the skin, hair, and nails, also
as eczema, and the terms can be used to coeliac disease, a condition in which called tinea or, popularly, ringworm.
interchangeably. The following are the lining of the small intestine reacts
types of dermatitis. to gluten, a constituent of wheat, rye, dermis
SEBORRHOEIC DERMATITIS and some other cereals. The inner layer of the skin.
This condition is a red, scaly, itchy rash
that develops on the face (particularly dermatology dermographism
the nose and eyebrows), scalp, chest, The branch of medicine that is con- Abnormal sensitivity of the skin to
and back. It often develops during cerned with the skin, hair, and nails, mechanical irritation, to the extent that
times of stress and is probably caused and their disorders. firm stroking leads to the appearance of
by an excessive growth of yeast on the itchy weals. The condition is a form of
skin. Corticosteroid drugs and drugs that dermatome urticaria (nettle rash). It is most com-
kill microorganisms may help. An area of skin that is supplied with mon in fair-skinned people who have a
CONTACT DERMATITIS nerve fibres by a single spinal nerve tendency to allergic conditions.
Contact dermatitis results from a reac- from the cervical, thoracic, lumbar, or
tion to some substance that comes in sacral regions of the spinal cord. dermoid cyst
contact with the skin. Common causes The entire body surface is an inter- A noncancerous tumour with a cell
are detergents, nickel, certain plants, locking pattern of dermatomes, which structure similar to that of skin. The
and cosmetics. It may be treated with is similar from one person to another. growth contains hairs, sweat glands,

223
 DERMOID TUMOUR

desensitization, allergy desmopressin

See hyposensitization. A synthetic form of ADH (antidiuretic
hormone) that is used to treat diabetes
desferrioxamine insipidus and bed-wetting (see enuresis).
A drug used to rid the body tissues of
excess iron that accumulates as a result desogestrel
of repeated blood transfusions in cer- A progestogen drug that is used with
tain types of anaemia, such as aplastic ethinylestradiol as an ingredient of some
D anaemia and thalassaemia. It is also
used to treat iron poisoning, and may
combined oral contraceptives. Desoges-
trel is reported to have a slightly higher
be used to treat excess aluminium in risk of venous thromboembolism than
people on dialysis. older drugs. Possible side effects of des-
Dermoid cyst of the ovary
Dermoid cysts commonly occur in the ovaries. They
The drug is administered by intra- ogestrel include weight changes and
can contain fragments of cartilage, bone, and, in venous injection or by subcutaneous fluid retention. There may, in addition,
this case, a whole tooth. infusion. It may be given with vitamin C be nausea, vomiting, headache, depres-
to boost excretion of the iron. Side sion, and breast tenderness.
and sebaceous glands. Dermoid cysts effects may include gastrointestinal dis-
may also contain fragments of cartilage, turbances, dizziness, and skin reactions. desquamation
bone, and even teeth. The cysts can The process by which the surface of the
occur in various parts of the body, but designer drugs epidermis (the outer layer of the skin) is
they are most commonly found in the A group of illegally produced chem- shed in the form of scales or small
ovaries and on the skin around the icals that mimic the effects of specific sheets. This process is a feature of seb-
head or neck, causing small, painless drugs of abuse. Made in illicit laborato- orrhoeic dermatitis (see dermatitis) and
swellings. Dermoid cysts only rarely ries, they are cheap to produce and ichthyosis (an inherited scaling condi-
become cancerous. undercut the street prices of drugs. tion of the skin). Desquamation of the
Surgical removal of the cysts is usually Designer drugs can cause drug depen- skin may occur after illnesses involving
recommended. (See also teratoma.) dence and drug poisoning. fever, particularly scarlet fever.
TYPES
dermoid tumour There are three major types: drugs that detached retina
See dermoid cyst. are derived from opioid analgesic drugs See retinal detachment.
(painkillers) such as fentanyl; drugs
Dermovate that are similar to amphetamines, such detergent poisoning
A brand name for clobetasol, a topical as ecstasy; and variants of phencyclidine The toxic effects that can result from
corticosteroid drug that is applied to the (PCP), a hallucinogenic drug. swallowing cleaning agents that are
skin. Dermovate is only prescribed for RISKS present in shampoos, laundry powders,
severe skin disorders that have not These highly potent drugs are not tested and household cleaning liquids. These
responded to treatment with another, for adverse effects or for the strength of effects include vomiting, diarrhoea,
weaker topical corticosteroid. the tablets or capsules, making their use and swelling of the abdomen.
hazardous. For example, some deriva-
De Sanctis–Cacchione tives of fentanyl are 20–2,000 times as detoxify
syndrome powerful as morphine. Amphetamine To remove the toxicity (the poisonous
A hereditary condition that is transmit- derivatives can cause brain damage at property) from a substance or to neu-
ted as an autosomal recessive trait (see doses only slightly higher than those tralize the substance’s toxic effects.
genetic disorders). De Sanctis–Cacchione required for a stimulant effect. Many Detoxification is one of the functions
syndrome is characterized by xeroderma designer drugs contain impurities that carried out by the liver.
pigmentosum (extreme sensitivity of the can cause permanent damage. The term “detoxification” is used to
skin to sunlight), impaired intellectual WARNING describe treatment for alcohol depen-
development, growth retardation (see Designer drugs carry a high risk of dence and also a short-term diet in
short stature), and underdevelopment of drug dependence, with severe withdrawal which toxins such as caffeine and alco-
the gonads (the testes or ovaries). reactions, and of drug poisoning, caus- hol are excluded and foods high in fats
ing effects such as brain damage. and sugar are avoided. “Detox” diets
desensitization are usually based on fruits, vegetables,
A technique that is used in behaviour desmoid tumour starches such as brown rice, and drink-
therapy for the treatment of phobias. The A growth, usually in the abdominal ing plenty of water. People who follow
patient is gradually exposed to the wall. The tumour feels hard and it these diets often feel physically and
feared object or situation while using occurs most frequently in women who mentally refreshed afterwards, although
relaxation techniques to control his or have had children, possibly due to there is no scientific evidence that the
her feelings. The exposure is carried stretching of abdominal muscles during diets eliminate toxins faster than nor-
out repeatedly over several weeks or pregnancy. They may also arise at the mal. Detox diets should be used only
months, until the person no longer sites of old surgical incisions. Removal for a few days, and preferably with
feels afraid when confronted with the of the tumour is the usual treatment, guidance from a doctor or dietician.
object or situation. but recurrence is common. They are not recommended for children

224
 DEVELOPMENTAL HIP DYSPLASIA

or adolescents, people with diabetes doctor should be consulted promptly.

mellitus or eating disorders, or those who
CAUSES OF Delays may also be detected during
have any other medical condition. DEVELOPMENTAL DELAY routine developmental checks with a
health visitor, family doctor, or paedia-
detrusor instability • Physical or emotional deprivation (child
trician. These checks are performed at
abuse). Lack of affection, stimulation,
Inappropriate contraction of the detru- or teaching. various ages, but usually at birth, six
sor muscle in the wall of the bladder weeks, six to eight months, 18 to 24
that causes an uncontrollable release of • Severe visual impairment. Vision is vital months, three years, and five years.
urine even when the bladder is not suf-
ficiently full to trigger urination. It may
for normal development in all areas.
Children learn to recognize objects
A child who shows signs of develop-
mental delay should undergo a full
D
before learning their names, they learn
have various causes, including bladder about sounds by seeing which objects
assessment. This will usually include a
inflammation, obstruction of the blad- make which sounds, and they become physical examination, along with hear-
der outlet (for example, by a stone or, motivated to crawl and walk by the ing tests, vision tests, and a thorough
in men, by an enlarged prostate gland), desire to explore their surroundings developmental assessment. The child
or damage to the nerves supplying the (see vision, disorders of; blindness). may need to undergo further investiga-
bladder. (See also incontinence, urinary.) tions, such as blood tests, to check for
• Severe hearing impairment (see deafness). any genetic abnormality, or referral to a
Deutschländer’s disease specialist such as a neurologist, speech
A tumour of one of the metatarsal bones • Learning difficulties.
therapist, or physiotherapist.
in the foot. TREATMENT
• Damage to the brain before, during, or
The treatment depends on the severity
after birth, or in infancy. The results of
development damage depend on which parts of the and probable cause of the delay. It may
The process of growth and change by brain are damaged and on severity (see include a course of speech therapy or
which an individual matures physically, brain damage; cerebral palsy). family therapy, or provision of physical
mentally, emotionally, and socially. It aids such as glasses or a hearing aid. Par-
takes place in major phases: during the • Severe, prolonged disease of any organ or ents are often of prime importance in
first two months of pregnancy (see body system (such as bone, heart, kidney, providing help for their child. In some
muscle, and nutritional disorders).
embryo), and, to a lesser extent, during cases, however, the child may also ben-
the rest of pregnancy (see fetus); dur- efit from being admitted to a school or
ing the first five years of life (see child special unit that provides education for
development); and then again during skills (the ability to pick up and use children with specific difficulties.
puberty and adolescence. objects with the hands) is often due to
lack of adequate stimulation. developmental hip dysplasia
developmental delay Delayed speech development may A disorder present at birth in which the
A term used if a baby or young child have various causes. The most impor- head of the femur (thigh-bone) fails to
has not acquired new skills within the tant is deafness, which may cause the fit properly into the cup-like socket in
expected time range. Normally, new child to be unresponsive to sound. the pelvis to form a normal joint. One
abilities and new patterns of behaviour Autism is a rare cause; in this condition, or both of the hips may be affected.
appear at given ages, and existing hearing is normal but the child may CAUSE AND INCIDENCE
behaviour patterns change and some- be unresponsive to the human voice. The cause of developmental hip dyspla-
times disappear (see child development). Another possible cause is generalized sia is not known. The condition is more
Delays vary in severity, and may difficulty with muscle control, which common in girls, especially in babies
affect the development of one or more may affect speech production; this may born by breech delivery or following
of the following skills: hand–eye coor- occur in children who have cerebral pregnancies in which there was an
dination, walking, listening, language, palsy. Damage to, or structural defects abnormally small amount of amniotic
speech, or social interaction. of, the speech muscles, the larynx fluid surrounding the fetus.
GENERALIZED DELAY (voicebox), or the mouth may also TREATMENT
A child who is late in most aspects of cause speech difficulties, as may any If the dislocation is detected in early
development usually has a generalized disorder that affects the speech area of infancy, splints are applied to the thigh
problem. This may be due to a severe the brain (see aphasia; dysarthria; dys- to manoeuvre the ball of the joint into
visual or hearing impairment, limited phonia; speech disorders). the socket and keep it in position.These
intellectual abilities (see learning difficul- Children vary enormously in the age splints are worn for about three
ties), or damage to the brain before, at which they gain control of bladder months and usually correct the prob-
during, or after birth. For further infor- and bowel function. Usually, bowel lem. Progress may be monitored by
mation on possible causes of generalized control is acquired first. Delay in blad- ultrasound scanning and X-rays. Correc-
delay, see the table above. der control is much more common tive surgery may also be required.
SPECIFIC FORMS OF DELAY than delay in bowel control. Such OUTLOOK
Delay in movement and walking often delays have many possible causes (see If treatment is delayed, there may be
has no serious cause. In some cases, enuresis; encopresis; soiling). lifelong problems with walking. With-
however, there are specific causes; these ASSESSMENT out treatment, the dislocation often
can include muscular dystrophy and spina Delays may first be noticed by parents; leads to shortening of the leg, limping,
bifida. Delay in developing manipulative if this is the case, a health visitor or and early osteoarthritis in the joint.

225
 DEVIATED NASAL SEPTUM

deviated nasal septum physical tolerance develops: the drug’s dextromethorphan

See nasal septum. stimulant effects lessen and a higher A cough suppressant that is available
dose must then be taken to produce the over the counter as an ingredient in
deviation, sexual same effect. Drug dependence (a physical many cough remedies.
An abnormal form of sexual behaviour, or mental need for the drug) also
most common in men, in which sexual develops after repeated use. dextromoramide
intercourse between adults is not the An opioid analgesic drug related to
final aim. Forms of sexual deviation DEXA scan opium that is used to relieve severe pain
D include exhibitionism, fetishism, paedo-
philia, and transvestism.
Dual-energy X-ray absorptiometry, a
technique that measures bone density
following injury or surgery and during
long-term illnesses. It relieves pain
by passing beams of low-dose radiation quickly but has only a short duration of
Devic’s disease through bone. DEXA scans are used to action. Regular use of dextromoramide
A rare condition, sometimes called assess the severity of the bone disorder can produce drug dependence.
neuromyelitis optica, in which there is osteoporosis. (See also densitometry.)
demyelination of the fibres in the optic dextropropoxyphene
nerves and the spinal cord. The condi- dextran A weak opioid analgesic drug that is
tion begins with inflammation of the A polysaccharide (a type of carbo- included in some compound analgesic
optic nerves (see optic neuritis), leading hydrate) consisting of branched chains preparations. The drug works rapidly
to loss of vision. There are also attacks of glucose units. Dextrans that are and relieves mild to moderate pain for
of numbness, muscle weakness, and formed by the action of bacteria on about four hours. Adverse effects of this
loss of coordination in the parts of the sucrose in the mouth produce plaque (a drug may include drowsiness, dizzi-
trunk and limbs below the diseased rough, sticky coating on the teeth), ness, nausea, and vomiting.
area of the spine. In addition, the spinal which is a major cause of tooth decay
cord damage may lead to disruption of (see caries, dental). dextrose
urinary and bowel control and impair- Commercially manufactured prepar- Another name for glucose.
ment of sexual function. ations of synthetic dextran solution
may be used in surgery or in emer- diabetes, bronze
dexamethasone gency treatment for shock, to increase Another name for haemochromatosis, a
A corticosteroid drug prescribed as a the volume of the plasma (the fluid part rare genetic disease in which excessive
nasal spray to relieve nasal congestion of the blood) in the circulation. Dex- amounts of iron are deposited in tis-
caused by allergic rhinitis (hay fever), as trans used for this purpose are known sues. Bronze diabetes causes a bronze
eye drops in the treatment of iritis as plasma expanders. skin coloration, and sufferers often
(inflammation of the iris), and as develop diabetes mellitus.
eardrops in the treatment of otitis externa dextrocardia
(outer-ear infection). A rare condition, which is present from diabetes insipidus
Dexamethasone is given in tablet birth, in which the heart is situated in, A rare condition that is characterized
form or by injection to treat severe and points towards, the right-hand side by excessive thirst and the passing of
asthma and other inflammatory disor- of the chest instead of the left. The large quantities of dilute urine. A per-
ders, and to reduce inflammation of heart may also be malformed. Some- son with diabetes insipidus may pass
the brain due to head injury, stroke, or a times, the position of the abdominal between five and 20 litres of urine
brain tumour. It may also be injected organs is also reversed, so that the liver every 24 hours, provided that this out-
into an inflamed joint to relieve the is on the left-hand side and the stom- put is matched by a sufficient intake of
symptoms of osteoarthritis. ach is on the right. The cause of water. If the lost water is not replaced,
Dexamethasone nasal spray may cause dextrocardia is not known. dehydration may occur, leading to con-
nosebleeds; eye drops may cause irrita- No treatment is necessary unless the fusion, stupor, and coma.
tion of the eyes. Prolonged use or high heart is malformed, in which case sur- Diabetes insipidus usually results
doses of dexamethasone tablets may gical correction may be performed. from a failure of the pituitary gland to
cause the adverse effects common to secrete ADH (antidiuretic hormone),
the corticosteroid group of drugs. which normally regulates the amount
of water excreted in the urine. This fail-
dexamfetamine ure may be due to a disease of the
A central nervous system stimulant (see pituitary gland, or may temporarily fol-
amphetamine drugs; stimulant drugs) low brain surgery. A rare form of the
sometimes used to treat narcolepsy (a disease, called nephrogenic diabetes
sleep disorder). It is also used in chil- insipidus, is due to failure of the kid-
dren with attention deficit hyperactivity neys to respond to ADH.
disorder who have not responded to Diagnosis mainly involves blood and
treatment with methylphenidate. urine tests. A doctor may measure out-
Abnormal position Normal position
Because of its stimulant properties, put of urine over 24 hours. He or she
Heart positions
dexamfetamine has become a drug of In dextrocardia, the heart is situated in, and points may also measure urine output when
abuse. Excessive use leads to anxiety and towards, the right-hand side of the chest instead fluid has been withheld for several
drug psychosis. With prolonged use, of the left-hand side. hours; an affected person will continue

226
 DIABETES MELLITUS

LIVING WITH DIABETES MELLITUS

As the level of glucose in the blood Fatigue

rises, the volume of urine required to SELF-MONITORING OF
carry it out of the body is increased, Blurred BLOOD GLUCOSE LEVELS
vision
causing not only a frequent need to
Testing of
urinate but also constant thirst. The Constant blood glucose
high levels of sugar in the blood and thirst A spring-loaded
urine impair the body’s ability to
fight infection, leading to urinary
pricking device is
used to obtain
D
tract infections (such as cystitis blood from the
Muscle fingertip. A drop of
and pyelonephritis), vaginal yeast weakness blood is spread on
infections (candidiasis), and
to a chemically
recurrent skin infections. impregnated strip.
Because the body’s cells are Pyelonephritis
and frequent The strip is inserted
starved of glucose, the sufferer need to urinate into a digital
feels weak and fatigued (see right). glucose meter,
The cells are able to obtain some which analyses the
Cystitis blood and gives an
energy from the breakdown of
stored fat, resulting in weight loss. almost instant
Candidiasis
reading of the
The chemical processes involved in
glucose level.
this breakdown of fat are, however,
defective, especially in insulin- Tingling and
dependent diabetics. They lead numbness in
to the production of acids and hands and feet
Symptoms of untreated
substances known as ketones, diabetes mellitus
which can cause coma and
sometimes death.
Other possible symptoms of DEVICES FOR INJECTING INSULIN
undiagnosed diabetes include
blurred vision, boils, increased Insulin can be injected using a disposable syringe
appetite, and tingling and numbness and needle or a pen with refill cartridges (below),
in the hands and the feet. or it may be infused continuously from a portable
Symptoms will develop in every pump (right).
untreated person who has insulin-
dependent (Type 1) diabetes, but
will appear in only one third of
Cannula
those who have the noninsulin- Insulin
dependent form (Type 2). There are pen Pump
many people with Type 2 diabetes Refill cartridge Portable pump
who are unaware of it. The disease Insulin pen The pump infuses insulin
is often diagnosed only after This device is useful if multiple by way of a cannula
complications of the diabetes have daily injections are needed. inserted through the skin.
been detected.

to pass a large volume of urine. The to generate energy, and enables the liver to developing the condition; the disease
person’s response to synthetic ADH may and fat cells to take in glucose for stor- process may be triggered by viral infec-
also be tested; if the urine output age. A lack of insulin in the cells may tion. They must have insulin injections
remains high even after the person has occur because the pancreas produces or they may fall into a coma and die.
taken ADH, this indicates the nephro- too little, or none at all; alternatively, it Type 2 (non-insulin-dependent) dia-
genic form of the disease. may occur because the tissues are resis- betes tends to develop gradually, mainly
Treatment of ADH-related diabetes tant to the hormone’s effects. in people over the age of 40. This type
insipidus is with desmopressin (syn- TYPES, CAUSES, AND INCIDENCE is becoming more common in younger
thetic ADH). Treatment of nephrogenic There are two main types of diabetes people, however, and is probably linked
diabetes insipidus is by a low-sodium mellitus, both of which tend to run to dieting. Although insulin is still pro-
diet and thiazide diuretic drugs. in families. Type 1 (insulin-dependent) duced, there is not enough to meet
diabetes usually develops suddenly in the body’s needs because the tissues
diabetes mellitus childhood or adolescence. This type of become relatively resistant to its effects.
A disorder that develops when the cells diabetes is an autoimmune disorder in Obesity and inheritance are possible
of the body do not receive enough which the immune system destroys contributory factors; many people who
insulin. This hormone is produced by insulin-secreting cells in the pancreas develop Type 2 diabetes are overweight,
the pancreas; it normally enables body and insulin production ceases. Affected and affected people often have close rel-
cells to take in glucose from the blood people may be genetically predisposed atives with the condition.

227
 DIABETIC ARTHROPATHY

Diabetes mellitus affects more than 120 confirmed by a blood test to detect OUTLOOK
million people worldwide. Type 2 dia- abnormally high levels of glucose in With modern treatment and efficient
betes is by far the more common form the blood. If the results of this test are self-monitoring, people with diabetes
of the disease. About 1 in 50 people in unclear, a glucose tolerance test may be mellitus can usually live a normal life;
the UK has this type. It is three to four done. The person is asked to fast for however, the disease is irreversible and
times more common in black people, several hours, and then is given glu- life expectancy is reduced.
and seven times more common in cose; the blood and the urine are tested
Asians. It also becomes more common at 30-minute intervals to show how diabetic arthropathy
D with increasing age.
SYMPTOMS
efficiently the body is utilizing the glu-
cose. Tests may also be carried out to
Joint damage associated with diabetes
mellitus. It results from the loss of pro-
Lack of insulin causes high levels of detect and assess damage to organs tective pain sensation that can occur
glucose to remain in the blood. This, in such as the eyes, kidneys, and heart. when peripheral nerves are damaged
turn, results in a high level of glucose Treatment aims to keep blood glu- (see diabetic neuropathy). The condition
in the urine. This condition, termed gly- cose levels as normal as possible. often affects the joints in the legs; the
cosuria, causes the passage of large Dietary control is an essential element. ankle is particularly vulnerable.
quantities of urine, excessive thirst, and The ideal diet for a person with dia- Affected joints (called neuropathic
urinary tract infections. Lack of glucose in betes resembles the sort of healthy joints or Charcot’s joints) tend to be
the cells causes weight loss, hunger, eating plan recommended for everyone swollen and deformed but painless.
and fatigue, and leads to chemical (see diabetic diet). If the person is over- Treatment includes fitting a special cast
imbalances. For further information on weight, and particularly if he or she has to reduce swelling in the limb, and the
the symptoms, see the illustrated box Type 2 diabetes, weight loss can be use of supportive footwear.
on the previous page. achieved by a reduced-calorie diet.
In Type 1 diabetes, symptoms such as Also, regular exercise and treatment diabetic cataract
thirst, weight loss, and excessive urina- with antidiabetic drugs may be required. An opacity in the lens of the eye (see
tion usually develop rapidly over a few In addition to general treatment, all cataract) due to diabetes mellitus. The
weeks. If it is not promptly diagnosed people with Type 1 diabetes need to have slow-growing opacities that often
and treated at this stage, it may lead to regular injections of insulin. The injec- appear in old age (senile cataracts) tend
diabetic ketoacidosis, which is a poten- tions are usually self-administered two, to develop 10–15 years earlier than
tially fatal condition. three, or four times a day. The insulin usual in people who have diabetes.
Type 2 diabetes may be present for doses need to be matched to activity lev- Occasionally, young people with poorly
months or years while causing few els and food intake. If the glucose/insulin controlled diabetes develop juvenile
noticeable symptoms. It may only be balance is not maintained, hyperglycaemia cataracts, which are diffuse opacities
diagnosed when a complication (see (too much glucose in the blood) or hypo- that develop rapidly. Treatment for dia-
below), such as poor vision, is detect- glycaemia (too little glucose in the blood) betic cataract is the same as for other
ed during a medical check-up. may develop. Careful monitoring of forms of cataract.
COMPLICATIONS blood glucose levels is also an essential
Some complications of diabetes mellitus part of self-treatment. Pancreas trans- diabetic coma
result from damage to capillaries (tiny plants have been tried as a possible cure A life-threatening state of uncon-
blood vessels) throughout the body. for the condition, but with little success. sciousness and unresponsiveness, due
These conditions include retinopathy Research is being done on a possible either to diabetic ketoacidosis or to hypo-
(damage to the retina, which is the light- treatment involving transplantation of glycaemia. The latter condition may be
sensitive part of the eye) and diabetic clusters of insulin-producing cells. induced either by excessive doses of
nephropathy (kidney damage). Damage to Treatment of type 2 diabetes usually oral hypoglycaemic drugs or by an inad-
the blood vessels supplying nerves causes consists of dietary measures, weight equate intake of food.
diabetic neuropathy (damage to nerve reduction, exercise, and antidiabetic
fibres); this may first appear in the fin- drugs, often hypoglycaemic drugs such diabetic diet
gers and toes, then spread up the limbs. as sulphonylureas. Some people eventu- A nutritional regime designed to pre-
The loss of sensation, and poor circula- ally need insulin injections. vent complications of diabetes mellitus
tion, may result in ulcers on the feet and In general, careful control of blood by controlling the timing and amount
legs. Other problems include dizziness glucose levels reduces the risk of com- of energy intake, thereby minimizing
on standing and, in men, impotence. plications or, if such problems have the occurrence of hyperglycaemia (high
People with diabetes have a greater already developed, slow their progres- blood glucose levels) or hypoglycaemia
risk of developing atherosclerosis (accu- sion. People with diabetes should have (low blood glucose levels).
mulation of fatty deposits on the lining regular medical check-ups so that any People with diabetes should follow
of the arteries), hypertension (high complications can be detected as early the same kind of healthy diet that is
blood pressure), other cardiovascular as possible. Additional tests, such as recommended for people in general
disorders, and diabetic cataract (opacity measurement of glycosylated haemoglo- (see nutrition). The diet should be rich
in the lens of the eye). bin (which shows blood glucose levels in complex carbohydrates (such as
DIAGNOSIS AND TREATMENT over the previous three months) and bread and pasta) and contain less than
If diabetes mellitus is suspected, a urine urine tests to detect proteinuria, can 30 per cent fat. In addition, the energy
sample will be taken and tested for the improve medical control and aid early intake (see calorie) needs to be con-
presence of glucose. The diagnosis is detection of problems. trolled in order to maintain a healthy

228
 DIABETIC PREGNANCY

body weight. People who take insulin disorder, intermittent pain and tingling head and face; damage to nerves sup-
need to coordinate their meals with the are felt in the extremities, particularly plying the eye muscles causes impaired
times for their insulin injections. in the feet. The pain gradually worsens vision and eye pain.
until, finally, pain sensation is lost to an
diabetic ketoacidosis area. People with sensory neuropathy diabetic pregnancy
A severe, acute complication of Type 1 in the feet can develop cuts, scrapes, or Pregnancy associated with diabetes mel-
diabetes mellitus, a condition in which blisters that they may not notice. If left litus. The term “diabetic pregnancy”
the pancreas produces too little insulin. untreated, serious complications may may refer to a pregnancy in a woman
If levels of insulin are too low, the liver
generates more glucose, but the tissues
result from such injuries. Daily obser-
vation of the feet is critical.
with pre-existing diabetes, or to dia-
betes that develops during pregnancy;
D
are unable to take up the glucose prop- Another form of diabetic neuropathy in the latter case, the condition is
erly and have to break down fats to is damage to motor nerves (which ini- known as gestational diabetes.
obtain energy, causing the production tiate movements). This problem causes Women with established diabetes can
of acidic chemicals called ketone bod- weakened muscles. The foot is particu- have a normal pregnancy provided that
ies. Diabetic ketoacidosis may be the larly susceptible, and may undergo a the diabetes is well controlled. Careful
first sign that a person has insulin- change of appearance as a result. A fur- control of blood glucose levels must
dependent diabetes, or it may develop ther form, diabetic amyotrophy, causes begin well before conception. Poor con-
in a person known to have the condi- painful wasting of the thigh muscles. trol may affect the baby’s growth, and
tion who has taken insufficient insulin. Autonomic neuropathies affect the increase the risk of fetal malformations
The features of diabetic ketoacidosis nerves that regulate involuntary vital and complications during pregnancy.
include nausea; vomiting; deep, rapid functions. Symptoms and signs include In gestational diabetes, the mother
breathing; breath that smells of acetone postural hypotension (low blood pres- does not produce enough insulin to
(like nail polish remover); and confu- sure on standing); diarrhoea at night; keep blood glucose levels normal. The
sion. The condition can progress to inability to empty the bladder com- condition is usually detected in the sec-
severe dehydration and coma. pletely, which may lead to urinary tract ond half of pregnancy, when urine tests
Treatment of diabetic ketoacidosis infection; and impotence. Cranial neuro- reveal the presence of glucose. Treat-
involves giving insulin to correct the pathies affect nerves that supply the ment is the same as for women who
deficiency and fluids containing salts to
relieve dehydration.
STEPS IN DIAGNOSING A CONDITION
diabetic maculopathy
A doctor may go through several steps a provisional diagnosis before
See maculopathy, diabetic. to ascertain the cause of a person’s beginning any treatment because
problem. The medical history, physical treatment can mask symptoms, making
diabetic nephropathy examination, and tests may prove vital the doctor’s task of establishing an
Kidney damage resulting from long- clues. A doctor usually makes at least exact diagnosis more difficult.
standing or poorly controlled diabetes
mellitus. The disorder includes damage Taking the medical history
to capillaries (tiny blood vessels) in the Perhaps the most important part of the given to medical students. Many doctors believe
kidneys and hardening of the tissues. As diagnostic procedure is the patient’s own that the medical history provides the strongest
account of his or her illness – the medical basis for ascertaining a diagnosis. The added
a result, the kidneys become less able to history. “Listen to the patients, they are telling information derived from the physical
filter the blood efficiently. Protein may you their diagnosis” is the traditional teaching examination may be small, but, at times, critical.
escape into the urine, depleting the
body’s supplies (see nephrotic syn- Conducting a physical examination
drome). In severe cases, chronic kidney After the medical history has been obtained, is a group of possible diseases that could
failure may develop. Many affected peo- the doctor has in mind a short list of probable account for patterns of symptoms and signs
ple have hypertension (high blood diagnoses. A physical examination helps (i.e., physical findings, such as enlargements
shorten the list. The doctor is then left with a of lymph nodes or tenderness in a specific
pressure), which may also cause dam- differential diagnosis. A differential diagnosis region of the abdomen).
age to the blood vessels.
People with diabetes should have
Ordering special tests
regular check-ups so any kidney prob- Next, based on his or her provisional diagnosis, scanning, X-rays, CT scanning, MRI, or
lems can be treated as soon as possible. the doctor may order a series of laboratory tests radionuclide scanning. The results of these tests
Checks may include urine tests for pro- on the blood (and sometimes the urine) and may either confirm the doctor’s provisional diagnosis
tein, as well as kidney function tests. also arrange for diagnostic imaging of suspect or narrow the possibilities so the doctor may be
organs by techniques such as ultrasound confident in making the correct diagnosis.
diabetic neuropathy
Any of various types of neuropathy (dis- Using a computer
Doctors today also use computer systems and assistance is to remind the doctor of the full
ease of or damage to the nerves) that algorithms to help reach a diagnosis. Both range of possible diagnoses for a particular
result from longstanding or poorly approaches rely on analysis of large numbers set of symptoms, thereby making it less likely
controlled diabetes mellitus. of patient records to quantity probabilities and that any possibility will be overlooked. It
The most common type of diabetic to devise an orderly series of questions – a remains the task of the doctor to integrate the
neuropathy is called peripheral sensory decision tree. The main purposes of computer facts and decide upon a diagnosis.
neuropathy. In the early stages of this

229
 DIABETIC PREGNANCY

PROCEDURE FOR DIALYSIS

There are two methods of removing wastes from the blood and
excess fluid from the body when the kidneys have failed. The WHY IT IS DONE
first, haemodialysis, may also be used as emergency treatment
in some cases of poisoning or drug overdose. It makes use of In people with damaged kidneys, the process of
an artificial kidney (or “kidney machine”) and can be carried maintaining the balance of electrolytes and water, and
out at home. Peritoneal dialysis needs an abdominal incision, of excreting waste products, may fail, causing harmful,
D which is performed in hospital but may also be done at home. even life-threatening, effects. Dialysis can take
over the function of the kidneys until they
HOW HAEMODIALYSIS IS DONE start working normally again. Or dialysis
can function for the kidneys for the rest
Access to the
1dialysis
bloodstream for
is obtained by a
of a seriously affected person’s life if a
kidney transplant is not performed.
shunt (in the short term
or in an emergency) or an Diseased kidney
arteriovenous fistula, in The kidney at left was removed from a person
which an artery is joined with adult polycystic kidney disease – one of
surgically to a vein. Vein Shunt many disorders that may damage kidney function
Shunt sewn to the extent that dialysis is needed.
Artery into blood vessel

Saline solution
2carriesAtheneedle inserted into
shunt or fistula
blood to the
3calledThe membrane separates the
patient’s blood from a special fluid
dialysate. Wastes, toxic molecules,
Artificial
machine. The machine kidney Blood pump and excess fluid pass across the membrane
pumps the blood through machine from the blood into the dialysate.
a filter attached to its Blood cell
side. Once inside the
filter, the blood flows on
one side of a membrane, Connection
and dialysate fluid flows Blood to vein
on the other. Waste filter
products and water pass Artificial
from the blood, across the membrane
membrane, and into the
dialysate fluid. The filtered
blood returns from the
machine to the body via
another needle inserted Dialysate Waste
into the shunt or fistula. tubing Dialysate chemicals

4EachThe dialysate is discarded and the

purified blood returned to the patient.
session lasts from two to six hours.

HOW PERITONEAL DIALYSIS IS DONE

A small abdominal incision is made, and a catheter is
1attached
inserted into the peritoneal cavity. A bag of dialysate is
to the catheter; the fluid passes into the cavity,
where it is left for several hours. Used fluid is then drained
out of the abdomen. Dialysate
tubing
Spinal column
Intestine Blood cell
Catheter Fluid Peritoneal Capillary
membrane wall

Bag for
used fluid
Fluid 2liningWaste products, and excess
water from the blood vessels
the peritoneal cavity, seep
Used fluid

through the peritoneal membrane

Bladder
into the cavity and mix with the
dialysate. The fluid is allowed to The bag is discarded and replaced with
drain out (by the release of a clamp)
through the catheter and into the
3procedure,
a bag containing fresh dialysate. The
which takes about an hour, can
empty dialysate bag. be performed during the day or overnight.

230
 DIAPHRAGM MUSCLE

have pre-existing diabetes mellitus. blood pass across a membrane into a Dianette
Gestational diabetes disappears after the solution called a dialysate, which is A brand name for a combination of
birth, but it is associated with an then discarded. cyproterone acetate with ethinylestradiol
increased risk of the woman develop- Haemodialysis filters out wastes by (synthetic sex hormones). Dianette may
ing Type 2 diabetes in later life. passing blood through an artificial kid- be used to treat severe acne or hirsutism
ney machine. The process needs to be (excessive hairiness) in women.
diabetic retinopathy performed three or four times a week,
See retinopathy. and each session lasts two to six hours. diaphragmatic hernia
diagnosis
In peritoneal dialysis, the abdominal
cavity is filled with dialysate, which is
The protrusion of an abdominal struc-
ture through the diaphragm muscle into
D
The process of identifying or finding changed regularly, and the peritoneum the thorax (chest cavity). The most
out the nature of a disorder. The doctor (the membrane lining the abdominal common form of this problem is a hia-
listens to a patient’s account of his or cavity) acts as a natural filter. The pro- tus hernia, in which part of the stomach
her illness, and may carry out a physical cedure is often carried out overnight or protrudes through the space in the
examination. If further information is continuously during the day and night. diaphragm that is normally occupied
needed, tests or imaging procedures may RISKS by the oesophagus.
be ordered after a provisional diagnosis Both types of dialysis carry the risk of
has been formed (see Steps in diagnos- upsetting body chemistry and fluid bal- diaphragm, contraceptive
ing a condition box, previous page). ance, which can cause complications. A female barrier method of contracep-
In addition, peritoneal dialysis carries a tion in the form of a hemispherical
diagnostic ultrasound risk of infection in the peritoneum. dome of thin rubber with a metal
The use of high-frequency sound waves spring in the rim. The diaphragm is
to form images of internal organs and diamorphine inserted into the vagina and positioned
so help doctors to make diagnoses (see A synthetic, opioid analgesic similar to over the cervix. (See also contraception,
ultrasound scanning). Certain forms of morphine; diamorphine is another name barrier methods.)
ultrasound scanning are used to form for heroin. It is used to relieve severe pain
moving images, such as images of the and to relieve distress in acute heart failure. diaphragm muscle
flow of blood through the heart (see Diamorphine carries the risk of depen- The dome-shaped sheet of muscle that
Doppler echocardiography). dence. It may cause nausea, vomiting, and separates the chest from the abdomen.
constipation. (See also heroin abuse.) The diaphragm is attached to the spine,
dialysis
A filtering technique used to remove
waste products from the blood and ANATOMY OF THE DIAPHRAGM
excess fluid from the body as a treat-
The diaphragm is attached to the spine, the lower pairs of ribs,
ment for kidney failure. and the lower end of the sternum (breastbone). Its muscle fibres
WHY IT IS DONE converge on the central tendon, which is a thick, flat plate of dense
Each day, the kidneys normally filter fibres. There are openings in the diaphragm for the oesophagus,
about 1,500 litres of blood. They help the phrenic nerve (which controls diaphragm movements and
to maintain the fluid and electrolyte bal- hence breathing), and the aorta and vena cava (the body’s main
ance of the body. Important minerals blood vessels).
and nutrients, such as potassium, sodi-
um, calcium, amino acids, glucose, and Rib
water are reabsorbed into the blood. Sternum
Urea, excess minerals, toxins, and drugs Diaphragm
are excreted in the urine. muscle
Dialysis is used to perform this func- Outline
Attachment of lung
tion in people whose kidneys have been
of diaphragm
damaged due to acute or chronic kidney to rib cage Central
tendon
failure. Without dialysis, wastes accumu- and sternum
late in the blood and the electrolyte Phrenic
nerve
levels become unbalanced; this may be Inferior
vena cava
life-threatening. In chronic kidney fail-
ure, patients may need to have dialysis
Aorta
several times a week for the rest of their Cut edge of
diaphragm
lives or until they can be given a kidney
transplant. In acute kidney failure, dialy-
sis is carried out more intensively until
the kidneys are working normally. Spine Oesophagus
HOW IT IS DONE
There are two methods: haemodialysis
and peritoneal dialysis. In both proce-
dures, excess water and wastes in the

231
 DIAPHYSIS

ribs, and sternum (breastbone). It has lateand loperamide may help if the diar- prescribed as a muscle-relaxant drug, as
openings for the oesophagus and major rhoea is disabling. They should not, an anticonvulsant drug in the emergency
nerves and blood vessels. however, be used to treat attacks of treatment of epilepsy, and to treat alco-
The diaphragm plays an important diarrhoea in children. hol withdrawal symptoms in people
role in breathing. During inhalation, its who are dependent on alcohol. It may
muscle fibres contract, causing it to diastole also be administered intravenously in
move downwards and drawing air into The period in the heartbeat cycle when order to produce sedation in people
the lungs. During exhalation, the dia- the heart muscle is at rest; it alternates undergoing certain medical procedures,
D phragm muscle relaxes and it moves
upwards, causing air to leave the lungs.
with systole, the period of muscular
contraction. (See also cardiac cycle).
such as endoscopy.
Diazepam may cause drowsiness,
(See also breathing.) dizziness, and confusion; therefore,
diastolic pressure driving and hazardous work should be
diaphysis The lowest level of blood pressure mea- avoided while taking the drug. Alcohol
The shaft, or central portion, of a long sured in the main arteries. Diastolic increases the sedative effects of the
bone, such as the femur (thigh-bone). pressure is the pressure between heart- drug, and should not be consumed
During bone formation, the epiphysis beats, when the ventricles (the lower while diazepam is being used.
(end of the long bone) develops inde- chambers of the heart) are relaxed and Like other benzodiazepines, diaze-
pendently from the diaphysis, as they filling with blood. Systolic pressure, the pam can be habit-forming if it is taken
are initially separated by a mass of car- highest level of blood pressure in the regularly, and its effects diminish with
tilage known as the epiphyseal plate. main arteries, occurs when the ventri- prolonged use. Individuals who have
The diaphysis and epiphysis eventually cles of the heart contract. been taking diazepam regularly for
fuse to form a complete bone. The normal range of blood pressure more than two weeks should never stop
varies with age and between individu- their treatment suddenly; instead, they
diarrhoea als, but a young adult usually has a should gradually decrease the dose of
An increase in the fluidity, frequency, or diastolic pressure of about 80 mmHg the drug, under medical supervision, in
volume of bowel movements, as comp- (mm of mercury) and a systolic pres- order to avoid withdrawal symptoms
ared to the usual pattern for a particular sure of about 120 mmHg. A persistently (such as anxiety, sweating, or, rarely,
individual. Diarrhoea may be acute or high diastolic pressure occurs in most after large doses, seizures).
chronic. The condition can be very seri- cases of hypertension.
ous in infants and in elderly people DIC
because of the risk of severe, potentially diathermy See disseminated intravascular coagulation.
fatal, dehydration. The production of heat in a part of the
CAUSES body using high-frequency electric diclofenac
Acute diarrhoea is usually a result of currents or microwaves. Diathermy can A nonsteroidal anti-inflammatory drug
consuming food or water contaminated be used to increase blood flow and to (NSAID) that is used to relieve pain and
with certain bacteria or viruses (see reduce some types of deep-seated pain, stiffness in arthritis and to hasten recov-
food poisoning). Infective gastroenteritis for example in rheumatic or arthritic ery following injury to muscles or
also causes diarrhoea and may be conditions. Diathermy can also be used ligaments. Possible adverse effects of
acquired as a result of droplet infec- to destroy tumours and diseased areas the drug include nausea, abdominal
tion. Other causes of acute diarrhoea of tissue without causing bleeding. A pain, and peptic ulcer.
include anxiety and, less commonly, diathermy knife is used by surgeons to
amoebiasis, shigellosis, typhoid fever and coagulate bleeding vessels or to sepa- Didronel
paratyphoid fever, drug toxicity, food rate tissues without causing them to A brand name for disodium etidronate
allergy, and food intolerance. bleed (see electrocoagulation). (see etidronate, disodium), which is a
Chronic diarrhoea generally takes bisphosphonate drug. Didronel is used to
the form of repeated attacks of acute diathermy, short-wave treat bone disorders such as Paget’s dis-
diarrhoea. Such a pattern may be the See short-wave diathermy. ease and osteoporosis.
result of an intestinal disorder such as
Crohn’s disease, ulcerative colitis, cancer diathesis diet
of the colon (see colon, cancer of), or A predisposition towards certain disor- See nutrition.
irritable bowel syndrome. Diarrhoea that ders. For example, a bleeding diathesis
recurs, persists for more than a week, is present when a bleeding disorder diet and disease
or is accompanied by blood requires (such as haemophilia) makes a person A variety of diseases are linked with
medical investigation. susceptible to prolonged bleeding after diet. Diseases due to a deficiency of
TREATMENT an injury. A diathesis may be inherited nutrients are a major problem in poor
The water and electrolytes (salts) lost or it may be acquired as a result of an countries. In children, starvation or
during a severe attack of diarrhoea illness or an injury. malnutrition may result in marasmus or
need to be replaced to prevent dehy- kwashiorkor, while vitamin deficiencies
dration. Ready-prepared powders of diazepam may cause rickets or keratomalacia (a
electrolyte mixtures can be bought One of the benzodiazepine drugs, used condition that causes blindness). Vita-
from chemists (see rehydration therapy). mainly for the short-term treatment of min deficiencies may lead to beriberi,
Antidiarrhoeal drugs, such as diphenoxy- anxiety and insomnia. Diazepam is also pellagra, or scurvy.

232
 DIGEORGE SYNDROME

(high blood pressure) and heart failure; diethylstilbestrol

GOOD DIETARY HABITS neurological disorders such as Wer- A synthetic form of the female sex hor-
nicke–Korsakoff syndrome; and mental or mone oestrogen, occasionally used to
• Eat fresh rather than preserved,
behavioural problems such as depres- treat prostate cancer (see prostate, cancer
packaged, or convenience foods.
sion or violence. of) and, in postmenopausal women
SALT only, to treat breast cancer. Common
• Eat plenty of vegetables and at least five
A high salt intake may predispose a adverse effects include nausea, oedema
portions of fruit every day. When raw or
lightly cooked, they retain a higher person to hypertension. (fluid retention) and breast enlarge-
nutritional value. FIBRE
Fibre, found in fruit, vegetables, and
ment (gynaecomastia) in men. D
• Eat whole-grain products, including grains, provides bulk, which helps the differential diagnosis
wholemeal bread. passage of food through the intestine One of two or more different disorders
and also aids the absorption of nutri- that could be the cause of a patient’s
• Cut down consumption of red meat; ents (see fibre, dietary). A lack of fibre is symptoms. If certain symptoms, such as
instead, eat fish, poultry, and pulses. thought to be a contributory factor in abdominal pain, might be caused by
digestive disorders such as diverticular various disorders, a doctor will carry
• Keep the fat content of your diet low and disease (a condition in which abnormal out further tests, observe the patient’s
use polyunsaturated fats and vegetable pouches form in the colon), chronic response to particular treatments, or
oils rather than saturated fats.
constipation, and haemorrhoids. monitor the course of the disease in
VITAMINS order to arrive at the true diagnosis.
• Cut down on sugar and salt in all foods.
Many people’s diets contain too few
natural vitamins; to remedy this prob- differentiation
• When choosing filling foods, eat
lem, it is better to eat vitamin-rich The process by which the cells of the
potatoes in their skins, pasta, or rice.
foods than to take vitamin supple- early embryo, which are almost identical
ments. Women who are planning a and have not yet taken on any particular
pregnancy need to increase their intake function, gradually diversify to form
In affluent countries, diseases due to of folic acid in order to reduce the risk the distinct tissues and organs of the
deficiency are rare, occurring only in of neural tube defects in the baby. more developed embryo.
certain groups of people (such as alco- FOOD ALLERGIES The word “differentiation” is also
holics). Instead, many disorders are due Many illnesses are commonly ascribed used in the assessment of cancer; it
at least partly to overconsumption of to food allergy, but it is only rarely that a means the degree to which the micro-
food. Overeating causes weight gain definite link is proved. Nut allergies, scopic appearance of cancerous tissue
and, in severe cases, obesity. The latter which may cause the life-threatening resembles normal tissue.
condition places a person at increased reaction anaphylaxis, and coeliac disease
risk of disorders such as diabetes melli- (a reaction to the protein gluten, which diffusion
tus, stroke, coronary artery disease, and is found in wheat and other cereals) are The spread of a substance (by move-
osteoarthritis. Diets causing weight gain examples of genuine food allergies. ment of its molecules) in a fluid from
tend to be high in fats and sugar, but (See also nutritional disorders.) an area of high concentration to one of
may be low in valuable components lower concentration, thus producing a
such as fibre and vitamins. dietary amenorrhoea uniform concentration throughout.
FATS A form of amenorrhoea (cessation of
A diet that is high in fats, particularly menstruation) caused by major weight diflunisal
saturated fats (see fats and oils), may loss, although not necessarily by a lack A nonsteroidal anti-inflammatory drug
contribute to atherosclerosis (narrowing of food. In some cases, the weight loss (NSAID) used to relieve joint pain and
of the arteries due to accumulation of is deliberate and severe (see anorexia stiffness in types of arthritis. The drug is
fatty deposits on the arterial walls); nervosa). Absence of menstrual periods also given for back pain, sprains, and
this, in turn, may lead to cardiovascular occurs because the loss of body fat dis- strains. Side effects include nausea,
diseases such as coronary artery disease, rupts the levels of the female sex diarrhoea, and a rash.
stroke, and peripheral vascular disease. hormone oestrogen.
A high-fat diet has also been linked DiGeorge syndrome
with cancer of the bowel (see colon, dietary fibre An immunodeficiency disorder that results
cancer of) and breast cancer. See fibre, dietary. in a failure of the immune system’s cells
ALCOHOL to fight infection. The disorder is here-
Overconsumption of alcohol can lead to dietetics ditary and congenital (present at birth).
alcohol-related disorders. In the digestive The application of nutritional science In DiGeorge syndrome, the thymus
system, it may cause cirrhosis of the to maintain or restore health. Dietetics gland is absent or fails to develop nor-
liver, pancreatitis, and oesophageal cancer involves not only a knowledge of the mally. The thymus is a key part of the
(see oesophagus, cancer of); in addition, composition of foods, the effects of immune system, so its absence may
people who are dependent on alcohol cooking and processing various foods, allow persistent, serious infections to
often become malnourished. Drinking and dietary requirements, but also of develop. Children with DiGeorge syn-
too much alcohol may cause cardiovas- psychological aspects of diet, such as drome are susceptible to opportunistic
cular problems such as hypertension eating habits (see nutrition). infections, such as candidiasis (thrush),

233
 DIGESTION

THE DIGESTIVE PROCESS

Digestion starts when food enters the Swallowing

mouth. It continues as the food is In the mouth, food is cut
and ground by the teeth
propelled through the digestive tract
and mixed with saliva,
by waves of muscular contractions which softens it and
(peristalsis). The digestive process also breaks down certain
involves various organs (the salivary carbohydrates. After
D glands, liver, gallbladder, and pancreas),
which produce enzymes and acids that
swallowing, the food
mass (bolus) enters the
help to break down the food. oesophagus.
Bolus Bolus
Oesophagus
ACTION OF DIGESTIVE AGENTS Food is carried down
the oesophagus by
peristaltic action and
Agent or enzyme Digestive enters the stomach.
(where produced) action

Amylase Converts starch

(mouth and pancreas) (a carbohydrate) Stomach
to maltose Food is broken down Gallbladder
further by churning
and by the action of Bile duct
Sucrase, maltase, Break down hydrochloric acid and
and lactase vegetable and digestive enzymes
(pancreas and small milk sugars into secreted by the
stomach lining.
intestine) glucose, fructose, Food remains in the
and galactose stomach until it is
reduced to a semi-
liquid consistency
Hydrochloric acid Assist in the (chyme), when it
(stomach), breakdown of passes into the
Pepsin (stomach), proteins into duodenum. Pancreas
Trypsin (pancreas), polypeptides,
Peptidase peptides, and
(small intestine) amino acids
Duodenum
Lipase (pancreas) Break down fats This is the first part of
Bile salts and acids into glycerol and the small intestine. As
(liver – stored in the fatty acids food travels through
the duodenum, it is
gallbladder) broken down further
by digestive enzymes
from the liver, the
gallbladder, and
TIME SCALE the pancreas.

The approximate period food spends

in each part of the digestive system
is shown below. Small intestine
Additional enzymes
secreted by glands in
the lining of the small
Mouth intestine complete the
1 minute digestive process.
Nutrients are absorbed
through the intestinal
Oesophagus lining into the network
10 seconds of blood vessels and
lymph vessels that
supply the intestine.
Undigested matter
Stomach
passes into the large
2–4 hours
intestine (the colon).

Small
intestine
1–6 hours
Appendix
Colon
Large
Water from undigested
intestine
matter is absorbed Rectum
10 hours–
through the lining of Undigested matter enters
several days
the colon. The residue this final part of the large
passes into the rectum. intestine and is expelled. Anus

234
 DIOXIN

and there may be evidence of failure to lining, help to break down proteins. dihydrocodeine
thrive (restricted growth). In addition, When the food has been converted to a A type of opioid analgesic drug (pain-
heart abnormalities and hypocalcaemia semi-liquid consistency, it passes into killer). Side effects of dihydrocodeine
(abnormally low levels of calcium in the duodenum, where bile salts and include nausea and vomiting.
the blood) may occur. acids (produced by the liver) help to
Transplants of thymus tissue, or bone break down the fats it contains. Diges- dilatation
marrow transplants, may be successful in tive juices released by the pancreas into A condition in which a body cavity,
treating the immunodeficiency. the duodenum contain enzymes that passage, or opening is enlarged or
digestion
further break down food.
Breakdown concludes in the small
stretched due to normal physiological
processes (such as childbirth) or because
D
The process by which food is broken intestine, carried out by enzymes that of the effects of disease.
down into smaller components that can are produced by glands in the intestinal The term “dilatation” also refers to
be transported and used by the body. lining. Nutrients are absorbed in the medical procedures for achieving such
(See also digestive system). small intestine through tiny projections enlargement, as in dilatation and curet-
from the intestinal wall, called villi. The tage (see D and C).
digestive system food residue enters the large intestine,
The group of organs responsible for where much of the water it contains is dilatation and curettage
digestion. The digestive system consists absorbed by the lining of the colon. See D and C.
of the digestive tract (also known as Undigested matter is expelled via the
the alimentary tract or canal) and vari- rectum and anus as faeces. dilation
ous associated organs. A term that is sometimes used as an
STRUCTURE digit alternative to dilatation.
The mouth, pharynx (throat), oesophagus A division, such as a finger or toe, that is
(gullet), stomach, intestines, and anus located at the end of a limb. dilator
make up the digestive tract. The intes- An instrument used for stretching and
tines consist of the small intestine digitalis drugs enlarging a narrowed body cavity, pas-
(comprising the duodenum, jejunum, A group of drugs that are extracted sage, or opening, for example to enable
and ileum) and the large intestine from plants belonging to the foxglove an investigative procedure or surgery.
(comprising the caecum, colon, and rec- family. They are used to treat heart con-
tum). Associated organs, such as the ditions, most commonly atrial fibrillation diltiazem
salivary glands, the liver, and pancreas, (irregular, rapid beating of the upper A calcium channel blocker drug that is
secrete digestive juices that help break chambers of the heart). Those most fre- used in the treatment of hypertension
down food as it goes through the tract. quently used are digitoxin and digoxin. (high blood pressure) and angina pec-
FUNCTION toris (chest pain due to impaired blood
Food and the products of digestion are digital subtraction angiography supply to the heart muscle). Side effects
moved from the throat to the rectum See angiography. of diltiazem may include headaches,
by peristalsis (waves of muscular con- loss of appetite, nausea, constipation,
tractions of the intestinal wall). digitoxin and swollen ankles.
Food is broken down into simpler A long-acting digitalis drug that is used
substances before being absorbed into to treat heart failure and certain types of dimeticone
the bloodstream. Physical breakdown is arrhythmia (irregular heartbeat). A silicone-based substance, also known
performed by the teeth, which cut and as simeticone, that is used in barrier
chew, and the stomach, which churns digoxin creams and as an antifoaming agent in
the food. Chemical breakdown of food The most widely used of the digitalis antacid preparations.
is performed by the action of enzymes drugs. Digoxin is used in the treatment
(biological catalysts), acids, and salts. of heart failure and certain types of dioptre
Carbohydrates are broken down into arrhythmia (irregular heartbeat), such A unit of the power of refraction (the
simple sugars. Proteins are broken down as atrial fibrillation. “strength”) of a lens; the greater the
into polypeptides, peptides, and amino Blood tests are sometimes needed to power, the stronger the lens. Lenses
acids. Fats are broken down into gly- ensure the correct digoxin dose, espec- that cause parallel light rays to con-
cerol, glycerides, and fatty acids. ially in patients with kidney disease. An verge have a positive dioptric number
In the mouth, saliva lubricates food excessive dose may cause headache, and are used to correct longsighted-
and contains enzymes that begin to loss of appetite, nausea and vomiting, ness (see hypermetropia). Those that
break down carbohydrates. The tongue and visual disturbances. Digoxin occa- cause light rays to diverge have a nega-
moulds food into balls (called boli) for sionally disrupts the normal heartbeat, tive number and are used to correct
easy swallowing. The food then passes causing heart block. shortsightedness (see myopia).
into the pharynx, from where it is
pushed into the oesophagus and is then Di Guglielmo’s disease dioxin
squeezed down into the stomach. Once A form of acute myeloblastic leukaemia The name of a highly toxic group of
in the stomach, the food is mixed with (see leukaemia, acute) characterized by chemicals. Dioxins are contaminants of
hydrochloric acid and pepsin. These excessive numbers of red blood cells in some defoliant weedkillers (see defo-
substances, produced by the stomach the bone marrow and bloodstream. liant poisoning; Agent Orange).

235
 DIPHENHYDRAMINE

diphenhydramine diplegia disciformis, keratitis

An antihistamine drug that is used to affecting both sides of the
Paralysis A form of keratitis (inflammation of the
treat allergic disorders such as urticaria body (both legs and, to a lesser extent, cornea at the front of the eye) in which
(nettle rash) and allergic rhinitis (hay both arms). (See also spastic diplegia.) a disc-like opacity forms in the corneal
fever). Diphenhydramine is also used tissue, usually as an immune response to
for the relief of temporary sleep distur- diplopia a viral infection.
bance, and is an ingredient in some The medical term that is used to
cough remedies. It can cause drowsiness, describe double vision. disc, intervertebral
D dry mouth, and blurred vision.
dipsomania
One of the flat, circular, platelike struc-
tures containing cartilage that line the
diphenoxylate A form of alcohol dependence in which joints between adjacent vertebrae
An antidiarrhoeal drug that is chemically periods of excessive drinking and crav- (bones) in the spine. Each interverte-
related to the opioid analgesic drugs ing for drink alternate with periods of bral disc is composed of a fibrous outer
(painkillers). Diphenoxylate lessens the relative sobriety. layer and a soft, gelatinous core. The
contractions of the muscles in the walls discs act as shock absorbers to cushion
of the intestines, thereby reducing the dipyridamole the vertebrae during movements of the
frequency of bowel movements. A drug that reduces the stickiness of spine. With increasing age, interverte-
platelets in the blood and thereby helps bral discs become less supple and more
diphtheria to prevent the formation of abnormal susceptible to damage from injury; one
A bacterial infection that causes a sore blood clots within arteries. Dipyrida- of the most common problems is disc
throat, fever, and sometimes serious or mole may be used with aspirin or prolapse (“slipped” disc).
even fatal complications. Diphtheria is warfarin to prevent the formation of
caused by the bacillus CORYNEBACTERIUM blood clots following stroke or transient disclosing agents
DIPHTHERIAE. The disease is now rare in ischaemic attack or in people who have Dyes that make the plaque deposits on
developed countries as a result of mass artificial heart valves. teeth more visible so that they can be
immunization. In the UK, the vaccine is Possible adverse effects may include seen and removed.
given at 2, 3, and 4 months, 3–5 years, headache, flushing, and dizziness.
and 13–18 years of age. discoid lupus erythematosus
SYMPTOMS disability A form of the chronic autoimmune
The infection may begin in the throat or A loss or impairment of normal func- disorder lupus erythematosus that is con-
in the skin. In the throat, multiplication tioning or activity as the result of a fined to the skin. It causes a red, itchy,
of bacteria causes the formation of a physical or mental impediment. (See scaly rash to appear, particularly on the
membrane that may cover the tonsils also handicap; rehabilitation.) face and scalp, behind the ears, and on
and spread up over the palate or down any parts of the body that are exposed
to the larynx (voicebox) and the trachea disaccharide to sunlight. The disorder most com-
(windpipe), causing breathing difficulty A carbohydrate comprising two linked monly occurs in women between the
and a husky voice. Other symptoms monosaccharide units. Lactose, maltose, ages of 25 and 45, and tends to run in
include enlarged lymph nodes in the and sucrose are all disaccharides. families. Over a period of several years,
neck, an increased heart rate, and mild discoid lupus erythematosus may sub-
fever. If infection is confined to the skin, discectomy side and recur repeatedly with different
the bacteria may produce a yellowish A procedure in which part or all of a degrees of severity. Diagnosis is by a
lesion covered by a hard membrane. damaged intervertebral disc (see disc, skin biopsy, and treatment is with topi-
Life-threatening symptoms occur only intervertebral) is surgically removed. cal corticosteroid drugs or drugs such
in people who are not immune to the Discectomy relieves the symptoms of as hydroxychloroquine.
disease.They are caused by a toxin that is disc prolapse (in which an intervertebral
released by the bacteria and affects the disc ruptures and part of its pulpy core discoloured teeth
heart and nervous system. Occasionally, a protrudes) by relieving the pressure Teeth vary in colour from individual to
victim collapses and dies within a day of that the protruding tissue places on individual and, in general, secondary
developing throat symptoms. More often, nerves or nerve roots. teeth are darker in colour than primary
the victim is recovering from diphtheria teeth. In addition, teeth often get dark-
when heart failure or paralysis of the discharge er with age. The term discoloured
throat or limbs develops. These com- A visible emission of fluid from an ori- teeth, however, refers to teeth that are
plications can occur up to seven weeks fice or a break in the skin (such as a abnormally coloured or stained.
after the onset of infection in the throat. wound or burst boil). A discharge may EXTRINSIC STAINS
TREATMENT be a normal occurrence, as in some Extrinsic stains (those found on the
Diphtheria is treated with antibiotics; types of vaginal discharge, but it could tooth’s surface) are common. They are
in addition, an antitoxin is given to also be due to an infection or to usually easily removed by polishing
neutralize the bacterial toxin. If severe inflammation, as occurs, for example, and can be prevented by regular tooth
breathing difficulties develop, a tracheo- in rhinitis (inflammation of the lining cleaning. Smoking tobacco produces a
stomy (the surgical introduction of a of the nasal passages), urethritis (infec- brownish-black deposit on the teeth.
breathing tube into the windpipe) may tion of the urethra), or in proctitis Pigment-producing bacteria can leave a
also be necessary. (infection of the rectum). visible, usually green, line along the

236
 DISC PROLAPSE

teeth, especially in children. Some dyes discoloration of the primary teeth. The back is most commonly affected, but
in foodstuffs can cause yellowing; dark teeth of children with congenital mal- disc prolapse can affect any of the ver-
brown spots may be due to areas of formation of the bile ducts may be tebrae, including those in the neck.
thinned enamel stained by foods. Some similarly affected. CAUSES
bacteria produce an orange-red stain. TREATMENT A prolapsed disc may sometimes be
Stains may also follow the use of drugs Many stains can be covered or dimin- caused by a sudden strenuous action
containing metallic salts. ished with whitening toothpastes or (such as lifting a heavy weight), but
INTRINSIC STAINS with cosmetic dental procedures such it usually develops gradually, due to
Intrinsic stains (within the tooth’s sub-
stance) are permanent, but they can be
as bonding and bleaching. degeneration of the discs with age.
SYMPTOMS
D
reduced by bleaching. Causes include disc, optic Symptoms depend on the location of
the death of the pulp inside the tooth See optic disc. the affected disc. If the sciatic nerve root
or the removal of the pulp during root- is compressed, it causes sciatica, which
canal treatment. The antibiotic drug disc prolapse may be accompanied by numbness and
tetracycline can be absorbed by develop- A common disorder of the spine, in tingling, and, eventually, by weakness in
ing teeth, and may cause yellowing of which one of the pads between the ver- the muscles of the leg. A prolapsed disc
the teeth if given to children. tebrae (see disc, intervertebral) ruptures in the neck causes neck pain and stiff-
Mottling of the tooth enamel occurs and part of its pulpy core protrudes. ness and weakness in the arm and hand.
if excessive amounts of fluoride are Commonly known as a slipped disc, it TREATMENT
consumed during development of the causes painful and at times disabling The symptoms of disc prolapse often
enamel (see fluorosis). Hepatitis (liver pressure on a nerve root or, less com- improve with time, as the swelling
disease) during infancy may lead to monly, on the spinal cord. The lower around the protruding disc tissue

PHYSICAL AIDS FOR THE DISABLED

A variety of specially designed or adapted articles are available aids, artificial limbs, corsets, and wheelchairs. For people
to help disabled people carry out everyday activities. Such aids with very severe conditions, ventilators, home dialysis, and
include prostheses, supports, and mobility aids to improve artificial feeding devices are used to sustain life.
disabled people’s general functioning, as well as items There are various household aids available that can help
designed to help them perform specific tasks more easily. people to cook, feed themselves, wash, dress, use the toilet,
Devices that help vision, hearing, and movement improve and get in and out of beds and chairs. Specially designed
the ability of disabled people to cope with all aspects of daily furniture and other devices can help disabled parents to care
life. Such devices include walking frames, glasses, hearing- for their children. Sexual aids can facilitate an active sex life.

Tap turner Tongs Bottle opener

A device that helps with gripping Extending tongs to pick up A small hand-held device
and turning taps. dropped items. The tongs close designed to grip and open small
up to fit in a pocket or handbag. bottle tops.

Cutlery Toothpaste extruder Scissors

A range of knives, forks, and A wall-mounted device that Self-opening scissors with “A” frame
spoons with thick, moulded dispenses toothpaste with easy-grip handles. A lightweight walking frame that doubles
handles for easy manipulation. minimal finger pressure. as a seat and can be folded flat.

237
 DISC, SLIPPED

subsides. In the meantime, painkillers

SYMPTOMS AND TREATMENT OF DISC PROLAPSE are often needed. In severe cases, surgi-
cal techniques, such as the removal of
A prolapsed disc in the lower back causes The sections of the spine part of the vertebra (see decompression,
low back pain and, if a sciatic nerve root is spinal canal) or removal of the protrud-
compressed, sciatica (pain running down the
back of the leg from the buttock to the ankle),
ing material and repair of the disc (see
sometimes accompanied by numbness and discectomy), may be used.
Cervical
tingling. Low back pain and sciatica are vertebrae
D usually aggravated by coughing, sneezing, disc, slipped
bending, and sitting for long periods. See disc prolapse.
Prolonged pressure on the sciatic nerve can
lead to weakness in the muscles of the leg. disease
A prolapsed disc in the neck causes neck Illness or abnormal functioning of a
pain and stiffness. If the disc compresses the body part or parts due to a specific
root of a nerve that supplies the arm, there will cause, such as an infection, and identi-
be tingling and weakness in that arm and hand. fiable by certain symptoms and signs.
In rare cases, pressure is exerted on the spinal
cord itself, sometimes leading to paralysis of the
Thoracic disease-modifying
legs and loss of bladder or bowel control. vertebrae antirheumatic drugs
Before treatment A group of antirheumatic drugs, known
This MRI scan of the as DMARDs, that are used in the treat-
lower back shows a ment of rheumatoid arthritis. Certain
prolapse of the disc
between the fifth antimalarial drugs, anticancer drugs, and
lumbar vertebra and immunosuppressant drugs are used for
the first fused this purpose. Examples of DMARDs are
vertebra of the sulfasalazine, chloroquine, methotrexate,
sacrum.
gold compounds (for example aurano-
Prolapse Lumbar fin), and penicillamine.
vertebrae DMARDs not only improve the symp-
(discs most
commonly toms and signs of inflammatory joint
affected) disease, but they also slow the course of
Normal spinal nerve root the illness. (In contrast, nonsteroidal anti-
Disc inflammatory drugs relieve symptoms but
do not alter the progress of the disease.)
Some DMARDs are cytotoxic, which
Normal
Sacrum means that they kill rapidly dividing
position cells. Gold compounds and penicillam-
of disc
ine may impede the immune system from
Pulpy interior producing specialized proteins called
protruding Coccyx antibodies (see antibody) that contribute
(prolapsed
part of disc)
towards damage to joints. Sulfasalazine
Cross-section of a prolapsed disc
interferes with a variety of inflammatory
The fibrous outer layer of the disc is ruptured, processes in the body, and chloroquine
Compressed spinal and some of its pulpy interior protrudes and suppresses the effects of arthritis.
nerve root presses on a spinal nerve root. In general, DMARDs may need to
be used for several months before the
TREATMENT full effects are felt. For this reason,
many specialists recommend starting
Disc prolapse often responds to analgesics, and special exercises (see therapy early to prevent or delay the
physiotherapy) are helpful. Patients are usually advised to be as mobile as progression of joint damage. Treatment
possible. For resting or sleep, they should lie flat on a firm mattress, with the with a combination of DMARDs may
head supported and the shoulders, hips, and ankles aligned to ease pressure be more effective than a single drug,
on the spine. If these measures fail and nerve root compression is causing and may enable lower doses of each
muscle weakness, an operation may relieve the pressure (see discectomy; drug to be used, reducing the risk of
decompression, spinal canal). adverse effects.
Possible side effects depend on the
drug taken. They include diarrhoea,
rash, anaemia (a reduced level of the
oxygen-carrying pigment haemoglobin
in the blood), leukopenia (a low white
blood cell count), and increased sus-
ceptibility to infection. Regular blood

238
 DISULFIRAM

tests and urine tests (see urinalysis) are address. Disorientation is usually due other parts of the body, either via the
needed during treatment to monitor to a head injury, intoxication, or a chron- lymphatic system or in the bloodstream
the effects of DMARDs on the bone ic brain disorder, such as dementia. It (see miliary tuberculosis).
marrow, kidneys, and liver. may occasionally be due to somatization
disorder (a psychological illness). (See dissociative disorders
disinfectants also confusion; delirium.) A group of psychological conditions
Substances that kill microorganisms in which a particular mental function
and thus prevent infection. The term is dispense becomes cut off from the rest of the
usually applied to strong chemicals that
are used to decontaminate objects, such
To prepare and distribute medicines to
a patient according to the details on a
mind. Examples of dissociative disor-
ders include hysterical amnesia (see
D
as items of medical equipment. doctor’s prescription. hysteria), fugue, multiple personality dis-
order, and depersonalization. (See also
dislocation, joint displacement conversion disorder.)
Complete displacement of the two The transference of feelings from one
bones in a joint so that they are no object or person to another. Displace- dissociative reaction
longer in contact, usually as a result of ment is usually performed consciously A psychological defence mechanism in
injury. (Displacement that leaves the to obtain emotional relief in a manner which a person views unpleasant ideas
bones in partial contact is called sublux- that will not cause harm to oneself or or events, such as being assaulted, in an
ation.) It is usually accompanied by to another person. Some psychothera- unusually detached way in order to
tearing of the joint ligaments and damage pists believe that displacement is an protect himself or herself from over-
to the membrane encasing the joint. unconscious defence mechanism. whelming feelings such as fear. In more
SYMPTOMS AND COMPLICATIONS severe cases, certain mental processes
Dislocation restricts or prevents the dissecting aneurysm are split off from the rest of a person’s
movement of the joint; it is usually An aneurysm (ballooning of an artery) mental activity and may function inde-
very painful. The affected joint looks that usually affects the first part of the pendently (see dissociative disorders).
misshapen and swells. Injuries that are aorta. It is caused by a tear in the inner
severe enough to cause dislocation layer of the arterial wall, which results dissonance
often also cause fractures. In some cases, in the inner layer peeling away from A term that is used in social psycholo-
dislocation is followed by complica- the outer layer. This results in blood gy to describe a state that arises when
tions such as paralysis. collecting in the space between the an individual has minimal awareness
TREATMENT inner and outer layers. of any discord, disagreement, or con-
The joint may be X-rayed to confirm A dissecting aneurysm may rupture flict within himself or herself. (See also
dislocation and check for fracture. The or may compress the blood vessels leav- cognitive dissonance.)
bones are then manipulated back into ing the aorta, producing infarction
their proper position, or an operation (localized tissue death due to lack of distal
is performed to reset them. The bones blood supply) in the organs supplied A term describing a part of the body
are then immobilized in a splint or cast by them. The patient will suffer from that is further away from another part
to allow healing to take place. severe chest pain that often spreads with respect to a central point of ref-
to the back or the abdomen. Surgical erence, such as the trunk. For example,
disodium etidronate repair may help relieve the symptoms. the fingers are distal to the arm. The
See etidronate disodium. opposite of distal is proximal.
dissection
disopyramide Cutting of body tissues during surgery Distalgesic
An antiarrhythmic drug that is used to or for the purpose of anatomical study. A brand name for co-proxamol, an anal-
treat an abnormally rapid heartbeat, as gesic drug containing paracetamol and
may occur after a myocardial infarction disseminated intravascular the weak opioid dextropropoxyphene.
(heart attack). It reduces the force of coagulation (DIC)
heart muscle contraction. As a result, it A type of bleeding disorder in which disulfiram
may aggravate pre-existing heart failure. abnormal clotting of blood leads to a A drug that acts as a deterrent to
Other possible side effects include dry depletion of coagulation factors in the drinking alcohol. It is prescribed for
mouth and constipation. blood; the consequence may be severe people who request help in overcom-
and spontaneous bleeding. ing alcohol dependence. Treatment with
disorder the drug is usually combined with a
Any abnormality of physical or mental disseminated lupus counselling programme.
function. erythematosis Disulfiram causes a buildup of
An alternative name for systemic lupus acetaldehyde in the body, causing flush-
disorientation erythematosus. ing, headache, nausea, dizziness, and
Confusion as to time, place, or personal palpitations. Symptoms may start with-
identity. Speech and behaviour tend to disseminated tuberculosis in 10 minutes of drinking alcohol and
be muddled, and the affected person A state in which the infectious disease can last for several hours. Occasionally,
often cannot answer questions about tuberculosis has spread from the site of large amounts of alcohol taken during
time, date, present location, name, or the original infection to affect several treatment can cause unconsciousness.

239
 DITHRANOL

dithranol often used as an emergency treatment diurnal rhythms

A drug that is used in the treatment of for heart failure. Potassium-sparing A biological pattern that is based on a
the skin condition psoriasis. Dithranol diuretics are used along with thiazide daily cycle; also called circadian rhythms.
is prescribed as an ointment, paste, or and loop diuretics, both of which may (See also biorhythms.)
cream and works by slowing the rate at cause the body to lose too much potas-
which skin cells multiply. This effect sium. Carbonic anhydrase inhibitors diverticula
can be boosted by ultraviolet light block the action of the enzyme carbon- Small sacs or pouches that protrude
treatment (see phototherapy). Dithranol ic anhydrase, which affects the amount externally from the wall of a hollow
D can cause skin inflammation. of bicarbonate ions in the blood; these
drugs increase urine output moderately
organ (such as the colon). They are
thought to be caused by pressure forc-
diuretic drugs but are effective only for short periods ing the lining of the organ though
Drugs that help to remove excess water of time. Osmotic diuretics are used to areas of weakness in the wall. Their
from the body by increasing the maintain urine output following seri- presence in the walls of the intestines is
amount that is lost as urine. Diuretic ous injury or major surgery. characteristic of diverticular disease.
drugs are used in the treatment of a POSSIBLE ADVERSE EFFECTS
variety of disorders, including hyperten- Diuretics may cause chemical imbal- diverticular disease
sion (high blood pressure), heart failure, ances in the blood. The most common The presence of small protruding sacs
the eye condition glaucoma, nephrotic is hypokalaemia (low blood levels of or pouches called diverticula in the
syndrome (a kidney disorder), and cir- potassium). This is usually treated with intestinal wall, and the symptoms or
rhosis of the liver. potassium supplements or potassium- complications caused by them. The term
TYPES sparing diuretic drugs. A diet rich in diverticulosis signifies the presence of
There are various types of diuretic potassium may also be helpful. Some diverticula in the intestine. Diverticulitis is
drug, which differ markedly in their diuretics raise the blood level of uric a complication produced by inflamma-
speed and mode of action. Thiazide acid, which increases the risk of gout. tion in one or more diverticula.
diuretics cause a moderate increase in Certain diuretic drugs increase the
urine production. Loop diuretic drugs blood glucose level, which may wors- diverticulitis
are fast-acting, powerful drugs that are en diabetes mellitus. Inflammation of diverticula (abnormal
pouches) in the wall of the intestine,
particularly in the colon. Diverticulitis is
HOW DIURETICS WORK a form of diverticular disease and a com-
plication of diverticulosis.
The normal filtration process of the Diuretics interfere with this normal
kidneys (which takes place in the kidney action. Osmotic, loop, and SYMPTOMS AND COMPLICATIONS
tubules) removes water, salts (mainly thiazide diuretics reduce the amount The symptoms include fever, abdomi-
potassium and sodium), and waste of sodium and water taken back into nal pain, vomiting, and rigidity of the
products from the bloodstream. Most the blood, thus increasing the volume abdomen. Intestinal haemorrhage may
of the salts and water are returned to of urine. Modifying filtration in this way cause bleeding from the rectum.
the bloodstream, but certain amounts reduces the blood’s water content. Less Diverticula may perforate, or absces-
are expelled from the body together water in the blood causes excess water ses may form in the tissue around the
with the waste products in the urine. in the tissues to be expelled in urine. colon, leading to peritonitis (inflamma-
tion of the lining of the abdomen).
Renal Other complications include intestinal
cortex Kidney bleeding, narrowing in the intestine, or
a fistula (an abnormal channel between
one part of the intestine and another).
Artery TREATMENT
Ureter Diverticulitis usually subsides with bed
Vein
rest and antibiotics. In severe cases, a
Pelvis of liquid diet or intravenous infusion may
kidney
be required. Surgery may be needed,
Bladder
Ureter in which the diseased section of the
intestine is removed and the remaining
Tubule
sections are then joined back together.
Some patients are given a temporary
colostomy (an operation in which part
of the colon is attached to the abdomi-
nal wall to form an opening for the
Osmotic diuretics Loop diuretics Thiazide diuretics discharge of faeces).
These act on the first part of These drugs take effect on This group acts on the last part
the tubules to reduce the the middle part of the of the tubules to reduce the diverticulosis
reabsorption of water into tubules and block sodium reabsorption of sodium into A form of diverticular disease in which
the bloodstream. and chloride reabsorption. the bloodstream.
diverticula (abnormal pouches) exist in
the wall of the intestine, particularly in

240
 DOGS, DISEASES FROM

it may be part of a more severe, pro- DNA

longed attack of vertigo (a condition The abbreviation for deoxyribonucleic
typified by a spinning sensation) with acid. DNA is the principal molecule
nausea, vomiting, sweating, or fainting. carrying genetic information in almost
CAUSES all organisms; the exceptions are cer-
Most attacks are harmless and are due tain viruses that use RNA.
to a fall in the pressure of blood to the DNA is found in the chromosomes of
brain. This can occur when getting up cells; its double-helix structure allows
quickly from a sitting or lying position
(called postural hypotension). Similar
the chromosomes to be copied exactly
during the process of cell division. A
D
symptoms may result from a transient special form of DNA exists in mito-
ischaemic attack, in which there is a chondria, the tiny energy-producing
temporary, partial blockage in the arter- structures within cells (see mitochondrial
ies that supply the brain. DNA). Sections of DNA can also be cre-
Other possible causes include tired- ated artificially (see recombinant DNA)
ness, stress, fever, anaemia, heart block during genetic engineering. (See also
Diverticulosis of the colon (impairment of electrical activity in the meiosis; mitosis; nucleic acids.)
Diverticula (pouches) are clearly visible in this
endoscopic view of the wall of the colon. The heart muscle), hypoglycaemia (low blood
condition is thought to be due to a low-fibre diet. sugar levels), and subdural haemorrhage DNA fingerprinting
(bleeding between the outer two mem- See genetic fingerprinting.
the colon. Complications of diverticulo- branes that cover the brain).
sis may include intestinal bleeding and Dizziness as part of vertigo is usually dobutamine
diverticulitis. The cause is believed to be due to a disorder of the inner ear, A drug that is used in the treatment of
a lack of fibre in the diet (see fibre, the acoustic nerve, or the brainstem. The heart failure and shock, and sometimes
dietary). Diverticulosis is very rare in principal disorders of the inner ear after cardiac arrest (a halt in the pump-
developing countries, where high-fibre that can cause dizziness and vertigo ing action of the heart). The drug may
foods make up much of the diet. are labyrinthitis and Ménière’s disease. be given by intravenous drip.
SYMPTOMS Disorders of the acoustic nerve, such Dobutamine stimulates nerve cells in
Symptoms occur in only a minority as acoustic neuroma, are rare causes of the heart to increase the heart rate and
of people who have diverticulosis. They dizziness and vertigo. Brainstem dis- raise the blood pressure. For this rea-
usually result from spasm or cramp of orders that can cause dizziness and son, the drug may be used in a cardiac
the intestinal muscle near diverticula. vertigo include a type of migraine, brain stress test to investigate potential coro-
Many patients have symptoms similar tumours, and vertebrobasilar insufficiency. nary artery disease in cases where the
to those of irritable bowel syndrome, TREATMENT patient is unable to exercise on a tread-
including abdominal pain, a bloated Brief episodes of mild dizziness usually mill (see exercise ECG).
sensation, and changes in bowel habits. clear up after taking a few deep breaths
In severe cases of diverticulosis, intesti- or after resting for a short time. doctor
nal haemorrhage can lead to bleeding Severe, prolonged, or recurrent dizzi- A qualified medical practitioner who is
from the rectum. ness should be investigated by a doctor. licensed to practise by the appropriate
TREATMENT Treatment depends on the underlying medical authority in his or her country,
In people with cramps, a high-fibre cause. For example, certain cases of such as the General Medical Council in
diet, fibre supplements, and antispas- dizziness and vertigo due to a disorder the UK.
modic drugs may relieve the symptoms. of the inner ear are treated with anti-
A high-fibre diet also reduces the inci- emetic drugs or antihistamine drugs. dogs, diseases from
dence of complications. Bleeding from Infectious or parasitic diseases that are
diverticula usually subsides without dizygotic twins acquired from contact with dogs. They
treatment, but surgery is an option. Nonidentical twins, also called fraternal may be caused by viruses, bacteria,
twins. Dizygotic twins are the result of fungi, protozoa, worms, insects, or
diving medicine the simultaneous fertilization of two egg mites living in or on a dog.
See scuba-diving medicine; decompression cells (ovum). They each have a placenta Many parasites that live on dogs can
sickness. of their own and may be of different be transferred to humans, for example
sexes. (See also monozygotic twins.) through stroking the dog’s fur.
Dixarit The most serious disease from dogs
A brand name for clonidine, an anti- DLE is the viral infection rabies. The UK is
hypertensive drug that is also used in the Discoid lupus erythematosus. free of rabies, but travellers to countries
treatment of migraine and, in meno- in which rabies exists should treat any
pausal women, hot flushes. DMARDs dog bite with suspicion. Dog bites can
See disease-modifying anti-rheumatic drugs. cause serious bleeding and shock and
dizziness may become infected.
A sensation of unsteadiness and light- DMSA scan Toxocariasis and hydatid disease are
headedness. Dizziness may be a mild, A type of kidney imaging technique (see potentially serious diseases caused by
brief symptom that occurs by itself, or radionuclide scanning). the ingestion of worm eggs from dogs.

241
 DOMINANT

In the tropics, walking barefoot on soil domperidone dopa-decarboxylase inhibitors

that is contaminated with dog faeces An antiemetic drug used to relieve nau- Drugs used in the treatment of the
can lead to dog hookworm infestation. sea and vomiting associated with some movement disorder Parkinson's disease.
Bites from dog fleas are an occasional gastrointestinal disorders or during The two principal dopa-decarboxylase
nuisance. Ticks and mites from dogs, treatment with certain drugs or radio- inhibitors, co-beneldopa and co-carel-
including a canine version of the sca- therapy. Adverse effects may include dopa, are a combination of levodopa
bies mite, are other common problems. breast enlargement and secretion of and benserazide and levodopa and car-
The fungi that cause tinea infections in milk from the breast. bidopa, respectively. These drugs stop
D dogs can be caught by humans.
Some people become allergic to ani- donepezil
levodopa from being activated except
within the brain, which reduces the
mal dander (tiny scales from fur or An acetylcholinesterase inhibitor that is incidence of common side effects such
skin). They may, for example, suffer used to treat mild to moderate dementia as nausea and vomiting.
from attacks of asthma or urticaria (net- due to Alzheimer’s disease.
tle rash) when a dog is in the house. dopamine
(See also zoonoses.) donor A neurotransmitter (chemical released
A person who provides blood for trans- from nerve endings) found in the brain
dominant fusion; body tissues or organs for and around some blood vessels. It helps
A term used in genetics to describe the transplantation; or eggs or semen for to control body movements: a defi-
characteristics of a gene. Many charac- artificial insemination. The organs that are ciency of dopamine in the basal ganglia
teristics are determined by a single most frequently donated are kidneys, (groups of nerve cells deep in the
pair of genes, one of each pair being corneas, heart, lungs, liver, and pan- brain) causes Parkinson’s disease.
inherited from each parent. The domi- creas. Certain organs can be donated Synthetic dopamine is injected as an
nant gene of the pair overrides its during a person’s lifetime; some are emergency treatment for shock caused
equivalent recessive gene, allowing it to only used following brain death. by a myocardial infarction (heart attack)
be expressed. All donors should be free of cancer, or septicaemia (blood infection) and as
For example, the gene for brown eye serious infection (such as hepatitis B), a treatment for severe heart failure.
colour is dominant, so that if a child and should not carry HIV. Organs for
inherits the gene for brown eyes from transplantation must be removed within Doppler echocardiography
one parent and the gene for blue eyes a few hours of brain death, and before An investigation in which blood flow
from the other parent, he or she will or immediately after the heartbeat has through the heart is assessed by the use
have brown eyes. stopped. In some kidney transplants, the of ultrasound (high-frequency sound
Some genetic disorders are deter- kidney is provided by a living donor, waves). An ultrasound transducer is
mined by a dominant abnormal gene usually a relative whose tissues match moved over the chest in the area of the
that overrides the effect of an equiva- well on the basis of tissue-typing. Tests heart. The waves emitted by the trans-
lent normal gene that is recessive. are performed to ensure that both kid- ducer are reflected by blood, forming
Examples of such disorders include neys are healthy before one is removed. echoes that are recorded to give a pic-
Marfan syndrome and Huntington’s dis- Suitable related donors may also pro- ture of blood flow. This allows the
ease. In this case, a child will have the vide bone marrow for transplantation direction and speed of the blood flow
disease if he or she inherits the gene and sometimes skin for grafting. (See to be measured.
from one or both parents. also blood donation; bone marrow trans- Doppler echocardiography can be
plant; organ donation; transplant surgery.) used to investigate the presence of some
dominant characteristic conditions of the heart and circulation,
An inherited characteristic (external or Doose syndrome including abnormalities of the heart
internal physical feature) that appears A rare, inherited form of epilepsy. The valves (see valvular heart disease). The
in offspring even if they have inherited condition is typified by muscular jerk- procedure is painless and takes between
the gene for it from only one of their ing, especially symmetrical jerking of 15 and 30 minutes to perform.
parents. See dominant. the arms and shoulders and, in severe
cases, twitching of the facial muscles. Doppler effect
dominant gene In addition, the affected person may A change in the frequency with which
See dominant. fall to the ground and briefly lose con- sound waves from a given source reach
sciousness. Doose syndrome can be an observer when the source is in rapid
dominant trait treated with anticonvulsant drugs. motion with respect to the observer.
An inherited trait (a characteristic or Approaching sounds seem higher in
condition) that appears when just a dopa pitch (frequency) than sounds that are
single copy of the gene for that trait An amino acid that the body uses to moving away. This is due to the fact that
is present, as opposed to a recessive form dopamine, an important neuro- the wavelengths of sounds from an
trait, which only appears when two transmitter. Dopa is also formed as an approaching source are progressively
copies of the appropriate gene are intermediate stage when the body foreshortened, whereas those from a
present. Dominant genes always mask makes epinephrine, norepinephrine, and receding source are stretched.
the presence of recessive genes, and melanin. Levodopa, a form of dopa, is The Doppler effect is used in various
dominant traits can be inherited from used to correct dopamine deficiency in medical ultrasound scanning techniques
one parent alone. people who have Parkinson’s disease. (see Doppler ultrasonography).

242
 DOWN’S SYNDROME

Doppler ultrasonography on body tissues. The amount of radia- TREATMENT

A type of ultrasound scanning in which tion that is absorbed by body tissues Double vision needs immediate investi-
shifts in the frequency of ultrasonic during a session of radiotherapy is gation. The treatment depends on the
waves are used to measure the velocity expressed in units called millisieverts underlying cause.
of moving structures. An emitter sends (see radiation units).
out pulses of ultrasound (inaudible, douche
high-frequency sound) of a specific dosulepin The introduction of water and/or a
frequency. When the pulses bounce off A tricyclic antidepressant drug used in cleansing agent into the vagina using a
a moving object (for example, blood
flowing through a blood vessel), the
the treatment of depression. The drug
has a sedative action and is particularly
bag and tubing with a nozzle. Douch-
ing is unnecessary for hygiene and is
D
frequency of the echoes is changed useful in cases of depression accom- ineffective contraception. It may cause
from that of the emitted sound. A sen- panied by anxiety or insomnia. Possible infection or spread existing infection
sor is able to detect the frequency adverse effects include blurred vision, into the uterus or fallopian tubes.
changes and converts the data into use- dizziness, flushing, and rash.
ful information (about how fast the Down’s syndrome
blood flows, for example). dothiepin A chromosomal abnormality that results
Doppler ultrasonography is widely The former name for dosulepin. in a variable degree of learning difficulty
used to detect narrowing of arteries in and a characteristic physical appearance
the neck due to atherosclerosis (accu- double-blind in affected individuals.
mulation of fatty deposits on the artery A type of controlled trial that tests the CAUSES
walls) and to detect blood clots in veins effectiveness of a particular treatment People with Down’s syndrome have an
(as occurs in deep vein thrombosis). In or compares the benefits of different extra chromosome (47 instead of the
addition, Doppler ultrasound tech- treatments. In double-blind trials, neither normal 46). Affected individuals have
niques are used to monitor the fetal the patients undergoing the treatments three copies of chromosome number
heartbeat, to detect air bubbles during nor the doctors who are assessing them 21 instead of two; for this reason, the
dialysis and in heart–lung machines, and know which of the patients are receiv- disorder is also called trisomy 21. In
to measure blood pressure. (See also ing which treatment. This eliminates most cases, it is the result of a sperm or
Doppler echocardiography.) any expectations about which treat- egg being formed with an extra chro-
ment will be most effective. mosome 21, due to the failure of the
Dorfman–Chanarin syndrome chromosome 21 pair to part and enter
A very rare, autosomal recessive genetic double contrast enema separate cells during meiosis. If one of
disorder affecting fat metabolism (see Radiologic investigation (see radiology) these abnormal egg or sperm cells takes
lipidosis). The disease is congenital (pre- of the intestine (the main part of the part in fertilization, the baby will also
sent from birth). It is characterized by digestive tract). A contrast medium (a have the extra chromosome. This type
ichthyosis (thickened, scaly skin); myo- substance opaque to X-rays) is intro- of abnormality is more likely if the
pathy (degeneration of muscle), and duced into the passage or cavity to be mother is aged over 35.
sometimes also defects in vision and in examined. The area is then distended A less common cause is a chromoso-
hearing. Blood tests show abnormal (widened) by the introduction of air. A mal abnormality called a translocation,
white blood cells containing vacuoles thin coating of the contrast medium is in which part of one parent’s own
(tiny spaces) filled with fat. left on the walls of the intestine. As a
result, the area to be examined is
dorsal shown in outline on X-ray images. (See
Relating to the back, located on or near also barium X-ray examinations.)
the back, or describing the uppermost
part of a body structure when a person double vision
is lying face-down. For example, dor- Also known as diplopia, double vision
salgia describes pain in the back, and is a condition in which a person sees
the dorsal part of the hand is the back two visual images of a single object
of the hand. In human anatomy, the instead of only one image. The two
term dorsal means the same as posteri- images are separate, but each of them is
or. The opposite of dorsal is ventral quite clearly focused.
(meaning anterior or front). CAUSES
It is usually a symptom of a squint,
dose especially of paralytic squint, in which
A term used to refer to the amount paralysis of one or more of the eye
of a drug to be taken at a particular muscles impairs eye movement. Other
time, or to the amount of radiation to causes include a tumour in the eyelid
which an individual is exposed during or a tumour or blood clot behind the Down’s syndrome child using sign language
a session of radiotherapy. Drug dose eye. Double vision can also occur in There is a greater than normal risk of congenital
deafness in Down’s babies. Typical features of the
may be expressed in terms of the exophthalmos, when the eyeballs pro- condition include upward sloping eyes that are
weight of the active substance, the vol- trude as the result of an underlying covered at the corners, small facial features, and a
ume of liquid to be taken, or its effects hormonal disorder. large tongue that tends to stick out.

243
 DOXAZOSIN

chromosome number 21 has joined doxorubicin dressings

with another chromosome. The parent An anticancer drug given by injection, Protective coverings for wounds that are
is unaffected but has a high risk of hav- often with other anticancer drugs. It is used to absorb blood or other body
ing Down’s children. used in the treatment of a variety of secretions, prevent contamination, or
SYMPTOMS cancers, including lung cancer. retain moisture. Pressure dressings are
Typical physical features of a person applied to stem bleeding or to reduce
with Down’s syndrome include small doxycycline swelling at the site of injury.
face and features; upward-sloping eyes A tetracycline drug used in the treatment
D with folds of skin that cover their inner of chronic prostatitis, pelvic inflammatory Dressler’s syndrome
corners; large tongue; flattened back to disease, acne, and chest infection in An uncommon disorder, also known
the head; short, broad hands, with a chronic bronchitis. It is also used to pre- as postinfarction syndrome, that may
single horizontal crease on the palm vent and treat malaria. Taking the drug occur following a myocardial infarction
(see simian crease); and short stature. with food reduces possible side effects. (heart attack) or heart surgery. Dressler’s
Learning difficulties are very common, syndrome is characterized by fever,
and range from mild to severe; howev- drainage angle chest pain, pericarditis (inflammation of
er, affected people often have cheerful, The gap between the outer edge of the the membrane lining the heart), and
friendly personalities. iris (the coloured ring of muscle in the pleurisy (inflammation of the mem-
People with Down’s syndrome have a eye) and the cornea (the transparent brane around the lungs). Treatment is
greater than normal risk for certain dis- covering of the eyeball). This structure, with aspirin or, in severe cases, with cor-
orders. One possible problem is a heart and the network of tissue behind it ticosteroid drugs.
defect at birth (see heart disease, congen- (the trabecular network), allows excess
ital), which affects up to two in five aqueous humour to drain from the front
babies. Others include intestinal atresia chamber of the eye. Blockage of the TYPES OF DRAINS
(a narrowing in the intestines) and drainage angle causes acute glaucoma.
congenital deafness. Acute leukaemia is
more common than in other children. drain, surgical
Down’s syndrome children are also An appliance that is inserted into a body
especially susceptible to ear infections. cavity or a wound in order to release air Wide-bore
Affected adults over the age of 40 have or permit drainage of fluid. Drains range drain
a higher than normal risk of develop- from simple soft rubber tubes that pass
ing Alzheimer's disease. from a body cavity into a dressing to
DIAGNOSIS wide-bore tubes that connect to a col-
Screening tests during early pregnancy, lection bag or bottle. Suction drains are
including a nuchal thickness scan (a form thin tubes containing many small holes
of ultrasound scanning to measure the to help collect fluid or air, which is then Corrugated
skin at the back of the neck) indicate drawn into a vacuum bottle. drain
those fetuses likely to have the syn-
drome. Amniocentesis is then offered; dream analysis
this test involves chromosome analysis of The interpretation of a person’s dreams
fetal cells. In some cases, Down’s syn- as part of psychoanalysis or psychother-
drome is only recognized once the apy. First developed by Sigmund Freud, Perforated
baby has been born. The diagnosis is it is based on the idea that repressed drain
confirmed by chromosome analysis of feelings and thoughts are revealed, in a
cells from the baby. disguised way, in dreams.
OUTLOOK
There is no cure for the condition, but dreaming T-shaped
many Down’s syndrome children can Mental activity that takes place during drain
make the most of their capacities with sleep. Dreaming is thought to occur
appropriate environmental and educa- only during periods of REM (rapid eye
tional stimulation and support. Some movement) sleep, which last for about dribbling
children learn skills such as reading 20 minutes and occur four to five times Involuntary leakage of urine from the
and writing, and some adults may be a night. Compared to other phases, the bladder (see incontinence, urinary) or of
able to work; however, most affected REM phase of sleep is active. Blood saliva from the mouth (drooling). Drib-
people cannot live independently and flow and brain temperature increase, bling of saliva is normal in infants. In
need long-term care from their families and there are sudden changes in heart adults, it may be due to poorly fitting
or in a residential home. rate and blood pressure. dentures; alternatively, it may be the
Dreams usually closely mirror the result of facial paralysis, dementia, or
doxazosin day’s preoccupations. Dreaming can be another disorder of the nervous system,
An antihypertensive drug taken to reduce seen as a process in which the mental most commonly Parkinson’s disease.
high blood pressure (see hypertension). impressions, feelings, and ideas are Dribbling of saliva may also be caused
Possible side effects include dizziness, sorted out. People roused during REM by an obstruction in the mouth that
headache, and nausea. sleep report especially vivid dreams. interferes with swallowing.

244
 DROWSINESS

drip drop attack MECHANISM OF DROWNING

See intravenous infusion. A brief disturbance that affects the ner- Initially, automatic contraction of a mus-
vous system, causing a person to fall to cle at the entrance to the windpipe, a
drip, postnasal the ground without warning. Unlike in mechanism known as the laryngeal reflex,
See postnasal drip. fainting, the person may not lose con- prevents water from entering the lungs;
sciousness, but injuries can occur from instead, the water enters the oesophagus
driving, health and the fall. Elderly women make up the and stomach. However, the laryngeal
Safe driving depends in part on the group most commonly affected. reflex impairs breathing and can quickly
health of the vehicle’s driver. Any state
or medical disorder that affects a driver’s
CAUSES
The causes are not fully understood,
lead to hypoxia and to loss of conscious-
ness. If the person is buoyant at this point
D
physical condition, or impairs mental but they may be a form of transient and floats face-up, his or her chances of
faculties such as judgment, alertness, or ischaemic attack (TIA) in which there is survival are reasonable because the laryn-
speed of reaction, increases the risk of a fall in blood flow to nerve centres in geal reflex begins to relax and normal
injury to the driver and also to other the brainstem. Elderly men may have a breathing may then resume.
road users and pedestrians. drop attack while passing urine or FIRST AID AND TREATMENT
One of the most obvious hazards is while standing, possibly due to low An ambulance should be called and the
being under the influence of alcohol. blood pressure or an abrupt alteration person’s condition assessed. If he or she
There are strict laws regarding the in heart rhythm. Akinetic seizures (a is not breathing and/or the pulse is
maximum blood alcohol level allowed, rare form of epilepsy) are also some- absent, resuscitative measures should be
because alcohol is known to impair times described as drop attacks; the started (see artificial respiration; cardio-
judgment and to slow reaction times. sufferer falls to the ground but does pulmonary resuscitation) and continued
Illicit drugs (see drug abuse) have a not have muscular spasms. until medical help arrives.
similarly harmful effect. Some pre- TREATMENT Victims can sometimes be resuscitated
scribed drugs can also affect ability to There is no treatment for drop attacks in despite a long period immersed in very
drive; for example, some antihista- elderly people. Akinetic seizures usually cold water (which reduces the body’s
mines (used to treat disorders such as respond to anticonvulsant drugs. oxygen needs). In all cases of successful
hay fever) can cause drowsiness. The resuscitation, the person should be sent
combination of drugs and alcohol is drop, foot to hospital, because life-threatening
more potent than either used alone. See foot-drop. symptoms may develop some hours
Other states that can be hazardous after rescue if water has passed from
include fatigue and any type of stress dropped beat the lungs into the blood.
reaction such as anger and anxiety. Dri- A type of cardiac arrhythmia (see
ving when tired is one of the most arrhythmia, cardiac) characterized by the drowning, dry
common causes of road accidents. absence of a single ventricular contrac- A form of drowning in which no
Impaired vision obviously affects a tion. The next heartbeat often comes fluid enters into the lungs. Some fatal
person’s fitness to drive. Various other slightly early, and is more forceful than drowning cases are “dry”. Victims of
health problems should be disclosed to usual; this beat is often the one that is dry drowning have a particularly strong
the driver’s vehicle licensing authority, noticed, rather than the dropped one. laryngeal reflex, which diverts water
and in some cases may preclude Dropped beat is very common and may into the stomach instead of the lungs,
driving for a period of time. Drivers be caused by alcohol, caffeine, and but at the same time impairs breathing.
who have diabetes mellitus must inform some medications. Single, infrequent As with cases of “wet” drowning, death
their vehicle licensing authority as well dropped beats are very unlikely to be occurs by suffocation.
as their insurance company if they due to heart disease.
begin insulin therapy. Careful monitor- drowsiness
ing of blood sugar levels is of vital dropsy A state of consciousness between full
importance, because abnormally high An outmoded term for generalized wakefulness and sleep or unconscious-
or low levels may impair the person’s oedema (fluid accumulation in body ness. Drowsiness is medically significant
judgment or cause loss of conscious- tissues). It is not a disease in itself, but if a person fails to awaken after being
ness. People who have had a stroke, or a sign of disease, especially of conges- shaken, pinched, and shouted at, or
who have had a pacemaker fitted, may tive heart failure or kidney disease. wakes but relapses into drowsiness.
also be subject to driving restrictions. Abnormal drowsiness must be treated
Stricter regulations are in place for cer- drowning as a medical emergency. It may be the
tain groups of drivers, for example Death caused by suffocation and hypoxia result of a head injury, high fever, menin-
people with epilepsy. (a lack of oxygen) associated with gitis (inflammation of the membranes
Regardless of the medical condition, immersion in a fluid. Most often, the surrounding the brain and spinal cord),
it is extremely important that the person inhales liquid into the lungs; but uraemia (excess urea in the blood due to
patient contacts the vehicle licensing sometimes no liquid enters the lungs, a kidney failure), or liver failure. Alcohol or
authority for advice on fitness to drive condition called dry drowning (see drugs may also produce this effect. In a
if there is the least cause for concern. drowning, dry). People who are resusci- person with diabetes mellitus, drowsi-
tated after prolonged immersion are ness may be a result of hypoglycaemia
drooping eyelid said to be victims of “near drowning”. (low blood sugar levels) or of hyper-
See ptosis. (See also Types of drowning, p.246.) glycaemia (high blood sugar levels).

245
 DRUG

Wet (MHRA). A licence may be withdrawn alcohol and barbiturate drugs; hallucino-
drowning if toxic effects are reported or if the genic drugs, such as LSD; and narcotics
drug causes serious illness. (see opioid drugs), such as heroin. Some
USES drugs are abused in order to improve
Larynx
Drugs can be used to relieve physical performance in sports (see sports, drugs
or mental symptoms, to replace a nat- and; steroids, anabolic).
Trachea ural substance that is deficient, or to Problems resulting from drug abuse
stop the excessive production of a hor- may arise from the adverse effects of
D mone or other chemical by the body.
Some drugs are given to destroy for-
the drug, accidents that occur during
intoxication, or from the habit-forming
Water in eign organisms, such as bacteria or potential of many drugs, which may
lungs
fungi. Others, which are known as vac- lead to drug dependence.
cines, are given to stimulate the body’s
immune system to form antibodies. drug addiction
METHODS OF ADMINISTRATION Physical or psychological dependence
Drugs are given by mouth or injection, on a drug (see drug dependence).
Dry or are applied directly or indirectly to
drowning
the affected site via transdermal, nasal, drug dependence
and other direct routes (for example, to The compulsion to continue taking a
Larynx the lungs through an inhaler). Drugs that drug, either to prevent the ill effects
are injected take effect more rapidly than that occur when it is not taken, or to
Oesophagus those taken by mouth because they enter produce the desired effects of taking it.
the bloodstream directly, without pass- TYPES
ing first through the digestive system. Drug dependence can be psychological
There are different routes for injection. or physical, or more commonly both. A
Water in
stomach The fastest is intravenous; intramuscular person is psychologically dependent if
is also fast because muscles have a good he or she experiences craving or distress
blood supply; subcutaneous injection is when the drug is withdrawn. In physical
Types of drowning the slowest method, but is easier for drug dependence, the body has adapted
In four-fifths of deaths due to drowning, the victim self-administration of drugs. to the drug, causing the symptoms and
has inhaled liquid into his or her lungs. In the
other fifth, no liquid is present in the lungs; this ELIMINATION signs of withdrawal syndrome when the
condition is called dry drowning. In both cases, Unabsorbed drugs are broken down in drug is stopped. These symptoms are
death is by suffocation. the liver. Those taken orally are excreted relieved if the drug is taken again.
in faeces; those that have entered the CAUSE
bloodstream are eliminated in urine. Dependence develops as a result of reg-
drug ADVERSE EFFECTS ular or excessive drug use, and it
A chemical substance that alters the Most drugs can produce adverse effects. develops most frequently with drugs
function of one or more body organs or These effects may wear off as the body that alter mood or behaviour.
the process of a disease. Drugs include adapts to the drug. Adverse effects are SYMPTOMS AND SIGNS
prescribed medicines, over-the-counter more likely if there is a change in the Drug dependence may cause physical
remedies, and various substances (such absorption, breakdown, or elimination problems, for example lung and heart
as alcohol, tobacco, and drugs of abuse) of a drug (caused, for example, by liver disease from smoking and liver disease
that are used for nonmedical purposes. disease). Unexpected reactions some- from excessive alcohol consumption.
CLASSIFICATION AND LICENSING times occur due to a genetic disorder, Mental problems, such as anxiety and
Drugs normally have a chemical name, an allergic reaction, or the formation of depression, are common during drug
an officially approved generic name antibodies that damage body tissues. withdrawal. Dependence may also be
(see generic drug), and often a brand Some drugs interact with food, alcohol, linked with drug tolerance, in which
name. Drugs for medical use are either or other drugs. increasing doses of the substance are
licensed for prescription by a doctor Many drugs can cross the placenta; needed to produce the same effect.
only or can be bought over the counter some affect the growth and develop- COMPLICATIONS
at a chemist’s or supermarket. ment of the fetus if taken by a pregnant Complications such as hepatitis or AIDS
Most drugs are artificially produced woman. Most drugs can pass into the are a particular risk for people who
to ensure a pure preparation with a pre- breast milk of a nursing mother, and abuse drugs by injection. Death may
dictable potency (strength). Some drugs some have adverse effects on the baby. occur as a result of taking a contami-
are genetically engineered. A drug is nated drug, or be due to accidental
classified according to its chemical drug abuse overdose from taking a purer, more
make-up, or the disorder it treats, or Use of a drug for a purpose other than potent preparation than usual.
according to its specific effect on the that for which it is normally prescribed TREATMENT AND OUTLOOK
body. All new drugs are tested for their or recommended. Commonly abused Controlled withdrawal programmes are
efficiency and safety. In the UK, drugs drugs include stimulant drugs, such as available in special centres and hospitals,
are licensed by the Medicines and cocaine and amphetamine drugs; central which usually offer gradual, supervised
Healthcare products Regulatory Agency nervous system depressants, such as reductions in dose. Alternative, less

246
 DRY SOCKET

harmful drugs may be given, as well as drug poisoning and liver damage. Antiarrhythmic drugs
treatment for any withdrawal symp- The harmful effects on the body that can be given to treat heartbeat irregu-
toms. Social service agencies and occur as a result of an excessive dose of larity. Fits are treated with anticonvulsant
support groups may provide follow-up a particular drug. drugs. Blood tests to monitor liver func-
care. The success of treatment depends INCIDENCE AND CAUSES tion and careful monitoring of urine
on the motivation of the affected per- Accidental poisoning most commonly output are carried out if the drug is
son. Problems often recur if people occurs in young children. Child-resistant known to damage the liver or kidneys.
return to the circumstances that origi- drug containers have helped to reduce
nally gave rise to the drug abuse. this risk. In adults, drug poisoning usu- drug psychosis D
ally occurs in elderly or confused people A mental condition in which a person
drug eruption who are unsure about their treatment loses contact with reality during or fol-
An adverse, allergic reaction (see allergy) and dosage requirements. Accidental poi- lowing use of certain drugs (see drug
that is provoked by the ingestion or soning may also occur in drug abuse. abuse). Drug psychosis may be produced
topical application of a particular drug. Deliberate self-poisoning may be a cry by drugs such as amphetamines, cocaine,
A drug eruption is usually manifested for help (see suicide; suicide, attempted). LSD (lysergic acid diethylamide) and
as a rash on the surface of the skin. Drugs that are most commonly taken cannabis. The condition may also be
in overdose include benzodiazepine caused by prescribed drugs, particular-
drug-induced disease drugs and antidepressant drugs. ly by high doses of corticosteroid drugs.
Any disorder resulting from the use of TREATMENT Other possible effects associated with
a drug. Examples include drug-induced Anyone who has taken a drug overdose, drug psychosis include abnormal behav-
lupus erythematosus, haemolytic anaemia and any child who has swallowed tablets iour, hallucinations, delusions, and extreme
(see anaemia, haemolytic), and parkinson- belonging to someone else, needs imme- emotion, such as excitement or a dazed,
ism. Factors that may increase the risk diate medical attention. It is important to unresponsive state. Treatment involves
of drug-induced disease are age, sex, identify the drugs that have been taken. withdrawal from the drug and the use of
individual sensitivity, underlying dis- Treatment in hospital may involve antipsychotic drugs to relieve symptoms.
ease (especially of the kidneys or liver), washing out the stomach by passing
and the combination of drugs a patient water through a tube introduced into drunkenness
is taking. Adverse effects associated the mouth (see lavage, gastric). Charcoal See alcohol intoxication.
with the use of medications may lead may be given by mouth to reduce the
to hospitalization, disability, or even absorption of the drug from the intes- drusen
death. (See also side effect.) tine into the bloodstream. To eliminate Abnormal yellowish deposits that build
the drug, urine production may be up in the retina (the light-sensitive layer
drug interaction increased by an intravenous infusion. at the back of the eye), which can lead
The effect of a drug when it is taken in Antidotes are available only for a few to a disturbance of central vision.
combination with other drugs or with specific drugs. Such antidotes include Drusen may be a sign of age-related
substances such as alcohol. naloxone (for morphine) and methionine macular degeneration.
(for paracetamol).
drug overdose COMPLICATIONS dry drowning
The taking of an excessive amount of a Drug poisoning may cause drowsiness, See drowning, dry.
drug, which may cause toxic effects breathing difficulty, irregular heartbeat,
(see drug poisoning). and, rarely, cardiac arrest, fits, and kidney dry eye
See keratoconjunctivitis sicca.
METHODS OF DRUG ADMINISTRATION dry gangrene
A type of gangrene.
How taken Action
dry ice
By mouth Drugs are digested and absorbed from the intestine in
the same way as nutrients. How quickly the tablet or liquid Frozen carbon dioxide. Carbon dioxide
works depends on how rapidly it is absorbed. This, in turn, changes from a gas to a solid when
depends on such factors as the drug’s composition, how cooled, without passing through a liquid
quickly the drug dissolves and the effect of digestive phase. Dry ice may be applied to the
juices on it. Some drugs are inactivated as soon as they
reach the liver and never enter the circulation. skin in cryosurgery, a freezing technique
that is used, for example, to treat warts.
By injection Drugs given by injection have a very rapid effect and are dry mouth
given if digestive juices would destroy a drug. See mouth, dry.
Topical These drugs have a local effect on the parts of the body that dry socket
are exposed to them as well as a systemic (generalized) Infection at the site of a recent tooth
effect if some of the drug is absorbed into the bloodstream extraction, causing pain, bad breath, and
from the site of application.
an unpleasant taste in the mouth. Dry
socket occurs when a blood clot fails to

247
 DSM-IV

form in the tooth socket after a difficult The vaccine should not be given to chil-
extraction, such as removal of a wisdom dren who have reacted severely to a LOCATION OF THE DUODENUM
tooth (see impaction, dental). The clot preceding dose or to the old DTP vac-
The duodenum is about
itself may become infected, or infection cine, or to children who could have a
25 cm long and shaped
may already have been present before severe reaction to neomycin, streptomycin, like a C; it forms a loop
extraction. The inflamed socket appears or polymyxin B (see polymyxins), which around the head of the
dry, and exposed bone is often visible. may exist in the vaccine in trace amounts. pancreas.
The socket is irrigated to remove
D debris and may then be coated with an DTP vaccine
Gallbladder
anti-inflammatory paste. The infection An injection providing immunity against
usually clears up within a few days. diphtheria, pertussis (whooping cough), Duodenum Pylorus
and tetanus. In 2004, the DTP vaccine
DSM-IV was replaced, in the UK, by the dTaP/IPV
The fourth edition of the Diagnostic and and DTaP/IPV/Hib vaccines.
Statistical Manual of Mental Disorders,
published by the American Psychiatric dual personality
Association. It classifies psychiatric illnes- See multiple personality.
ses and is widely used in other countries.
Dubin–Johnson syndrome
dTaP/IPV An inherited disorder that is caused by
A combined vaccine, introduced in 2004, an autosomal recessive genetic trait (see
that provides immunity against diphthe- genetic disorders). Dubin–Johnson syn-
ria (in a low dose), tetanus, pertussis drome is characterized by long-standing,
(whooping cough), and poliomyelitis. It mild jaundice (yellowing of the skin and
is given to children aged three to five the whites of the eyes), which may not
years as part of the childhood immuni- become apparent until puberty or
zation programme. (See Typical childhood adulthood. There is an abnormality in
immunization schedule, p.414.) the transportation of bilirubin (the main Duodenal cap Stomach
pigment found in bile) from the liver to
DTaP/IPV/Hib the biliary system, which causes the Ampulla
A combined vaccine, introduced in 2004, bilirubin to accumulate in the liver. of Vater Pancreas

that provides immunity against diphthe- No specific treatment is available.

ria, tetanus, pertussis (whooping cough), Affected people are advised to avoid
poliomyelitis, and Hib. In this vaccine drinking alcohol, and to avoid taking a Duke’s classification
(and in the dTaP/IPV vaccine), the polio range of medications that are processed A staging system for carcinomas (cancer-
and pertussis parts have been altered to by the liver, for example oral contracep- ous tumours arising from cells in an
minimize the risk of adverse effects. tives. Genetic counselling may be offered organ’s surface layer or lining mem-
to prospective parents who have a fami- brane) in the lower gastrointestinal
HOW IT IS DONE ly history of Dubin–Johnson syndrome. tract. Carcinomas of the colon (the main
The injection is given in three doses to part of the large intestine) or rectum
infants at two, three, and four months Duchenne’s dystrophy (the muscular tube that connects the
of age, so that they are protected as soon The most common and severe form of large intestine to the anus) are classi-
as possible. (Meningitis C vaccination is muscular dystrophy. fied according to this system.
given at the same time.) The childhood
immunization schedule also includes a duct dumbness
preschool booster (see dTaP/IPV), and a A tube or a tube-like passage leading See mutism.
further diphtheria, tetanus, and polio from a gland to allow the flow of
booster before leaving school. (See Typical fluids, such as the tear ducts. dumping syndrome
childhood immunization schedule, p.414.) Symptoms that include sweating, faint-
PROTECTION ductal carcinoma ing, and palpitations due to the rapid
The vaccine provides a very high level Any carcinoma (a cancerous tumour passage of food from the stomach into
of immunity to diphtheria, tetanus, arising from cells in an organ’s surface the intestine. Dumping syndrome (also
pertussis, polio, and Hib infections. layer or its lining membrane) of a duct known as rapid gastric emptying) is
POSSIBLE ADVERSE EFFECTS (a tube or tube-like passage leading uncommon but mainly affects people
DTaP/IPV/Hib is less likely to cause re- from a gland). who have had a gastrectomy (surgical
actions than the older vaccines. Any side Examples of ducts that are most fre- removal of the stomach).
effects are usually mild and tend to quently affected by carcinomas are the Symptoms may occur within about
occur within 12–24 hours.They include pancreatic duct (see pancreas) and the 30 minutes of eating (early dumping)
a slightly raised temperature, irritability milk ducts in the female breast. Ductal or after 90–120 minutes (late dump-
and fretfulness, and a small lump, red- carcinomas of the breast that have not ing). Some very anxious people may
ness, and swelling at the injection site. yet spread into the breast tissue can experience the symptoms of dumping
Severe side effects are very rare. usually be cured by surgery. even though their stomach is intact.

248
 DYING, CARE OF THE

CAUSES pancreas, liver, and gallbladder feed into dura mater

Gastric surgery interferes with the nor- it through a small opening. Digestive The outer of the three membranes
mal mechanism for emptying food from enzymes in the pancreatic secretions and (meninges) covering the brain.
the stomach (see digestion). If a meal chemicals in the bile are released into
containing a high level of carbohydrates the duodenum through this opening. Duroziez’s disease
is “dumped” too quickly from the sto- A congenital (present at birth) form of
mach, the upper intestine may swell. duplex kidney mitral stenosis (a narrowing of the
This, together with excessive amounts Two fused kidneys on one side of the opening of the mitral valve, which is
of certain hormones released into the
bloodstream, causes the symptoms of
body. Another structural abnormality of
the kidney is duplex renal pelvis, in
situated on the left side of the heart). D
early dumping. As sugars are absorbed which a single kidney has two renal dust diseases
from the intestine, they rapidly increase pelvises (urine-collecting chambers). A Lung disorders caused by dust particles
the blood glucose level, causing excess third possibility is duplex ureter, in inhaled and absorbed into the lung
insulin hormone release. This may, in which there are two ureters leading from tissues. There, they may cause fibrosis
turn, later lower the blood glucose level one kidney. The ureters may open into (formation of scar tissue) and progres-
below normal, causing the symptoms the bladder, or, in females, one may open sive lung damage. The main symptoms
of late dumping. into the vagina. These malformations are a cough and breathing difficulty. It
PREVENTION arise during formation in the embryo. may take at least ten years of exposure
A person who has had a gastrectomy Surgical correction may be necessary to to dusts containing coal, silica, talc, or
can prevent symptoms by eating fre- prevent complications such as infections. asbestos before serious lung damage
quent, small, dry meals that contain no develops (see pneumoconiosis). Hyper-
refined carbohydrates. Symptoms may duplex uterus sensitivity to moulds on hay or grain
also be prevented by lying down for a Duplication of part or all of the uterus. may lead to allergic alveolitis.
rest after a large meal. Adding guar gum There may be two uteri joined to one Preventive measures, such as the
to food is also sometimes effective. vagina, or two uteri with two vaginas. installation of dust extraction machin-
A more common condition is septate ery, have reduced the incidence of dust
duodenal cap uterus, in which a band of tissue (sep- diseases, and replacements have been
The upper area of the first part of the tum) divides the uterine cavity into found for especially hazardous sub-
duodenum; this is revealed in a barium X- two spaces instead of one. stances such as asbestos.
ray examination.
Dupuytren’s contracture DVT
duodenal ulcer A disorder of the hand in which one or Deep vein thrombosis (see thrombosis,
A raw area in the wall of the duodenum more fingers become fixed in a bent deep vein).
(the first part of the small intestine) position. In about half of the cases, both
due to erosion of its inner surface lin- hands are affected. In most cases there dwarfism
ing. Duodenal and gastric (stomach) is no apparent cause, but the disease See short stature.
ulcers are types of peptic ulcer, and have may be, in part, inherited. Men over
similar causes, symptoms, and treatment. the age of 40 are most often affected. dydrogesterone
The tissues just under the skin in the A drug that is derived from the female
duodenitis fingers or palm become thickened and sex hormone progesterone. It is used to
Inflammation of the duodenum (the first shortened, which causes difficulty in treat premenstrual syndrome and certain
part of the small intestine), producing straightening the fingers. Surgery can menstrual problems (see menstruation,
vague gastrointestinal symptoms. It is correct deformity of the fingers, but in disorders of). Dydrogesterone is also
diagnosed by oesophagogastroduoden- some cases the condition recurs. given together with an oestrogen drug
oscopy (see gastroscopy): examination as hormone replacement therapy to
of the walls of the upper digestive tract women after or during the menopause.
with a flexible viewing instrument. The Dydrogesterone may be prescribed to
treatment for duodenitis is similar to that treat endometriosis or to prevent miscar-
for a duodenal ulcer (see peptic ulcer). riage. Possible side effects include
swollen ankles, weight gain, breast ten-
duodenum derness, and nausea.
The first part of the small intestine. The
duodenum begins at the duodenal cap, dying, care of the
just beyond the pylorus (the muscular Physical and psychological care that is
valve at the lower end of the stomach). It given with the aim of making the final
extends to the ligament of Treitz, which months or days of a dying person’s life
marks the boundary with the second part Thickened band as free from pain, discomfort, and
of the small intestine (the jejunum). (See of tissue emotional distress as possible.
Location of the duodenum, opposite page.) Carers may include doctors, nurses,
Dupuytren’s contracture
The duodenum is about 25 cm long A band of tissue in the hand thickens and
and other medical professionals, coun-
and C-shaped; it forms a loop around contracts, gradually pulling the fingers into sellors, social workers, clergy, and the
the head of the pancreas. Ducts from the a permanently bent position. person’s family and friends.

249
 DYS-

PHYSICAL CARE TREATMENT that is most often caused by an X-

Pain can be relieved by regular low Drug or surgical treatment of the under- linked recessive genetic trait, although
doses of analgesic drugs. Opioid anal- lying disease or structural defect may autosomal dominant and autosomal
gesics, such as morphine, may be given improve the person’s ability to speak recessive forms also exist (see genetic
if pain is severe. Other methods of pain clearly. Speech therapy is also useful. disorders). The condition affects more
relief include nerve blocks, cordotomy, males than females and first become
and TENS. Nausea and vomiting may be dyscalculia apparent in childhood.
controlled by drugs. Constipation can A disorder in which there is difficulty Dyskeratosis is characterized by pre-
D be treated with laxatives. Breathlessness
is another common problem in the
in solving mathematical problems. (See
also learning difficulties.)
mature thickening of epithelial cells
(see epithelium) in the skin; leukoplakia
dying, and this may be relieved by (raised white patches on the mucous
administering morphine. dyschondroplasia membranes of the mouth or vulva);
Towards the end, the dying person A rare disorder, also called multiple nail dystrophy (a disorder caused by
may be restless and may suffer from enchondromatosis or Ollier’s disease, inadequate nutrition); and pancytopenia
breathing difficulty due to heart failure that is present from birth and charact- (a simultaneous decrease in the num-
or pneumonia. These symptoms can be erized by the presence of multiple ber of red cells, (anaemia), white cells
relieved by drugs and by placing the tumours of cartilaginous tissue within (neutropenia), and platelets (thrombocy-
patient in a more comfortable position. the bones of a limb. It is caused by a topenia) in the blood).
EMOTIONAL CARE failure of normal ossification during
Emotional care is as important as the bone development. The bones are short- dyskinesia
relief of physical symptoms. Many peo- ened, resulting in deformity. Rarely, a Abnormal muscular movements. These
ple who are terminally ill feel angry or tumour in the bone may become can- uncontrollable twitching, jerking, or
depressed, and feelings of guilt or of cerous (see chondrosarcoma). writhing movements cannot be sup-
regret are common responses. Loving, pressed, and they may affect control of
caring support from family, friends, dysentery voluntary movements. The disorder
and others is very important. An intestinal infection, causing diar- may involve the whole body or be
HOME OR HOSPICE? rhoea (often mixed with blood, pus, or restricted to a group of muscles.
Many terminally ill people would prefer mucus) and abdominal pain. There are Types of dyskinesia include chorea
to die at home, and few terminally ill two distinct forms of dysentery: shigel- (jerking movements), athetosis (writhing
patients need specialized nursing for losis, which is due to shigella bacteria; movements), choreoathetosis (a combined
a prolonged period. Specially trained and amoebic dysentery, which is caused form), myoclonus (muscle spasms), tics
nurses or health-care workers from a by the protozoan parasite ENTAMOEBA (repetitive fidgets), and tremors.
hospital, hospice, or charity may be HISTOLYTICA . The main risk with dysen- Dyskinesia may result from brain
able to provide additional support for tery is dehydration caused by loss of damage at birth or may be a side effect
the dying person and his or her carers. fluid in the diarrhoea. of certain drugs (see tardive dyskinesia),
Care in a hospice may be offered. which often disappears when the drug
Hospices are small units that have been dysfunction is stopped. Otherwise, dyskinesia is dif-
established specifically to care for ter- An abnormality or impairment in the ficult to treat. (See also parkinsonism.)
minally ill people and their families. functioning of an organ or body sys-
tem. (See also bleeding, dysfunctional dyslexia
dys- uterine; minimal brain dysfunction; psycho- A reading disability characterized by
A prefix meaning abnormal, difficult, sexual dysfunction.) difficulty interpreting written symbols.
painful, or faulty, as in dysuria (pain on The term “dysfunctional” may be CAUSE
passing urine). used to describe a poor relationship Dyslexia is more common in males,
between two or more people. and evidence suggests that a specific,
dysarthria sometimes inherited, neurological dis-
A speech disorder caused by disease or dysgraphia order underlies true dyslexia.
damage to the physical apparatus of Problems with writing (see learning dif- SYMPTOMS
speech or to the nerves controlling this ficulties). A child with dyslexia has normal intel-
apparatus. Affected people can formu- ligence, but his or her attainment of
late, select, and write out words and dyskaryosis reading skills lags far behind other
sentences grammatically; the problem Abnormal changes in the nuclei of scholastic abilities.
is with vocal expression only. cells, particularly in the early stages of While many young children tend to
CAUSES cancer. Dyskaryosis may be detected by reverse letters and words (for example,
Dysarthria is common in many degen- microscopic examination of cells in writing or reading p for q, or was for
erative neurological conditions, such as procedures such as a cervical smear test. saw), most soon learn to correct such
multiple sclerosis and Parkinson’s disease. errors. Dyslexic children continue to
It may also result from a stroke, brain dyskeratosis confuse these symbols. Letters are often
tumour, or an isolated defect or damage An abnormality in keratinization (the transposed (as in pest for step), and
to a particular nerve. Structural defects deposition of the tough protein keratin) spelling errors are common. The chil-
of the mouth, as occur in cleft lip and in the surface of the skin or nails. One dren may even be unable to read words
palate, can also cause dysarthria. form is due to a rare, inherited disorder that they can spell correctly.

250
 DYSURIA

TREATMENT ing. It is caused by damage to speech

It is very important to recognize the and comprehension regions of the
problem early to prevent added frustra- brain. (See also aphasia.)
tions. Specific teaching can help an
affected child develop “tricks” to over- dysphonia
come the deficit. Avoidance of pressure Defective production of vocal sounds
from parents combined with praise for in speech, either as a result of disease
what the child can do is equally or of damage to the larynx (voicebox)
important in helping progress. or to the nerve supply to the laryngeal
muscles. (See also larynx, disorders of;
D
dysmenorrhoea speech disorders.)
Pain or discomfort experienced during
or just before a menstrual period. dysphoria
TYPES AND CAUSES A feeling of disquiet or restlessness.
Primary dysmenorrhoea is common in Dysphoria may be a side effect of cer-
teenage girls and young women. It usu- tain drugs, or it may be a symptom of a Scoliosis due to dystonia
Injury to the back may result in dystonia and
ally starts two to three years after psychiatric disorder. abnormal spasm of the back muscles. This
menstruation begins, but often dimin- Gender dysphoria is a persistent feel- problem, in turn, may lead to scoliosis (abnormal
ishes after the age of 25. The exact ing that one has been born the wrong sideways curvature of the spine).
cause is unknown. One possibility is sex (see gender identity).
excessive production of, or undue sen- neurological disorders such as Parkin-
sitivity to, prostaglandins, which are dysplasia son’s disease, or it may
be a side effect
hormone-like substances that stimulate Any abnormality of growth. The term of antipsychotic drugs.
spasms in the uterus. applies to deformities in structures Dystonia may be reduced by treat-
Secondary dysmenorrhoea is due to such as the skull and to abnormalities ment with anticholinergic drugs or with
an underlying disorder, such as pelvic of single cells. Abnormal cell features benzodiazepine drugs. In some cases,
inflammatory disease or endometriosis, include the size, shape, and rate of biofeedback training may be helpful.
and usually begins in adult life. multiplication of cells (see, for exam- Injections of botulinum toxin into the
SYMPTOMS ple, cervical dysplasia). affected muscles are effective in treat-
Cramp-like pain or discomfort is felt in ing some types of dystonia.
the lower abdomen, sometimes accom- dyspnoea
panied by a dull ache in the lower The medical term for shortness of dystrophy
back. Some women also have nausea breath (see breathing difficulty). Any disorder in which the structure
and vomiting. and normal activity of cells within a
TREATMENT dysrhythmia, cardiac body tissue have been disrupted by
Mild primary dysmenorrhoea is often A medical term meaning disturbance of inadequate nourishment of that part.
relieved by analgesic drugs (painkillers). heart rhythm, sometimes used as an The cause is usually unknown, but may
In severe cases, symptoms can usually alternative to arrhythmia (see arrhyth- be poor circulation of blood through
be relieved by taking oral contraceptives mia, cardiac). the tissue, nerve damage or deficiency
or other hormonal preparations that of a specific enzyme in the tissue.
suppress ovulation. The treatment of dystocia Examples of dystrophy include mus-
secondary dysmenorrhoea depends on A term that means difficult or abnor- cular dystrophies and leukodystrophies.
the cause of the condition. mal labour (see childbirth). Dystocia Corneal dystrophies, in which cells lin-
may occur, for example, if the baby is ing the cornea of the eye are damaged,
dysmorphia very large, or if the mother’s pelvis is are a rare cause of blindness.
An abnormality in the shape of a body abnormally shaped or too small for the
tissue or structure. baby to pass through. (See also child- dysuria
birth, complications of.) The medical term for pain, discomfort,
dyspareunia or difficulty in passing urine (see urina-
Painful sexual intercourse (see inter- dystonia tion, painful).
course, painful). Abnormal muscle rigidity, which caus-
es painful spasms, unusually fixed
dyspepsia postures, or strange movement pat-
The medical term for indigestion. terns. Dystonia may affect a localized
area of the body, or may be more gen-
dysphagia eralized. The most common types of
The medical term for swallowing difficulty. localized dystonia are torticollis (painful
neck spasm), and scoliosis (an abnor-
dysphasia mal sideways curvature of the spine),
A disturbance in the ability to select the which is caused by an injury to the
words with which to speak and write back that produces muscle spasm. Gen-
and/or to understand speech or writ- eralized dystonia may be caused by

251
 EALES’ DISEASE

E
The middle ear is cut off from the out- snail’s shell, containing nerve fibres that
side by the eardrum. However, it is not detect different sound frequencies. (For
completely airtight; a ventilation pas- more information about how this sys-
sage, called the eustachian tube, runs tem works, see hearing.)
forwards and downwards into the back The rear part of the inner ear con-
of the nose. The eustachian tube is tains three semicircular canals and is
normally kept closed, but it opens by concerned with balance. The semicircu-
muscular contraction when an individ- lar canals are connected to a cavity
ual yawns or swallows. called the vestibule and contain hair
The middle ear acts as a transformer, cells bathed in fluid. Some of these cells
passing the vibrations of sound from are sensitive to gravity and acceleration;
E Eales’ disease the air outside (which is a thin medium) others respond to the positions and
A rare condition seen mainly in young to the fluid within the inner ear (which movement of the head. Information
men that is characterized by inflamma- is a thicker medium). from the inner ear is conducted to the
tion of the retinal veins and recurrent INNER EAR brain via the vestibulocochlear nerve. (See
vitreous haemorrhage (leakage of blood The inner ear is an intricate series of also disorders of the ear box.)
into the vitreous humour, the gel-like structures contained deep within the
substance that fills the rear chamber of bones of the skull. It consists of a maze earache
the eye). The presence of blood in the of winding passages, collectively known Pain in the ear, which may originate in
vitreous humour may affect vision and as the labyrinth. The front part, called the ear itself or may result from a disor-
lead to headaches. If vision is impaired, the cochlea, is a tube that resembles a der in one of the structures situated
laser treatment may be performed to pre-
vent further haemorrhage.
ANATOMY OF THE EAR
ear
The outer ear comprises the pinna and ear canal; the middle ear – the eardrum,
The organ of hearing and balance. The malleus, incus, stapes, and eustachian tube; and the inner ear – the vestibule,
ear consists of three parts: the outer ear, semicircular canals, and cochlea. Sensory impulses from the inner ear pass to the
the middle ear, and the inner ear. The brain via the vestibulocochlear nerve.
outer and middle ear are concerned
mainly with the collection and trans-
mission of sound. The inner ear is
responsible for analysing sound waves;
it also contains the mechanism by
which the body keeps its balance.
OUTER EAR
The outer ear comprises the pinna (the
visible part of the ear), which is com-
posed of folds of skin and cartilage, and
the ear canal, which is approximately
2.5 cm long in adults.
The outer part of the ear canal is
composed of cartilage and produces ear-
wax, which traps dust and foreign Malleus
Incus Vestibulocochlear nerve
bodies. The canal is closed at its inner
end by the eardrum, a thin, fibrous, cir- Stapes Oval
Semicircular canals window
cular membrane that is covered with a
Pinna
layer of skin. The eardrum vibrates in
response to the changes in air pressure
that constitute sound.
Ear canal
MIDDLE EAR
The middle ear is a small cavity between
the eardrum and the inner ear that con-
ducts sound to the inner ear by means
of three tiny, linked, movable bones
known as ossicles. The first bone, the Vestibule
malleus, is joined to the inner surface of
Eardrum
the eardrum. The second, the incus, has
one broad joint with the malleus (which Cochlea
lies almost parallel to it) and a delicate
Eustachian tube
joint to the third bone, the stapes. The
base of the stapes fills the oval window
leading to the inner ear.

252
 EARDRUM, PERFORATED

near the ear. Earache is an extremely

common symptom, especially in infan- DISORDERS OF THE EAR
cy and childhood. Pressure changes associated with flying
The ear is susceptible to many disorders,
CAUSES
some of which can lead to deafness. or scuba diving can also cause minor
A frequent cause of earache is acute oti- damage (see barotrauma).
tis media (infection of the middle ear),
Congenital defects
which occurs most commonly in young Tumours
In rare cases, the ear canal, ossicles
children and results in severe, stabbing Acoustic neuroma is a rare, noncancerous
(small bones in the middle ear), or
pain. There may also be loss of hearing tumour of the acoustic nerve that may
pinna (visible part of the ear) are absent
and a raised temperature. press on structures in the ear to cause
or deformed at birth. Rubella (German
Another common cause of earache is
otitis externa (inflammation of the ear
measles) in early pregnancy can
damage the baby’s developing ear,
deafness, tinnitus, and problems with
balance. In cholesteatoma, skin cells
E
canal), which is often caused by infec- accumulate in the middle ear.
leading to deafness. Most cases of
tion. Infection can affect the whole
congenital sensorineural deafness
canal, or it may be localized, sometimes
(deafness due to problems with the Obstruction
taking the form of a boil or abscess.
inner ear, nerves, or the brain’s auditory Obstruction of the ear canal is often due
The earache may be accompanied by
area) are genetic. to earwax, although in small children,
irritation in the ear canal and a dis-
an object may have been pushed into
charge of pus.
Infection the ear (see ear, foreign body in).
Intermittent earache may also occur
Infection is the most common cause of
in people with dental problems, tonsil-
ear disorders. Infection in the ear canal Other disorders
litis, throat cancer (see pharynx, cancer
leads to otitis externa; in the middle ear, In otosclerosis, a hereditary condition,
of), pain in the jaw or neck muscles,
it causes otitis media. This can lead to a bone in the middle ear becomes
and other disorders affecting areas near
perforation of the eardrum (see immobilized, causing deafness. Meniérè’s
the ear. Earache in such cases occurs
eardrum, perforated). Glue ear (buildup disease is a rare condition in which
because the ear and nearby areas are
of fluid in the middle ear), often due deafness, vertigo, and tinnitus occur
supplied by the same nerves; the pain is
to infection, is the most common cause due to buildup of fluid in the inner ear.
said to be “referred” to the ear.
of childhood hearing difficulties.Viral Progressive, age-related hearing loss is a
DIAGNOSIS AND TREATMENT
infection of the inner ear may cause condition known as presbyacusis.
To determine the cause of earache, the
labyrinthitis with severe vertigo or Certain drugs, such as aminoglycoside
ear is inspected (see ear, examination of).
sudden hearing loss. drugs and some diuretic drugs, can also
The mouth, throat, and teeth may also
damage ear function.
be examined.
Injury
Analgesic drugs (painkillers) may be
Cauliflower ear occurs as the result of one
prescribed to relieve the pain. Other INVESTIGATION
major or several minor injuries to the
treatment depends on the underlying
pinna. Perforation of the eardrum can Hearing and balance are explored
cause of the earache. Antibiotic drugs
result from poking objects into the ear using hearing tests, caloric tests, and
may be prescribed for an infection. Pus
or from loud noise. Prolonged exposure electronystagmography. The ear canal and
in the outer ear may be removed by
to loud noise can cause tinnitus (noises eardrum are viewed with an otoscope.
suction. Pus in the middle ear may be
within the ear) and/or deafness.
drained through a hole in the eardrum,
a procedure known as myringotomy.
ear, cauliflower DIAGNOSIS AND TREATMENT eardrum, perforated
See cauliflower ear. A swab of the discharge may be taken The rupture or erosion of the eardrum.
and sent to a laboratory for analysis to Perforation of the eardrum can cause
ear, discharge from identify the cause of any infection. Hear- brief, intense pain. There may also be
Also called otorrhoea, emission of fluid ing tests may also be performed. X-rays slight bleeding, a discharge from the
from the ear. Not all discharge is the of the bones of the skull will be taken ear (see ear, discharge from), and a
same; it may be watery or thick, clear or if there has been a head injury or if a reduction in hearing.
coloured, odourless or foul-smelling, serious type of middle-ear infection is CAUSES
and intermittent or continuous. suspected from the symptoms. Most commonly, perforation occurs as a
CAUSES Treatment depends on the cause and result of buildup of pus in the middle
A discharge from the ear may be due usually includes antibiotic drugs. ear due to acute otitis media (middle-ear
to an outer-ear infection (see otitis ex- infection). Perforation may also be asso-
terna). It may also follow perforation of eardrum ciated with cholesteatoma (accumulation
the eardrum (see eardrum, perforated), The circular membrane that separates of skin cells and debris in the ear).
which is usually due to a middle-ear the outer ear from the middle ear. The Another cause is injury, for example
infection (see otitis media). Rarely, after eardrum vibrates in response to sound from insertion of an object into the ear,
a skull fracture (see skull, fracture of), waves, conducting the sound to the inner a loud noise, barotrauma (damage caused
cerebrospinal fluid or blood may be dis- ear through the ossicles (the three small by pressure changes) or a fracture to the
charged from the ear. bones in the middle ear). base of the skull (see skull, fracture of).

253
 EAR, EXAMINATION OF

In some cases, a doctor may deliberately ear, nose, and throat surgery occurs predominantly in Africa. There is
puncture the eardrum to drain pus from See otorhinolaryngology. no specific treatment for the disease,
the middle ear (see myringotomy). which is fatal in many cases.
DIAGNOSIS AND TREATMENT ear piercing
Diagnosis is confirmed by examination Making a hole in the earlobe or another, eburnation
of the ear (see ear, examination of). Hear- usually cartilaginous, part of the exter- The conversion of bone into an ivorylike
ing tests may also be performed to assess nal ear to accommodate an earring. Ear mass. The cartilage that covers an articu-
any hearing loss. piercings are best cleaned twice a day lating bone surface wears away, exposing
Analgesic drugs (painkillers) may help with salt water. Earlobe piercing takes the underlying bone tissue, which
to relieve any pain and antibiotic drugs about 4 weeks to heal; cartilage piercing becomes increasingly dense and worn.
may be prescribed to treat or prevent may take 8–12 weeks. Eburnation is a feature of osteoarthritis.
E infection. Most perforations heal very
quickly, usually within a month. How- ears, pinning back of EB virus
ever, if the perforation has failed to heal See otoplasty. See Epstein–Barr virus.
after about six months, myringoplasty
(an operation to repair the eardrum) earwax ecchymosis
may be required. A yellow or brown secretion, also The medical term for a bruise that is vis-
called cerumen, produced by glands in ible through the skin.
ear, examination of the outer ear canal. In most people,
The ear may be examined to investigate wax is produced in small amounts, eccrine gland
the possible causes of earache, discharge comes out on its own, and causes no A type of sweat gland.
from the ear (see ear, discharge from), problems. However, some people pro-
hearing loss, a feeling of fullness in the duce so much wax that it regularly ECG
ear, disturbed balance, tinnitus (noises obstructs the canal. Excess earwax may The abbreviation for electrocardiogra-
within the ear), or swelling of lymph produce a sensation of fullness in the phy, a method of recording the electrical
nodes (see glands, swollen) below or in ear and, if the canal is blocked com- activity of the heart muscle. An ECG is
front of the ear. pletely, partial deafness. These symp- useful for diagnosing heart disorders,
HOW IT IS DONE toms are worsened if water enters the many of which produce electrical pat-
The doctor begins by examining the ear and makes the wax swell. Pro- terns that deviate from normal. Electrodes
pinna (the visible part of the outer ear) longed blockage may irritate the skin connected to a recording machine are
for any evidence of swelling, tender- of the ear canal. placed on the patient’s chest, wrists, and
ness, ulceration, or deformity. To view TREATMENT ankles. The machine displays the heart’s
the ear canal and eardrum, an otoscope Wax that causes blockage or irritation electrical activity on a screen or as a trace.
(a viewing instrument for examining may come out after being softened with (See also ambulatory ECG; exercise ECG.)
the ear) may be used. warmed olive oil or almond oil. Other-
To obtain images of the middle and wise, the wax should first be softened echinachea
inner ears, X-rays, or CT scanning or and then removed by a doctor or nurse A preparation of the plant genus ECHI-
MRI (techniques that produce cross-sec- (see syringing of the ears). NACEA . Three species of echinacea are
tional or three-dimensional images of used in herbal medicine; they are
body structures), may be carried out. eating disorders believed to boost the body’s immune sys-
Hearing and balance can be assessed by Illnesses that are characterized by obses- tem and therefore increase its resistance
means of hearing tests or caloric tests. sions with weight and body image. to bacterial, viral, and fungal infections.
Electronystagmography is a technique in Eating disorders are most common in
which balance is assessed by observing young adolescent females, but they can echocardiography
the movements of the eye as water is also affect males. A method of obtaining an image of
poured into the ear. In the eating disorder anorexia nervosa, the structure and movements of the
patients, despite being painfully thin, heart using ultrasound (inaudible, high-
ear, foreign body in perceive themselves as fat and starve frequency sound waves).
Foreign bodies can easily enter the ear themselves. Binge-eating followed by self- WHY IT IS DONE
canal. Children often insert small objects, induced vomiting is one of the main Echocardiography is a diagnostic tech-
such as peas or stones, into their ears, features of bulimia, although, in this dis- nique that is used to detect structural,
and insects may crawl or fly in. order, weight may be normal. The two and some functional, abnormalities of
If people try to remove objects from conditions sometimes occur together. In the heart wall, heart chambers, heart
the ear themselves, they may push the morbid obesity, there is a constant desire valves, and large coronary arteries.
items further into the ear canal and risk to eat large quantities of food. The procedure is also used to diag-
damaging the eardrum. Foreign bodies nose congenital heart disease (see heart
in the ear must always be removed by Ebola fever disease, congenital), cardiomyopathy (heart
doctors. This can be done by syringing A dangerous and highly contagious viral muscle disorders), aneurysms (balloon-
(see syringing of ears) or by using fine- infection that causes severe haemorrhag- ing of the heart or blood vessel walls),
toothed forceps. Insects can sometimes ing (see bleeding) from the skin and the pericarditis (inflammation of the mem-
be floated out using warmed olive oil mucous membranes (the thin, moist tis- brane that surrounds the heart), and
or lukewarm water. sue that lines body cavities). Ebola fever blood clots in the heart.

254
 ECLAMPSIA

ELECTROCARDIOGRAPHY

Electrocardiography causes no
discomfort. Electrodes connected to HOW ECG IS DONE
a recording machine are applied to the
chest, wrists, and ankles. The machine Small electrodes, ECG machine Trace Chest electrode
displays the electrical activity in the connected by leads to
heart as a trace on a moving graph or the recording machine,
a screen. Any abnormality is thereby are attached to the
revealed to the doctor, nurse, or chest, wrists, and
paramedic. Normal and abnormal ankles using conducting Wrist
recordings are shown, below right. jelly or pads. Signals
from the electrodes
electrode
E
An ECG can be taken at home, in the
doctor’s surgery, or in the hospital; a produce a trace.
recording lasting 24 hours or longer Technician
can be obtained from a monitoring
device worn by the patient. Ankle electrode

Normal rhythm
R The heart chambers are
contracting regularly.
Seconds
0 0.2 0.4 0.6
Ventricular fibrillation
T Here, the contractions of the
lower heart chambers are
P Q extremely irregular.
S
Complete heart block
The upper and lower heart
Normal ECG
chambers are beating
This tracing shows the electrical activity
independently.
associated with one normal heartbeat. The
blue line shows the current flowing toward the
recording lead. The rise at P occurs just before Atrial fibrillation
the atria (upper heart chambers) begin to Here, the upper heart
contract, the QRS “spike” occurs just before chambers are beating fast and
the ventricles (lower chambers) begin to irregularly, triggering irregular
contract, and the rise at T occurs as the contraction of the ventricles.
electrical potential returns to zero.

HOW IT IS DONE echo-free conditions, including skin rashes, colds

Echocardiography is harmless and causes A term used in ultrasound scanning to (see cold, common), gastrointestinal dis-
no discomfort. A transducer (an instru- denote a structure that does not give rise orders, and viral meningitis.
ment that sends out and receives sound to reflections (echoes) of ultrasound
signals) is placed on the patient’s chest, waves. A cyst filled with clear fluid, for eclampsia
or an ultrasound probe is passed into example, is echo-free. An uncommon but serious condition
the oesophagus using a flexible endo- that develops in a woman in late preg-
scope (viewing tube). Ultrasound waves echogenic nancy, during childbirth, or after delivery.
are reflected differently by each part of A term used in ultrasound scanning to Eclampsia is characterized by hyperten-
the heart, resulting in a complex series denote a structure that gives rise to sion (high blood pressure), proteinuria
of echoes. These are viewed on a screen reflections (echoes) of ultrasound waves. (protein in the urine), oedema (accumu-
and may be recorded, or the results can lation of fluid in body tissues), and the
be printed out. echolalia development of seizures. The condition
DEVELOPMENTS The compulsive repetition of something is life-threatening for both the mother
Developments such as multiple moving spoken by another person. The tone and and the baby.
transducers and computer analysis have accent of the speaker are copied as well Eclampsia occurs as a complication
helped to provide clear anatomical pic- as the words. Echolalia is sometimes seen of moderate or severe, although not
tures of the heart. in schizophrenia and may occur in peo- mild, pre-eclampsia.
Doppler echocardiography is used to ple with learning difficulties or autism. SYMPTOMS
measure the velocity (speed) of blood The warning symptoms of impending
flow through the heart. It allows for ECHO virus eclampsia include headaches, confu-
the assessment of structural abnorm- The name for a specific group of RNA sion, blurred or disturbed vision, and
alities such as a mitral valve prolapse viruses. There are 32 types of ECHO abdominal pain. If untreated, seizures
and septal defects. virus, and these cause a wide range of may occur and may be followed by

255
 ECONAZOLE

coma (a state of unconsciousness and which reduces the physical effects of ectopic pregnancy
unresponsiveness to stimuli). Levels of the induced seizure. The treatment is A pregnancy that develops outside the
blood platelets may fall severely, result- usually given once or twice a week, for uterus, most commonly in a fallopian
ing in bleeding; liver and kidney six weeks. Temporary amnesia (memory tube, but sometimes in an ovary, the
function may also be affected. loss) is a possible side effect. abdominal cavity, or the cervix (neck of
TREATMENT AND OUTLOOK the uterus). As the pregnancy develops,
Careful monitoring of blood pressure ectasia it may damage surrounding tissues,
and proteinuria throughout pregnancy A term that means widening, usually causing serious bleeding. An ectopic
is required to enable prompt treatment used to refer to a disorder of a duct. For pregnancy is potentially life-threatening
of impending eclampsia, and immedi- example, mammary duct ectasia is an and requires emergency treatment.
ate delivery, often by caesarean section, abnormal widening of the ducts that
E together with antihypertensive drugs and carry secretions from the breast tissue
Fallopian tube

anticonvulsant drugs is needed. Patients to the nipple.

may need intensive care to prevent the
development of complications, such as ectomorph
kidney failure. A term formerly used to describe an
Blood pressure often returns to nor- individual with a tall, thin body, a low
mal in the months following delivery, level of body fat, slender limbs, small
although it may remain high. There is a bones, and little muscle mass. (See also
Uterus
risk of a recurrence of eclampsia in sub- endomorph; mesomorph.)
sequent pregnancies. Ovary
-ectomy
econazole A suffix that denotes surgical removal.
An antifungal drug used as a cream in the For example, tonsillectomy is surgical
treatment of fungal skin infections removal of the tonsils.
(such as athlete’s foot and tinea), and in
cream or pessary form to treat vaginal ectoparasite
candidiasis (thrush). Skin irritation is a A parasite that lives in or on its host’s
rare side effect. skin. An ectoparasite derives nourish- Cervix Vagina
ment from the skin or by sucking the
Ecstasy host’s blood. Various lice, ticks, mites,
An illegal designer drug, related to the and some types of fungi are occasional
Location of an ectopic pregnancy
amphetamine drugs. Ecstasy has a mildly ectoparasites of humans. By contrast, The pregnancy usually develops in the fallopian
hallucinogenic effect and generates feel- endoparasites live inside the body. tube; occasionally it develops in the ovary, the
ings of euphoria, making users feel alert abdominal cavity, or the cervix.
and sociable. In most people, the drug ectopic
has no ill effects in the short-term, but A term used to describe a body struc- CAUSES
repeated use carries a risk of liver dam- ture that occurs in an abnormal location The fertilized ovum (egg) may become
age. The most common side effect is or position or a body function that stuck in the fallopian tube if there is
hyperthermia (very high body tempera- occurs at an abnormal time. a congenital abnormality of the tube or
ture). Taking the drug causes intense if the tube has been damaged in any
thirst; drinking large quantities of water ectopic heartbeat way. Damage is most commonly due to
to combat this may result in fatal damage A contraction of the heart muscle that is a pelvic infection (see pelvic inflammato-
to the body, including brain swelling out of normal timing. An ectopic heart- ry disease) or from surgery on the
beat occurs shortly after a normal beat fallopian tubes. Ectopic pregnancy has
ECT and is followed by a longer-than-usual also been associated with the use of
The abbreviation for electroconvulsive interval before the next one. some types of IUD (intrauterine contra-
therapy, a treatment for very severe Ectopic beats can occur in a healthy ceptive device) and progestogen-only
depression. ECT is less commonly used heart and may be symptomless. Multi- oral contraceptives.
today than it was in the past, since the ple ectopic beats can cause palpitations SYMPTOMS
introduction of newer, more effective (awareness of a rapid or forceful heart- The majority of ectopic pregnancies
antidepressant drugs; however, the pro- beat). When occurring after a myocardial are discovered in the first two months,
cedure usually relieves depression more infarction (heart attack), such multiple often before the woman even realizes
rapidly than drugs, and it may be life- beats are a sign of damaged heart mus- that she is pregnant. Symptoms usually
saving in severe cases that are resistant cle. They may lead to a condition called include severe pain in the lower abdo-
to other forms of treatment. ventricular fibrillation, a rapid, unco- men and bleeding from the vagina.
In this procedure, an electric current ordinated, potentially fatal heartbeat. Internal bleeding may cause symptoms
is passed through the brain in order to Multiple ectopic beats that are caus- of shock, which include pallor, sweat-
induce a seizure. ECT is administered ing palpitations, or those that occur ing, and faintness.
under a short-lived general anaesthetic after a myocardial infarction, are often DIAGNOSIS AND TREATMENT
(see anaesthesia, general) and in com- treated with an antiarrhythmic drug. (See Diagnosis is made by a transvaginal
bination with a muscle-relaxant drug, also arrhythmia, cardiac.) ultrasound examination, in which an

256
 EEG

ultrasound probe is inserted into the people who have an inherited tendency be applied to the affected areas; these
vagina, and it can be confirmed by towards allergy. The condition is com- may then be covered with a dressing
laparoscopy (internal examination using mon in babies. An intensely itchy rash to prevent scratching. Absorbent, non-
a viewing instrument). occurs, usually on the face, in the elbow irritating materials (such as cotton)
If the diagnosis is made early on, creases, and behind the knees. The skin should be worn next to the skin; irri-
treatment using the drug methotrexate often scales and small red pimples may tants (such as wool, silk, and rough
may be considered. In most cases, sur- appear. Infection may occur if the rash synthetics) should be carefully avoided.
gery, usually minimally invasive surgery, is is scratched, breaking the skin.
carried out to remove the embryo For mild cases, emollients (such as EDD
(which is usually already dead), the pla- petroleum jelly) help to keep the skin The abbreviation for expected date of
centa, and any damaged tissue at the site soft. In severe cases, ointments contain- delivery, the date on which a baby is
of the pregnancy. If blood loss is severe, ing corticosteroid drugs may be used. due to be born. The EDD is calculated as E
blood transfusions may be necessary. An Antihistamine drugs may be prescribed to 40 weeks from the first day of the
affected fallopian tube is removed if it reduce itching. Excluding certain foods woman’s last menstrual period (see
cannot be repaired. from the diet may help to control the period, menstrual). In practice, babies are
OUTLOOK condition. Atopic eczema often clears rarely born exactly on their EDD.
It is still possible to have a normal preg- up on its own as a child grows older.
nancy even if one fallopian tube has Nummular eczema Nummular eczema edentulous
been removed, although the chances usually occurs in adults and is of un- A term meaning without teeth, a condi-
of conception are slightly reduced. known cause. It produces round, itchy, tion arising either because the teeth have
Women with two damaged tubes may scaling patches on the skin that are similar not yet grown or because they have fallen
require in vitro fertilization to achieve an to those of tinea (ringworm). Topical out or been removed by a dentist.
intrauterine pregnancy. corticosteroids may reduce inflamma-
tion, but the eczema is often persistent. Edwards’ syndrome
ectopic testis Hand eczema Hand eczema is usually A genetic disorder, also known as trisomy
See testis, ectopic. caused by irritant substances such as 18 syndrome, that is associated with
detergents, but it may occur for no the presence of a third copy of chro-
ectropion apparent reason. Itchy blisters develop, mosome 18. Edwards’ syndrome affects
A turning outwards of the eyelid so that usually on the palms, and the skin may about three times as many girls as boys.
the inner surface is exposed. Ectropion become scaly and cracked. Characteristics of Edwards’ syndrome
is most common in elderly people, in Hand eczema usually improves if include a low birth weight, severe learn-
whom it usually affects the lower lid emollients are used and if cotton gloves ing difficulties, low-set and malformed
and is due to weakness of the muscle with rubber gloves over them are worn ears, a small jaw, hand abnormalities,
surrounding the eye. when coming into contact with irritants. opacities in the cornea of the eye, con-
The condition may also be caused by If the eczema is severe, corticosteroids genital heart disease (see heart disease,
the contraction of scar tissue in the skin may be prescribed. congenital), hernias, ventricular septal defect
near either lid. Ectropion often follows Stasis eczema Stasis eczema occurs in (a hole between the lower chambers of
facial palsy, which causes paralysis of the people with varicose veins. The skin on the heart), and kidney abnormalities.
muscles around the eye. the legs may become irritated, inflamed, Approximately half the babies born
Even slight ectropion interferes with and discoloured. The swelling of the with Edwards’ syndrome do not survive
the normal drainage of tears by distor- legs may be controlled with compres- beyond the first week of life. Very few
tion of the opening of the tear duct. sion bandages or stockings. Application infants live longer than a year. People
Chronic conjunctivitis may result, caus- of ointments containing corticosteroids with a family history of Edwards’ syn-
ing redness, discomfort, and overflow may give temporary relief. drome should consider genetic coun-
of tears so that the skin becomes damp GENERAL TREATMENT selling before starting a family.
and inflamed. Constant wiping tends to To reduce irritation and the risk of
pull the lid farther from the eye. scratching, a soothing ointment should EEG
Surgery to tighten the affected eyelid The abbreviation for electroencephalo-
may be required. graphy, a method of recording the
electrical activity of the brain. A trace of
eczema the activity is displayed on a monitor or
An inflammation of the skin, usually printed out on a moving strip of paper.
causing itching and sometimes scaling In EEG, small electrodes are attached
or blisters. There are several different to the scalp and connected to an instru-
types of eczema and some forms are ment that records minute electrical
better known as dermatitis (such as con- impulses produced by the brain’s activity.
tact dermatitis and photodermatitis). By revealing characteristic wave patterns,
Eczema is sometimes the result of an an EEG can help in diagnosing different
allergy, but is often of unknown cause. types of epilepsy and identifying areas
TYPES Atopic eczema
in the brain where abnormal electrical
Atopic eczema Atopic eczema is a chronic, In this example of atopic eczema, the skin on the activity develops. (See also How electro-
superficial inflammation that occurs in backs of the knees is raw and inflamed. encephalography is done box, overleaf.)

257
 EFFUSION

the affected joint is rested, bandaged

HOW ELECTROENCEPHALOGRAPHY IS DONE firmly, cooled with ice-packs, and kept
elevated. In some cases, the excess fluid
A number of small electrodes are Electrodes Monitor
connected to is drawn out of the joint using a needle
attached to the scalp. Shaving of the
scalp is unnecessary. The electrodes
control panel and syringe.
are connected to an instrument that Recording Technician
measures the brain’s impulses in electrodes egg
microvolts and amplifies them for See ovum.
recording purposes. The technique
is painless, produces no side effects, ego
and takes about 45 minutes. The conscious sense of oneself. In
E Recordings are taken while the Freudian psychoanalytic theory, the ego
subject is at rest, with the eyes open maintains a balance between the primi-
and then shut, during and after tive, unconscious instincts of the id, the
hyperventilation (overbreathing), controls of the superego, and the de-
and while looking at a flashing light.
mands of the outside world.
Electroencephalography is also
helpful to record activity as the
patient goes to sleep, especially
Ehlers–Danlos syndrome
when epilepsy is suspected. An inherited disorder of collagen, the
most important structural protein in the
EEG WAVE PATTERNS body. Individuals with Ehlers–Danlos
Alpha waves syndrome have abnormally stretchy,
The prominent pattern of an awake, relaxed adult thin skin that bruises easily. Wounds are
whose eyes are closed. slow to heal and leave paper-thin scars,
Beta waves
and the joints are loose and prone
The lower, faster oscillation of a person who is to recurrent dislocation. Sufferers bleed
concentrating on an external stimulus. easily from the gums and digestive tract.
Ehlers–Danlos syndrome is most
Delta waves commonly inherited in an autosomal
The typical pattern of sleep, also found in young
infants; rarely, delta waves indicate the presence dominant pattern (see genetic disorders).
of a brain tumour. There is no known specific treatment
for the condition, although unnecessary
Theta waves accidental injury, such as that which
The dominant waves of young children. In adults, may occur in contact sports, should be
they may indicate an abnormality of the brain.
avoided by sufferers.
Eisenmenger complex
effusion lubricate the joint. However, if the A condition in which deoxygenated
The process by which fluid escapes. The synovium is damaged or inflamed (for blood flows directly back into the circu-
term effusion also describes an abnor- example, as a result of arthritis), it pro- lation rather than through the lungs.
mal collection of fluid (such as blood, duces excessive fluid. This is due to an abnormal connection
pus, or plasma) in the tissues or a body The pain and inflammation may be between the left and right sides of the
cavity. An effusion can form as a result relieved by analgesic drugs (painkillers) heart and to pulmonary hypertension (in
of inflammation or changes in pressure and nonsteroidal anti-inflammatory drugs which there is abnormally high blood
within blood vessels; alternatively, it can and by having injections of corticosteroid pressure in the arteries supplying the
be due to changes in the blood con- drugs. The swelling usually reduces if lungs). The resultant hypoxia (lack of
stituents, such as in nephrotic syndrome oxygen in the blood) causes cyanosis
(a kidney disorder). (bluish coloration of the skin), fainting,
Effusion commonly occurs around the and difficulty in breathing.
lung (see pleural effusion) or heart (see Eisenmenger complex occurs most
pericardial effusion) or within joints, caus- commonly in individuals who have
ing swelling (see effusion, joint). certain uncorrected congenital heart
defects (see heart disease, congenital),
effusion, joint such as ventricular septal defect.
The accumulation of fluid in the space The diagnosis of Eisenmenger com-
around a joint, resulting in swelling, plex may be confirmed by cardiac
limitation of movement, and usually catheterization (the insertion, under X-ray
also pain and tenderness. All joints are control, of a thin tube into the heart via
enclosed by a capsule lined with a a blood vessel). Once the condition has
Location of knee joint effusion
membrane called the synovium.The syno- Excessive production and accumulation of fluid
developed, surgical correction of the
vium normally secretes small amounts within the right knee joint (left in image) as a original defect will not help. Drug treat-
of fluid (known as synovial fluid) to result of injury or inflammation. ment may help control the symptoms.

258
 ELECTIVE

ejaculation the prostate gland). There is no treat- surrounding muscles, tendons, and liga-
The emission of semen from the penis ment, but sexual intercourse with a full ments. Repeated strain on the tendons of
at orgasm. Just before ejaculation, mus- bladder can sometimes result in normal the forearm muscles, where they attach
cles around the epididymides (ducts in ejaculation. If an affected man and his to the elbow, can result in inflammation
which sperm are stored; see epididymis), partner wish to have a baby, it is some- that is known as epicondylitis. There are
the prostate gland, and the seminal vesi- times possible to harvest sperm from two main types of epicondylitis: tennis
cles contract rhythmically, forcing the the bladder for use in in vitro fertilization. elbow and golfer’s elbow. Alternatively,
sperm from the epididymides to move (See also azoospermia; psychosexual dys- a sprain of the ligaments around the
forwards and mix with secretions from function; sexual problems.) elbow joint may occur.
the seminal vesicles and the prostate. At Olecranon bursitis develops over the
ejaculation, this fluid is propelled out of elasticated bandage tip of the elbow in response to local
the body through the urethra. A type of stretchable bandage that is irritation. Strain on the elbow joint can E
Because both semen and urine leave especially useful in the treatment of produce an effusion (the accumulation
the body by the same route, the bladder joint injuries and for swelling of the legs of fluid in a joint) or traumatic synovitis
neck closes during ejaculation. This not due to varicose veins. An elasticated ban- (inflammation of the membranes that
only prevents ejaculate from going into dage helps to minimize swelling while line the joint capsule).
the bladder but also stops urine from not impeding movement. A sharp blow on the olecranon
contaminating the semen. (See also process (the bony tip of the elbow, also
reproductive system, male.) elbow known as the “funny bone”) may im-
The hinge joint formed where the pinge on the ulnar nerve as it passes in a
ejaculation, disorders of lower end of the humerus (upper-arm groove in this area, causing temporary
A group of conditions in which the bone) meets the upper ends of the discomfort: a pins-and-needles sensa-
normal process or timing of ejaculation radius and ulna (the forearm bones). tion and lancing pains that shoot down
is disrupted. The elbow is stabilized by ligaments the arm into the fourth and fifth fingers.
TYPES at the front, the back, and the sides. A fall onto an outstretched hand or
Premature ejaculation In premature ejac- The elbow joint enables the arm to be onto the tip of the elbow can cause a
ulation, semen emission occurs before bent and straightened, and the forearm fracture or dislocation of the elbow.
or almost immediately following pene- to be rotated through almost 180
tration. Premature ejaculation is the degrees around its long axis without elderly, care of the
most common sexual problem in men, more than a very slight movement of Appropriate care to help minimize
particularly in young men who have the upper arm. physical and mental deterioration in the
only recently become sexually active. It DISORDERS elderly. For example, failing vision and
is often due to over-stimulation or to Disorders of the elbow include arthritis hearing are often regarded as inevitable
anxiety about sexual performance. If the and various injuries to the joint and its in old age, but removal of a cataract
problem occurs frequently, sexual coun- (loss of transparency in the lens of the
selling and techniques for delaying eye) or use of a hearing-aid can often
ejaculation may help (see sex therapy). ANATOMY OF THE ELBOW improve quality of life.
Inhibited ejaculation This is a rare condi- Isolation or inactivity leads to depres-
tion in which erection is normal, or even The elbow is a hinge joint between sion in some elderly people. Attending a
the lower end of the humerus and the
prolonged, but ejaculation is abnormally upper ends of the radius and ulna.
day-care centre can provide social con-
delayed or fails to occur. The problem The biceps muscle bends and rotates tact and introduce new interests.
may be psychological in origin, in the arm at the elbow. Many elderly people are cared for by
which case counselling may help, or it family members. Voluntary agencies can
may arise as a complication of a disor- Biceps often provide domestic help in order to
muscle
der such as diabetes mellitus or alcohol ease the strain on carers. The option of
dependence. In some cases, inhibited sheltered housing allows independence
Ulnar nerve
ejaculation occurs as a side effect of cer- while providing a degree of supervision
tain drugs, such as some antihypertensive and assistance when it is needed. Elder-
Humerus
drugs and antidepressant drugs. ly people who have dementia (loss of
The cause is treated where possible; if Ligaments
normal brain function) or a physical
drug treatment is thought to be the disability may require more supervi-
cause, a change to another drug may Tendon sion, in a residential care or hospital
resolve the problem. setting. (See also geriatric medicine.)
Retrograde ejaculation In retrograde ejac-
ulation, the neck of the bladder, which elective
normally closes during ejaculation, stays A term used to describe a procedure,
open. As a result, semen is forced back- usually a surgical operation, that is not
wards into the bladder and none is urgent and can be performed at a sched-
expelled from the penis. uled time. Elective surgery includes the
Retrograde ejaculation may be due to correction of nonurgent medical con-
Olecranon Ulna Radius
a neurological disease, surgery on the ditions, such as haemorrhoids, and some
bladder, or prostatectomy (removal of cosmetic procedures, such as rhinoplasty.

259
 ELECTRICAL INJURY

electrical injury to the chest wall to detect electrical hair sometimes grows around the are-
Damage to tissues caused by an electric impulses from the heart. Other proce- ola, the pigmented area surrounding
current passing through the body and dures using electrodes include certain the nipple) and does not affect breast-
the associated heat release. The internal types of physiotherapy, in which elec- feeding. The legs are not well suited to
tissues of the body, being moist and trodes are attached to the skin and emit electrolysis because treatment of this
salty, are good conductors of electricity. electrical impulses to stimulate the extensive area requires so many sessions
Dry skin provides a high resistance to underlying muscles. (See also ECT; that the procedure would be very time-
current flow, but moist skin has a low electrocautery; electrocoagulation; electrol- consuming and expensive.
resistance and thus allows a substantial ysis; electronystagmography.) NEWER TREATMENTS
current to flow into the body. Serious Alternative methods of hair removal,
injury or death from domestic voltage electroencephalography which are faster and less painful than
E levels is therefore more likely to occur See EEG. electrolysis, are now available.
in the presence of water. One new method is a form of laser
PHYSICAL EFFECTS electrolysis treatment in which hair follicles are dis-
All except the mildest electric shocks Permanent removal of unwanted hair abled by a laser beam.The treatment can
may result in unconsciousness. Alternat- by introducing a short-wave electric be used on several hundred hair follicles
ing current (AC) is more dangerous current into the hair follicle. The current simultaneously. It works best on people
than direct current (DC): it causes sus- destroys the hair root either by causing with pale skin and dark hair, because
tained muscle contractions, which may a chemical reaction (a process that is the melanin (dark pigment) in the hair
prevent the victim from releasing the called galvanism) or by generating heat, absorbs energy from the laser, while the
source of the current. A current as small which seals off the blood vessels sup- skin (which has little melanin) is rela-
as 0.1 amp passing through the heart plying the hair (see diathermy). tively unaffected.
can cause a fatal arrhythmia (irregular WHY IT IS DONE Another new technique, known as
heartbeat). The same current passing Hair on the face and body can be photo-epilation, involves the use of
through the brainstem may cause cessa- removed temporarily by shaving or intense pulsed light to disable hundreds
tion of the heartbeat and breathing. plucking or by the use of depilatory of hair follicles at the same time, with
Larger currents may cause charring of creams, abrasives, or wax preparations. minimal side effects.
tissues, especially where the current However, electrolysis is the only method
enters and exits the body. of permanent hair removal. electrolyte
AREAS THAT CAN BE TREATED A substance whose molecules dissociate
electric shock treatment With a few exceptions, electrolysis can (split) into its constituent ions (electri-
See ECT. be safely used on any part of the body. cally charged particles) when dissolved
Its use should be avoided on the lower or melted. For example, sodium chlo-
electrocardiography margins of the eyebrows because the ride (table salt) dissociates into sodium
See ECG. skin above the eyelids is very delicate cations (positively charged ions) and
and easily damaged. It is also question- chloride anions (negatively charged ions)
electrocautery able whether the technique should be when dissolved in water.
A technique for destroying tissue using used on the armpits due to the risk of
heat produced by an electric current. bacterial infection. Electrolysis has no electromyography
Electrocautery is used to remove skin harmful effect on the breasts (where See EMG.
blemishes such as warts. (See also cauter-
ization; diathermy; electrocoagulation.) Electrolysis needle electronystagmography
A method of recording types of nys-
electrocoagulation Hair tagmus (abnormal, jerky movements of
Use of a high-frequency electric current the eye) in order to investigate their
to seal blood vessels by heat, stopping cause. In electronystagmography, elec-
bleeding. Electrocoagulation is used in trical changes caused by eye movements
surgery; the current is delivered through are picked up by electrodes that are
a surgical knife, enabling the surgeon to placed near the eyes and are recorded
make bloodless incisions. The procedure on a graph.
is also used to stop nosebleeds and to
destroy abnormal blood vessel forma- electrophoresis
tions, such as spider naevi, in which case The movement of electrically charged
current is applied through a fine needle. particles that are suspended in a colloid
Hair follicle solution under the influence of an elec-
electroconvulsive therapy How electrolysis is done tric current. The direction, distance, and
See ECT. To remove each hair, a fine needle is inserted into rate of movement of the particles vary
the follicle and a small electric current is passed according to their size, shape, and
electrode through it. The current destroys the root of the electrical charge.
hair and the hair is then pulled out. The procedure
A device through which an electrical may cause some pain, but, in skilled hands, it is Electrophoresis is used to analyse
current is transmitted or received. In harmless. If the treatment is successful, there mixtures (to identify and quantify the
ECG, for example, electrodes are applied should be no further hair growth from that follicle. proteins in blood, for example), and it

260
 EMBOLISM

may be used as a diagnostic test for mul- tube. In balloon embolectomy, a balloon myocardial infarction (heart attack), or in
tiple myeloma, a bone marrow tumour catheter (a flexible tube with a balloon the atria (upper chambers of the heart)
that produces abnormally high blood at its tip) is passed into the affected in atrial fibrillation, and then travel to
levels of a specific antibody (a protein blood vessel, to just beyond the embo- the brain. This results in a cerebral
manufactured by the immune system). lus. The balloon is inflated and the embolism, which is an important cause
catheter is withdrawn from the body, of stroke (damage to part of the brain
elephantiasis bringing the embolus out with it. due to interruption to its blood supply).
A disease that occurs in the tropics and Air embolism, in which a small artery
is characterized by massive swelling of embolism is blocked by an air bubble, is rare. Fat
the legs, the arms, and, in men, the Blockage of an artery by an embolus embolism, in which a vessel is blocked
scrotum (the pouch behind the penis (a fragment of material carried in the by fat globules, is a possible complica-
that contains the testes). There is also bloodstream). An embolus may consist tion of a major fracture of a limb; it E
thickening and darkening of the skin. of various substances. It is usually occurs when fat is released from the
Most cases of elephantiasis are due to formed from a blood clot. Other sub- marrow of the broken bone. Amniotic
chronic lymphatic obstruction caused stances that may form an embolism fluid embolism occurs during labour
by filariasis (a worm infestation). include a bubble of air or other gas; a or immediately after delivery of the
piece of tissue or tumour; a clump of baby. This rare complication of child-
elimination diet bacteria, bone marrow, cholesterol, or birth is often fatal.
A dietary programme used to identify fat; or, rarely, amniotic fluid forced into SYMPTOMS
a food allergy or food intolerance. Test a woman’s circulation during childbirth. Symptoms of an embolism depend on
foods, such as milk, are gradually omit- TYPES the site of the embolus. Pulmonary
ted from the diet one at a time to see if A blood clot that has broken off from a embolism can lead to breathlessness
they are responsible for the symptoms. larger clot elsewhere in the circulation and chest pains. If the embolus lodges
(See also exclusion diet.) is the most common type of embolus. in the brain, a stroke may occur, affect-
Pulmonary embolism is a disorder that ing speech, vision, or movement. If an
ELISA test may be due to a blood clot. The condi- embolism blocks an artery to the leg,
A laboratory blood test used in the diag- tion is usually the result of a fragment the limb will become painful and turn
nosis of infectious diseases. ELISA stands breaking off from a deep vein thrombo- pale. If left untreated, gangrene (tissue
for enzyme-linked immunosorbent assay. sis (see thrombosis, deep vein) and being death) may develop.
(See also immunoassay.) carried via the heart to block an artery In serious cases of fat embolism,
supplying the lungs. Pulmonary embol- heart and breathing rates rise dramati-
elixir ism may cause sudden death. Blood cally and there may be restlessness,
A clear, sweetened liquid, which often clots may form inside the heart after a confusion, and drowsiness.
contains alcohol, that forms the basis
of many liquid medicines, such as
cough remedies.
TYPES OF EMBOLISM

ellipsoidal joint Embolisms are named after the part of Cerebral embolism
the circulation affected by the embolus A blockage of one of the
A type of mobile joint, such as the wrist arteries that supply blood
involved (for example, a fat embolism to the brain; it is one of
joint, that allows all types of movement is caused by fat globules, sometimes the most common causes
except full rotation. released from a bone fracture). When of stroke.
an embolus is released, it is carried
Eltroxin through branches of an artery until it
Pulmonary embolism
A brand name for levothyroxine, a syn- becomes lodged. Blood is prevented A blockage of one of the
thetic thyroid hormone. from reaching parts of the body beyond. arteries that supply blood to
the lungs. This may cause
emaciation Left subclavian
chest pain, breathlessness,
and sudden death.
Abnormal thinness or wasting away of artery
the body, which may be the result of a Brachial artery
Amniotic fluid embolism
variety of conditions including malnutri- The escape of some of the
tion, worm infestation, or diseases such as fluid that surrounds the
Humerus
tuberculosis or cancer. baby in the uterus into the
mother’s circulation. This
Extent of blood may cause blockage of an
embolectomy flow into arm artery in one of her lungs.
Surgical removal of an embolus (a frag-
ment of material, often a blood clot,
Angiogram of embolism in the arm
that is carried in the bloodstream and This X-ray was taken after injection of a contrast Embolism in leg
has blocked an artery; see embolism). medium into the blood vessel. It shows the An embolism may block
one of the arteries that
There are two methods of embolec- obstruction, by an embolus, of the normal flow supply blood to the leg.
tomy. In one procedure, an incision is of blood through the subclavian artery and the Gangrene may occur
brachial artery beside the humerus. below the blockage.
made in the affected artery and the
embolus is removed through a suction

261
 EMBOLIZATION

TREATMENT but divides several times as it travels After eight weeks, the embryo is about
If a severe embolism causes the person along the fallopian tube to the uterus 2.5 cm long. Most of the internal organs
to collapse, emergency life-saving mea- (womb) to form a spherical mass of cells. have formed and all the external fea-
sures are undertaken to maintain the About six days after conception, this tures are present.
breathing and circulation (see cardio- mass becomes embedded in the uterus
pulmonary resuscitation). lining. At the site of attachment, the embryo diagnosis
Embolectomy (surgical removal of the outer layer of cells obtains nourishment Also called preimplantation diagnosis, a
blockage) may be possible. If the embo- from the woman’s blood; this part will procedure carried out on embryos at an
lus is formed from a blood clot and later become the placenta. In the cell early stage of development to determine
surgery is not possible, thrombolytic mass, a flat disc forms, consisting of whether they are affected by a genetic
drugs (drugs that dissolve blood clots) layers of cells from which all the baby’s disorder. Embryo diagnosis may be car-
E and anticoagulant drugs (drugs that pre- tissues will form. The amniotic sac devel- ried out following in vitro fertilization
vent clot formation) may be given. ops around the embryo. (IVF) if the parents are known to be
THE THIRD WEEK carriers of a specific disorder.
embolization Early in the third week, the disc of cells Several eggs are fertilized; they are
Deliberate obstruction of a blood vessel becomes pear-shaped. The head of the grown for a few days in specialized
using an artificial embolus (a fragment embryo forms at the rounded end and laboratories until the first two or three
of material carried in the bloodstream) the lower spine at the pointed end. A cell divisions have taken place and
made of material such as gel foam, PVA group of cells develops along the back the clusters contain approximately eight
(resin), liquid sclerosants (hardeners), of the embryo to form the notochord, a cells. One cell from each cluster is
or medical glue. Embolization is carried rod of cells that constitutes the basis for removed in order for its DNA to be
out to stop uncontrollable internal bleed- the spine. From this time onwards, the analysed. Embryos that are found to
ing or to cut off the blood supply to a embryo has two recognizable halves that be healthy can then be implanted in the
tumour, especially a fibroid. In the latter develop more or less symmetrically. mother’s uterus (womb).
case, embolization can relieve pain; cause The notochord then furrows and the
the tumour to shrivel, making surgical edges grow towards each other before embryology
removal easier; or stop the tumour from fusing to form the neural tube. Later, The study of the development and
spreading. Embolization can also be the neural tube will develop into the growth of the embryo and then the fetus
used to block flow through vascular brain and spinal cord. from conception through the months of
abnormalities such as haemangiomas, in THE FOURTH WEEK gestation until birth.
both the skin and internal organs. During the fourth week, the embryo’s Embryology is an essential part of a
A catheter (flexible tube) is introduced back grows more rapidly than its front, medical student’s training because it
into a blood vessel near the one to be giving it a C-shape. The neural tube leads to a greater understanding of the
blocked. An embolus is released through extends towards the embryo’s head, anatomy of an adult and of the ways in
the catheter; it lodges inside the vessel, where a fold that will eventually form which structural defects in the body
blocking blood flow to the affected area. the brain becomes visible. may arise. For example, the occurrence
Developing ears appear as pits and of congenital heart defects is easier to
embolus rudimentary eyes form as stalks. Within understand when the stages of fetal
A fragment of material, usually a blood the embryo, buds of tissue form that heart development are explained. (See
clot, that is carried in the bloodstream will become the lungs, pancreas, liver, also embryo diagnosis.)
and obstructs an artery. An embolus is and gallbladder. A heart starts to develop
life-threatening if it blocks blood flow in the form of a tube. Outer layers of embryoma of the kidney
through a vital artery (see embolism). the embryo begin to form the limb An alternative name for Wilms’ tumour.
buds and paired bulges appear on the
embrocation sides of the neural tube that will even- emergency
A medication rubbed into the skin in tually become the cartilage, bone, and Any condition requiring urgent medical
order to relieve muscular or joint pain. muscle of the back. treatment, such as cardiac arrest (a halt
THE FIFTH WEEK in the pumping action of the heart), or
embryo During the fifth week of pregnancy, any procedure that must be performed
The unborn child during the first eight the embryo’s external ears become vis- immediately, such as cardiopulmonary
weeks of its development following con- ible; pits mark the position of the resuscitation.
ception; for the rest of the pregnancy it nose; the jaws form; and the limb buds
is known as a fetus. extend, becoming flattened at the ends emergency contraception
Development of the embryo is gov- where the hands and feet will develop. See contraception, emergency.
erned internally by genes inherited Folds of tissue fuse to form the front
from the parents and externally by fac- wall of the chest and abdomen. The emesis
tors such as the mother’s diet and any umbilical cord develops. The medical term for vomiting.
drugs taken during pregnancy. THE SIXTH TO EIGHTH WEEKS
THE FIRST TWO WEEKS During weeks six to eight, the embryo’s emetic
The embryo develops from an ovum face becomes recognizably human, the A substance that causes vomiting, used to
(egg) that has been fertilized by a sperm neck forms, the limbs become jointed, treat some types of poisoning and drug
(see fertilization). It starts as a single cell, and fingers and toes appear. overdose. Emetics act by stimulating the

262
 EMETIC

THE DEVELOPING EMBRYO

From the time of conception until the attachment, the outer layer of cells
eighth week, the developing baby is forms the placenta, while a group of
known as an embryo. At conception, the cells within one area of the cell ball
fertilized egg consists of a single cell, the develops into the embryo. A sac filled
zygote, which contains genetic material with amniotic fluid forms around the
from the sperm and the ovum. The embryo to protect it. As the embryo
zygote divides several times to form a grows, it begins to form features and,
ball of cells, which then implants into by the fifth week, it has developed a
the lining of the uterus. At the point of recognizable head and limb buds.
E
Passage to the uterus
The egg is fertilized in one of the
fallopian tubes and is carried to the
uterus, where it embeds in the
uterine lining.
Embryo at about six weeks
The embryo is floating in the amniotic sac.
Fertilization of egg The smaller sac above (the yolk sac) provides
in fallopian tube nourishment for the early embryo.
Ovary
Ear
Fertilized egg
implants in uterine wall
Eye

Forebrain Nose and mouth

Head Limb buds
Heart bulge
Umbilical cord
Umbilical cord
Notochord
Tail
Lower spine
Actual
Actual size Actual size size

Three weeks Four weeks Six weeks

The embryo now becomes pear-shaped, with The embryo now becomes C-shaped and a tail Eyes are visible and the mouth, nose, and ears
a rounded head, pointed lower spine, and is visible. The umbilical cord forms and the are forming. The limbs grow rapidly from initial
notochord running along its back. forebrain enlarges. tiny buds.

INTERNAL ORGANS AT FIVE WEEKS

Blood
vessel
All the internal organs (such as the liver, pancreas, stomach, kidneys, heart, Eye
lungs, and sex organs) have begun to form by the fifth week. During this critical
Ear
stage of development, the embryo is highly vulnerable to harmful substances
that are consumed by the mother (such as alcohol and medication), which may Nose
cause birth defects. Mouth

Stomodeum Pharyngeal gut

(mouth)

Heart bulge Lung bud

Liver Stomach

Gallbladder Pancreas
Umbilical
cord
Umbilical cord
Intestinal loop
Actual size
Urinary bladder
Hindgut Eight weeks
The face is more “human”, the head is more
upright, and the tail has gone. Limbs become
jointed and digits appear.

263
 EMG

part of the brain that controls vomiting bonding does not occur in the early thought to protect against this chemical
and/or by directly irritating the lining months of life or if a child is frequently damage; therefore, people with a defi-
of the stomach. The most widely used separated from his or her parents for ciency of this substance are particularly
emetic is ipecacuanha. long periods during the first five years. badly affected by emphysema.
Emotionally deprived children may The damage is slight at first, but in
EMG be impulsive, unable to cope with frus- heavy smokers it becomes progressively
The abbreviation for electromyogram, a tration, hungry for attention, and may worse; the alveoli burst and merge to
recording of the electrical activity with- have impaired intellectual development. form fewer, larger sacs with less surface
in a muscle. area, which consequently impairs oxy-
WHY IT IS DONE emotional overlay gen and carbon dioxide exchange. Over
An EMG can help to diagnose muscle A term used by some doctors to the years the lungs become increasing-
E disorders, such as muscular dystrophy, or describe physical symptoms that they ly less elastic, which further reduces
conditions in which the nerve supply to feel have been worsened by emotional their efficiency.
the muscle is impaired, such as neuropa- difficulties. For example, it is common SYMPTOMS AND SIGNS
thy, radiculopathy, or motor neuron disease. for symptoms of a condition to worsen Initially, there are no symptoms, but as
In cases of nerve injury, the actual site of when an individual is unhappy or wor- the disease progresses and the lungs
the nerve damage can often be located. ried. (See also pain.) suffer damage, there is an increasing
HOW IT IS DONE shortness of breath. In some people, the
Electrical activity is measured during emotional problems chest becomes barrel-shaped as air is
muscle contraction and at rest. Small A common term for a range of psycho- trapped in the lungs. There may also be
disc electrodes are attached to the skin logical difficulties, often related to anxiety a chronic cough (caused by the accom-
over the muscle; alternatively, needle or depression. Emotional problems may panying bronchitis) and a slight wheeze.
electrodes are inserted into the muscle. have various causes. Eventually (sometimes after many
The impulses from the muscle are years) the level of oxygen in the blood
displayed on an oscilloscope screen, empathy starts to fall. In some cases, pulmonary
which shows muscle contraction and The ability to understand and share the hypertension (raised blood pressure in
relaxation in the form of a wave pattern thoughts and feelings of another per- the pulmonary artery) develops, lead-
and reveals whether or not the muscle son. In psychoanalysis, the therapist ing to cor pulmonale (enlargement and
activity is normal. A permanent record partly relies on empathy to establish a strain on the right side of the heart).
can be made of the EMG. The procedure relationship with a patient. Affected people start to turn blue due
has no side effects. to a lack of oxygen in the blood; their
emphysema legs subsequently swell as a result of
EMLA A disease in which the walls of the oedema (accumulation of fluid in the
An acronym for “eutectic mixture of alveoli (see alveolus, pulmonary) are pro- tissues). Other sufferers are able to
local anaesthetics”. (The word “eutec- gressively destroyed, thereby reducing compensate for oxygen deficiency to
tic” means “easily melted”.) EMLA is a the area of lung available for exchange some extent by breathing faster, there-
brand-named cream applied to the of gases. The alveoli, of which there are by retaining their normal colouring.
skin to produce local anaesthesia (see many millions in each lung, are groups Many people show signs falling some-
anaesthesia, local). It is used to reduce of air sacs at the end of bronchioles where between these two extremes.
discomfort before intravenous injec- (tiny air passages). Through their thin DIAGNOSIS
tion and venepuncture, particularly in walls, inhaled oxygen is passed into the A diagnosis is made from the patient’s
children, and before treating localized bloodstream and carbon dioxide is symptoms and signs, from a chest
skin conditions such as genital warts removed from the capillaries to be examination, and from various tests. A
(see warts, genital). breathed out. blood sample from an artery may be
Emphysema usually develops along analysed to measure the concentration
emollient with chronic bronchitis, in a condition of oxygen and carbon dioxide in the
A substance, such as lanolin or petrol- known as chronic obstructive pul- blood; blood oxygen levels may alter-
eum jelly, that has a soothing and monary disease (see pulmonary disease, natively be measured using an oximeter.
softening effect when applied to the chronic obstructive). A blood test for alpha1-antitrypsin defi-
skin. Emollients have a moisturizing CAUSES ciency may be performed if there is a
effect on the skin because they form In almost all cases, emphysema is a family history of the disorder. Chest
an oily film on its surface, which direct result of smoking. In rare cases, X-rays are taken to exclude the possi-
prevents loss of water. Emollients are an inherited deficiency of a chemical bility of another lung disease being
used in creams, ointments, lotions, and called alpha1-antitrypsin in the body responsible for the symptoms and to
bath additives. results in emphysema and, in a minor- determine how great an area of the
ity of people, also affects the liver (see lungs has been affected. Pulmonary func-
emotional deprivation alpha1-antitrypsin deficiency). tion tests are carried out to assess
A lack of sufficient loving attention and Tobacco smoke and other air pollu- breathing capacity and the efficiency of
of warm, trusting relationships during tants are believed to cause emphysema the alveoli in exchanging gases.
early childhood, causing normal emo- by provoking the release of chemicals TREATMENT AND PREVENTION
tional development to be inhibited. within the alveoli that cause damage to Once the damage to the lungs has
Emotional deprivation may result if the alveolar walls. Alpha1-antitrypsin is occurred, there is no treatment that can

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 ENCEPHALOMYELITIS

reverse it. However, giving up smoking EMU alitis occur elsewhere in the world; for
will greatly reduce the rate at which the An abbreviation for early morning example, an outbreak of West Nile virus,
lungs deteriorate. The efficiency of the urine, a specimen of urine collected on another mosquito-borne form of the
remaining lung tissue may be improved the patient’s first visit to the toilet after disease, occurred in New York in 1999.
in various ways. For example, broncho- waking up. This type of urine specimen People with HIV are particularly at risk
dilator drugs may be given to widen the is often requested in an investigation for from severe viral encephalitis, and may
bronchioles and patients who are defi- tuberculosis affecting the kidney. also develop cerebral abscesses (collec-
cient in alpha1-antitrypsin may be given tions of pus in the brain tissue).
replacement alpha1-antitrypsin therapy. emulsifying ointment SYMPTOMS
To treat oedema, diuretic drugs may A type of emollient containing emulsify- Mild cases of encephalitis usually de-
help to reduce the volume of fluid in the ing wax, white soft paraffin, and liquid velop over several days and may cause
body by promoting its output through paraffin. Emulsifying ointment is used only a slight fever and mild headache. In E
increased urine production. If the blood to smooth, soothe, and hydrate the skin serious cases of encephalitis, the symp-
oxygen level is continually low, oxygen in all dry or scaling conditions. Rarely, toms develop rapidly and include
therapy at home may be needed. ingredients such as preservatives may weakness or paralysis; speech, memory,
People who have a localized area of result in skin sensitization. and hearing problems; and a gradual loss
emphysema in one lung may be offered of consciousness. Coma (a state of uncon-
surgery to remove the affected area of enalapril sciousness and unresponsiveness to
tissue, which will allow the remaining An ACE inhibitor drug that is used in the external stimuli) and seizures may also
lung tissue to re-expand. A single lung treatment of hypertension (high blood occur. If the meninges are inflamed, cer-
transplant operation (see transplant sur- pressure) and heart failure (a reduced tain other symptoms (for example, a stiff
gery) may be considered if respiratory pumping efficiency of the heart). The neck and abnormal sensitivity to light)
failure is life-threatening. drug inhibits a chemical reaction that may develop (see meningitis).
causes blood vessels to constrict, and DIAGNOSIS AND TREATMENT
emphysema, surgical thus allows vessels to dilate (widen); as Diagnosis is based on results of blood
The abnormal presence of air in tissues a result, it lowers blood pressure and tests; CT scanning or MRI (techniques that
under the skin following surgery or reduces the workload of the heart. produce cross-sectional or three-dimen-
injury. Surgical emphysema most com- One side effect of enalapril is a sud- sional images of the brain); EEG (a
monly occurs as a complication of den drop in blood pressure on taking method of recording the electrical activ-
pneumothorax (the abnormal presence of the first dose. For this reason, the ity of the brain); lumbar puncture (taking
air in the pleural cavity between the patient should rest while the dose is a sample of fluid from the spinal canal
lung and the chest wall). taken and for two or three hours after- for analysis); and, very occasionally, a
wards. More common adverse effects of brain biopsy (removal of a small sample
empirical treatment the drug include headaches and dizzi- of tissue for analysis).
Treatment that is given simply on the ness; these effects should diminish with Encephalitis due to herpes simplex is
grounds that its effectiveness has been continued treatment. treated with intravenous infusion of the
observed in previous, similar cases. antiviral drug aciclovir, but there is
Empirical treatment is different to enamel, dental no known treatment for encephalitis
treatment that is based on an under- The hard outer layer of a tooth (see caused by other viral infections.
standing of the nature of a disorder and teeth) that protects the inner structures.
the way in which the particular method encephalitis lethargica
of treatment works. encephalitis An epidemic form of encephalitis (brain
Inflammation of the brain, and some- inflammation). There have been no
empyema times also the meninges (the three major outbreaks of the condition since
An accumulation of pus in a body cavity membranes that cover and protect the the 1920s, but rare sporadic cases still
or an internal organ. Empyema can brain and the spinal cord), usually due occur. Symptoms of encephalitis leth-
occur around a lung as a rare complica- to a viral infection. Encephalitis varies argica are those of encephalitis, with
tion of an infection such as pneumonia in severity from a mild problem, in additional lethargy and drowsiness.
or pleurisy. The main symptoms are which symptoms are barely noticeable, Many survivors of the initial illness
chest pain, breathlessness, and fever. to a serious and potentially life-threat- during the major epidemics developed a
Treatment is generally by aspiration (re- ening disorder. movement disorder that became known
moval of the pus by suction) and the CAUSES as post-encephalitic Parkinson’s disease.
injection of antibiotic drugs. An opera- Mild cases of encephalitis may be due to
tion to open the chest cavity and drain glandular fever (see mononucleosis, infec- encephalocele
the pus may sometimes be performed. tious) or may be a complication of viral A type of neural tube defect resulting in
Empyema of the gallbladder is a com- diseases such as mumps or measles. defects of the brain rather than of the
plication of cholecystitis (inflammation In Europe, the most common cause of spinal cord, as occurs in spina bifida.
of the gallbladder), causing abdominal life-threatening encephalitis is herpes
pain, fever, and jaundice (yellowing of simplex. In South-east Asia, Japanese B encephalomyelitis
the skin and the whites of the eyes). encephalitis, due to a virus spread by Inflammation of the brain and spinal
This type of empyema is treated by sur- mosquitoes, is the most dangerous type. cord, resulting in damage to the nervous
gical removal of the gallbladder. Occasionally, outbreaks of viral enceph- system, usually due to a viral infection.

265
 ENCEPHALOPATHY

CAUSES known as a prion. Some cases of variant endarteritis

Encephalomyelitis develops as a rare Creutzfeldt–Jakob disease in humans have Inflammation of the inner (intimal)
complication of measles or, less com- been attributed to infection with the layer of an artery wall. Endarteritis most
monly, of other viral infections, such as prions responsible for BSE, which were commonly occurs as a result of a bac-
chickenpox, rubella (German measles), probably transmitted to humans via terial infection such as syphilis. The
or glandular fever (see mononucleosis, consumption of meat products. (See causative infection is treated with anti-
infectious). It may also occasionally fol- also hypertensive encephalopathy.) biotic drugs, such as penicillin.
low vaccination against rabies.
SYMPTOMS enchondroma end artery
Symptoms of encephalomyelitis include A noncancerous bone tumour that orig- An artery (a blood vessel that carries
fever, drowsiness, headache, seizures, inates in cartilage in the metaphysis (the blood away from the heart), or the final
E partial paralysis or loss of sensation, area in which new tissue is added as branch of an artery, that does not
and, in some cases, coma (a state of the bone grows). communicate with any other arteries.
unconsciousness and unresponsiveness An end artery is therefore the sole sup-
to internal or external stimuli). encoding plier of blood to its surrounding
DIAGNOSIS AND TREATMENT The first stage in the memory process, tissues. If an end artery is damaged and
Diagnosis is based on the results of blood also called registration. In this stage, can no longer supply blood to an area,
tests; CT scanning or MRI (techniques that information received by one of the the tissues of that area may die. End
produce cross-sectional or three-dimen- senses (such as hearing or sight) is reg- arteries are found in the brain, heart,
sional images of the body structures); istered and then modified ready for retina, kidneys, and spleen.
EEG (a method of recording the electrical storage by the brain. The information
activity of the brain); lumbar puncture can then be retrieved when it is needed. endemic
(taking a sample of fluid from the spinal A term applied to a disease or disorder
canal for analysis); and, rarely, a brain encopresis that is constantly present in a particular
biopsy (removal of a small sample of A type of soiling in which children pass region or in a specific group of people.
brain tissue for microscopic analysis). normal faeces in unacceptable places AIDS, for example, has become endemic
There is no cure for the disease, but after the age at which bowel control has in central Africa. An endemic disease
corticosteroid drugs are given to reduce been achieved. There is usually an contrasts with an epidemic, which is
inflammation and anticonvulsant drugs underlying behavioural problem (see not generally present but occasionally
to control seizures. behavioural problems in children). affects a large group of people.
OUTLOOK
The disease is often fatal; those who endarterectomy endemic goitre
survive may suffer permanent damage An operation to remove the lining A type of goitre (a swelling of the neck
to the nervous system. of an artery affected by atherosclerosis due to enlargement of the thyroid gland)
(narrowing due to deposits of fatty that occurs in certain parts of the world
encephalomyelitis, myalgic material). Removing the diseased lining due to a deficiency of iodine in the diet.
Another term for the disorder chronic restores normal blood flow to the part Iodine is necessary for the production
fatigue syndrome. of the body supplied by the artery. of the thyroid hormones triiodothyronine
WHY IT IS DONE (T3) and thyroxine (T4). If there is too
encephalopathy Endarterectomy is used to treat cere- little iodine in the diet, the thyroid
Any disorder affecting the brain, espe- brovascular disease (in which the blood gland compensates for the deficiency by
cially chronic degenerative conditions. supply to the brain is seriously reduced) enlarging in order to produce sufficient
TYPES and peripheral vascular disease (in which amounts of thyroid hormones.
Wernicke’s encephalopathy is a degen- blood supply to the limbs is impaired). Endemic goitre is rare in the devel-
erative condition of the brain caused by HOW IT IS DONE oped world. It may be treated using
a deficiency of vitamin B1 (see Wer- Endarterectomy is a delicate procedure dietary measures alone.
nicke–Korsakoff syndrome). that may take several hours. The opera-
Hepatic encephalopathy is caused by tion may be performed endoscopically endocarditis
the effect on the brain of toxins that (see endoscopy) or by open surgery. In Inflammation of the endocardium (the
have built up in the blood as a result of open surgery, the artery is exposed, membrane that lines the inside of
liver failure. It may lead to impaired con- clamps are applied, an incision is made, the heart), particularly the endocardium
sciousness, memory loss, a change in and the diseased lining, as well as any lining the heart valves.
personality, tremors, and seizures. thrombus (blood clot) that may have CAUSES AND INCIDENCE
In spongiform encepalopathy, the formed, are removed. The incision is Endocarditis is most often caused by
brain tissue shrinks and spaces develop closed with stitches. infection with bacteria, fungi, or other
within it; this leads to severe problems, RESULTS microorganisms, which may be intro-
such as paralysis and dementia. Bovine New lining grows in the artery within a duced into the body during surgery
spongiform encephalopathy (BSE) is a few weeks of surgery. When narrowing (including dental procedures); by intra-
disorder contracted by cattle after they of the arteries is widespread (in other venous injection using dirty needles; or
are given feed containing material from words, it is not confined to a single through breaks in the skin or mucous
sheep or cattle. The cause of BSE is artery), arterial reconstructive surgery may membranes. The organisms travel in the
believed to be an infective agent that is have to be performed. bloodstream to the heart. As a result, the

266
 ENDOCRINOLOGY

lining of the valves becomes inflamed, endocervix thyroid gland, pancreas, testes (see testis),
the valves may be damaged, and blood The mucous membrane (layer of thin, ovaries, and adrenal glands. Hormones
clots may form on the affected areas. moist tissue) that lines the cervical that are produced by these glands are
People whose endocardium has pre- canal. The cervical canal connects the responsible for numerous bodily pro-
viously been damaged by disease are uterus to the vagina and runs through cesses, including growth, metabolism,
particularly vulnerable to endocarditis, the centre of the cervix (the neck of the sexual development and function, and
as are those with artificial heart valves womb). (See also endometrium.) response to stress.
or some forms of congenital heart dis- Any increase or decrease in the pro-
ease. This is because clots that form on endocrine gland duction of a specific hormone interferes
the injured surface trap the causative A type of gland that secretes hormones with the process it controls. To prevent
microorganisms, which then multiply directly into the bloodstream rather under- or overproduction, hormone
rapidly at the site of damage. than through a duct. The thyroid gland, secretion from many endocrine glands E
Intravenous drug users are vulnerable pituitary gland, ovaries, testes (see testis), is regulated by the pituitary gland; the
to endocarditis, even if their hearts are and adrenal glands are all endocrine pituitary gland is, in turn, influenced by
healthy, because microorganisms from a glands. The endocrine glands in the the hypothalamus in the brain according
dirty syringe or from unclean skin at body make up the endocrine system. (See to a feedback mechanism (see Control of
the site of injection can be introduced also exocrine gland.) hormone production box, overleaf).
into the bloodstream.
Those with a suppressed immune sys- endocrine system endocrinology
tem are at increased risk of endocarditis The collection of glands around the The study of the endocrine system, or
due to a lowered resistance to infection; body that produce hormones (chemical hormonal system, including the investi-
organisms that would normally be substances necessary for normal body gation and treatment of its disorders. A
harmless can cause serious infection. functioning). These glands include the physician who specializes in diseases and
SYMPTOMS
Endocarditis may be either subacute or
acute. In the subacute form, symptoms
ENDOCRINE DISORDERS
are often general and nonspecific; they
In all endocrine disorders, there is
may include fatigue, feverishness, and either deficient or excess production of Hypothalamus
vague aches and pains. On physical and pituitary
a hormone by a gland. Common causes Strong negative
examination, the only evident abnor- of abnormal hormone production feedback
mality may be a heart murmur. include a tumour or an autoimmune TSH reduced
Acute endocarditis, which occurs less disease affecting a gland, or a disorder Thyroid
frequently, develops suddenly and caus- of the pituitary or the hypothalamus,
Excess secretion
es shortness of breath, severe chills, which control many other glands. of hormone
high fever, and a rapid or irregular Abnormal hormone production often
heartbeat. The infection quickly pro- has a feedback effect on the secretion
gresses and may destroy the heart of trophic (stimulating) hormones by
valves, leading to heart failure. the pituitary and the hypothalamus,
Thyrotoxicosis
as in Addison’s disease and Cushing’s This disorder is usually due to an autoimmune
DIAGNOSIS AND TREATMENT
disease (shown below). The blood disease of the thyroid gland. Excess thyroid
Endocarditis is diagnosed by physical levels of different hormones may need hormones cause the symptoms; the output of
examination and analysis of blood sam- to be measured in order to pinpoint TSH and its hypothalamic-releasing hormone is
ples. Tests performed on the heart may the cause of a disorder. reduced, but the thyroid gland continues to
include ECG (measurement of the heart’s overproduce hormones.
electrical activity) and echocardiography
(an ultrasound technique that produces
detailed images of the heart). Echocar- Hypothalamus Hypothalamus
and pituitary and pituitary
diography shows the structure and
movement of the heart and can reveal ACTH ACTH
any collections of infected material on Weak negative Strong negative
the valves or in a chamber of the heart. feedback feedback fails
Treatment is with high doses of anti-
biotic drugs, usually given intravenously. Adrenal cortex Adrenal cortex
Antibacterial drugs are given as preven- Underproduction Excess secretion
tive treatment for those people at risk. of hormone of hormone
Heart-valve surgery may be needed to
replace a damaged valve. Addison’s disease Cushing’s disease
Symptoms result from reduced hormone This disorder results from excess ACTH
production by the defective adrenal cortices secretion by a pituitary tumour. The excess
endocardium (outer zones of the adrenal glands). Feedback amounts of ACTH stimulate the adrenal cortices
The innermost of the three layers of the is weak, so the pituitary gland pours out to make excess hydrocortisone, which causes
heart wall. The endocardium is formed adrenocorticotrophic hormone (ACTH), but it the symptoms of the syndrome. Feedback fails
of endothelial cells and is continuous fails to stimulate the adrenals. to suppress ACTH secretion.
with the linings of the blood vessels.

267
 ENDOCRINOLOGY

ENDOCRINE SYSTEM

The system consists of a collection of Pituitary gland

hormone-producing glands. Many of these The pituitary gland secretes
glands are regulated by trophic (stimulating) hormones that stimulate
the adrenals, the thyroid,
hormones secreted by the pituitary. The
pigment-producing skin
pituitary is itself influenced by hormones cells, and the gonads; it also
secreted by the hypothalamus in the brain. secretes growth hormone,
Shown here are the principal glands, with antidiuretic hormone,
a note on the hormones they produce. prolactin, and oxytocin.
TSH
E Pituitary
gland
Hypothalamus
Pancreas
Thyroid gland
This gland secretes insulin and
This gland produces the
glucagon, which control the
hormones thyroxine,
body’s utilization of glucose.
triiodothyronine, and calcitonin,
ACTH which stimulate metabolism,
Adrenal cortex body heat production, and bone
When stimulated by ACTH growth. Thyroid activity is
(adrenocorticotrophic controlled by TSH (thyroid-
hormone), the adrenal cortex stimulating hormone), secreted
produces hydrocortisone, by the pituitary.
which has widespread
Parathyroid glands
effects on metabolism; it also
These glands, at the back of
produces androgen hormones
the thyroid, secrete parathyroid
and aldosterone, which
hormone, which maintains the
maintains blood pressure
calcium level in the blood.
and the body’s salt balance.
Gonadotrophins Testes
Ovaries In males, the testes produce
In females, the ovaries testosterone in response to
produce oestrogen and gonadotrophins secreted by
progesterone, which influence the pituitary. A combination
many aspects of female of gonadotrophins and
physiology. This hormone testosterone stimulates
production is controlled by sperm production and the
gonadotrophin hormones, development of other male
secreted by the pituitary. characteristics.

CONTROL OF HORMONE PRODUCTION

Production of too much or too little hormone by a gland the brain known as the hypothalamus, which prompts the
is prevented by feedback mechanisms. Variations in the pituitary to modify its production of the appropriate trophic
blood level of the hormones are detected by the part of (gland-stimulating) hormones accordingly.

Hypothalamus

Pituitary
gland
Trophic
hormone

Target
gland Hormone Feedback
produced

1gland)The production of hormone by the target

gland (in this illustration, the thyroid
and of trophic hormone by the
2 If hormone production by the target gland
rises, the feedback effect causes less
trophic hormone to be produced, which tends
3 If hormone production by the target gland
drops, the feedback lessens and more
trophic hormone is produced, which tends to
pituitary gland is normal. to return the situation to normal. return the situation to normal.

268
 ENDOMETRIOSIS

disorders of the endocrine glands and as the body moves, causing nerve recep- endometriosis
the hormones that they secrete is called tors in the labyrinth to send signals to A condition in which fragments of the
an endocrinologist. the brain about the motion of the body. endometrium (the lining of the inside of
A significant increase in the volume of the uterus) are found in other parts
endodontics endolymph in the labyrinth may occur of the body, usually in the pelvic cavity.
A branch of dentistry concerned with in Ménière's disease. Endometriosis can cause infertility in up
the causes, prevention, diagnosis, and to two in five affected women.
treatment of disease and injury that endometrial ablation INCIDENCE AND CAUSES
affect the nerves and pulp in teeth A treatment for persistent menorrhagia Endometriosis most commonly occurs
and the supportive tissues in the gum. (heavy menstrual bleeding) involving in women who are aged between 25
Common endodontic procedures are removal of the endometrium (the inner and 40. The cause of the disorder is not
root-canal treatment and pulpotomy. lining of the uterus). In this procedure, clear. In some cases, it is thought to be E
endoscopy is used to view the interior of due to the failure of certain fragments
endogenous the uterus, while the endometrium is of the endometrium, shed during men-
A term that refers to a disease or disor- removed by diathermy (heat treatment), struation, to leave the body. Instead, they
der that arises within the body. For laser, or a microwave probe (MEA). travel up the fallopian tubes and into
example, an endogenous infection may Endometrial ablation can only be car- the pelvic cavity, where they can adhere
occur if bacteria from the anus invade ried out if the woman has no desire to to and grow on any pelvic organ. These
the urinary tract. Most disorders are become pregnant in the future. displaced patches of endometrium con-
exogenous (caused by external factors). tinue to respond to hormones that are
endometrial biopsy produced in the menstrual cycle and
endogenous depression A procedure in which a small sample of bleed each month.
A term formerly used for a type of tissue is taken from the endometrium SYMPTOMS
depression (feelings of sadness, hope- (the inner lining of the uterus) and sent The symptoms of endometriosis vary
lessness, and a lack of interest in life) for microscopic analysis. Endometrial greatly. Some women have no symp-
originating from biological factors in an biopsies are used to detect areas of toms, but the disorder most commonly
individual. In contrast, “reactive depres- abnormal tissue such as tumours (see causes abnormal or heavy menstrual
sion” was seen to result from a stressful uterus, cancer of). Samples may be taken bleeding. There may be severe abdomi-
or emotional event or period of life. In during hysteroscopy (examination of nal pain and/or lower back pain during
many cases, however, depression is a the interior of the uterus with a view- menstruation. Other possible symptoms
combination of both of these types. ing instrument) or collected using a include dyspareunia (see intercourse, pain-
small vacuum device that is introduced ful), diarrhoea, constipation, and pain
endolymph through the cervix. Mild cramping during defaecation.
The fluid contained within the mem- pains may be a side effect. The internal bleeding causes pain and
branous labyrinth (the structures in the is followed by healing, which produces
inner ear that help to control balance). endometrial cancer internal scarring. Bleeding into an ovary
Endolymph flows around the labyrinth See uterus, cancer of. may result in a blood-filled ovarian cyst

SITES OF ENDOMETRIOSIS

Fragments of the endometrium may travel from the uterus into the pelvic cavity via Endometrial Peritoneum
cyst
the fallopian tubes. They then implant on parts of the pelvic organs (such as the
ovaries, vagina, cervix, bladder, and rectum) or on the peritoneum. The patches of
endometrium continue to respond to the menstrual cycle and bleed every month.
This causes the formation of painful cysts, which can be very small or may be as
large as a grapefruit.

Fallopian tube

Ovary
Uterus

Bladder
Rectum

Vagina
Peritoneal endometriosis
In this endoscopic view of the pelvic cavity,
a fragment of endometrium has attached
itself to the peritoneum (the membrane that
lines the inside of the pelvic cavity) and a
cyst has formed.

269
 ENDOMETRITIS

(known as a “chocolate cyst” because end organ Many operations are now being per-
of its appearance). Endometrial tissue The specialized structure occurring at formed by passing surgical instruments
may be deposited in the muscular wall the end of a peripheral nerve that acts down an endoscope. The procedure is
of the uterus (myometrium); this condi- as a receptor for a particular sensation. valuable in the treatment of acute emer-
tion is called adenomyosis. In rare An example of an end organ is one of gencies, such as bleeding from the
cases, there is bleeding from the rec- the taste buds in the tongue. stomach or the removal of foreign bod-
tum during menstruation. ies from the lungs. Operations such as
DIAGNOSIS AND TREATMENT endorphins female sterilization, the treatment of
Laparoscopy (examination of the abdo- A group of pain-relieving protein mol- torn ligaments or cartilage within the
minal cavity with a viewing instrument) ecules that are produced by the body. knee joint, and the treatment of chronic
confirms the diagnosis. Certain drugs Endorphins relieve pain by activating infections of the nasal sinuses, are all
E (including danazol, progestogen drugs, opiate receptors in the nervous system. routine endoscopic procedures. (See
gonadorelin analogues, or the combined They have a similar chemical structure also minimally invasive surgery.)
oral contraceptive pill) may be given to to the pain-relieving drug morphine. In
prevent menstruation. Local ablation of addition, endorphins are thought to be endothelium
the endometrial deposits, using either involved in the body’s response to The layer of cells that lines the heart,
laser treatment or electrocautery (the stress, as well as in regulating intestinal blood vessels, and lymphatic ducts (see
application of heat produced by an elec- contractions, determining mood, and lymphatic system). Endothelial cells are
tric current), may sometimes be needed. controlling the release of certain hor- squamous (thin and flat), providing a
If the woman is fertile, pregnancy mones from the pituitary gland. (See smooth surface that aids the flow of
often results in significant improve- also enkephalins.) blood and lymph and helps to prevent
ment. A hysterectomy (surgical removal the formation of thrombi (blood clots).
of the uterus) and oophorectomy (sur- endoscope (See also epithelium.)
gical removal of the ovaries) may be A tubelike viewing instrument, with
offered if the woman does not have lenses and a light source attached, that endotoxin
plans to have children. is inserted into a body cavity for the A poison produced by certain bacteria
purposes of investigating or treating that is not released until the death of
endometritis disorders (see endoscopy). Endoscopes those bacteria. Endotoxins cause fever
Inflammation of the endometrium (the are named according to their use, and when they are released in infected
inner lining of the uterus) resulting they can be flexible or rigid, depending people. They also make the walls of the
from infection. Endometritis is a feature on the part of the body to be exam- capillaries (the smallest blood vessels)
of pelvic inflammatory disease (PID). It ined. A selection of the common types more permeable, causing fluid to leak
may also be a complication of abortion of endoscope and their uses are shown into the surrounding tissue. This some-
or childbirth, occur after insertion of in the illustrated box at right. times results in a reduction in blood
an IUD, or be the result of a sexually pressure, a condition called endotoxic
transmitted infection. endoscopy shock. (See also enterotoxin; exotoxin.)
Symptoms of endometritis include Examination of a body cavity by means
fever, vaginal discharge, and lower of an endoscope (a rigid or flexible endotracheal tube
abdominal pain. Treatment includes viewing tube) for the purposes of diag- A tube that is passed into the trachea
removing any foreign body (such as an nosis and/or treatment. The technique (windpipe) through the nose or mouth
IUD or retained placental tissue) and makes use of both fibre-optics and video to enable delivery of oxygen during
antibiotic drugs. technology and enables almost any artificial ventilation or anaesthetic gases
hollow structure in the body to be in- (see anaesthesia) during surgery. An
endometrium spected directly. Many procedures that inflatable cuff around the lower end of
The inner lining of the uterus. The formerly required major surgery can the endotracheal tube prevents any
endometrium contains numerous glands now be performed much more simply secretions or stomach contents from
and gradually increases in thickness and safely by endoscopy. entering the lungs.
during the menstrual cycle (see men- USES
struation) until ovulation (release of an Endoscopes are named according to the end stage
egg from the ovary) occurs. The surface part of the body for which they are The most advanced stage of a disease, in
layers of the endometrium are shed being used (see endoscopes box). The which an affected organ or system is no
during menstruation if conception does endoscope is inserted via a natural body longer able to carry out its normal
not take place. opening, such as the mouth or vagina, functions. In these circumstances, the
or into a small incision. Endoscopy is damage done to the body cannot be
endomorph also used in diagnosis to inspect hollow reversed; therefore, treatment is aimed
A term formerly used to describe an organs.The organ may be photographed at improving the patient’s condition
individual with a round head and a and a biopsy (removal of a small sample wherever possible and at relieving the
large abdomen; short arms and legs of tissue for microscopic analysis) may symptoms (see palliative care). In some
with slender wrists and ankles; weak be performed. Endoscopy can be cases, a machine may be able to take
muscular and skeletal development; and repeated safely at frequent intervals to over the function; for example, in end-
a large proportion of body fat. (See also allow monitoring the progress of a con- stage kidney failure, filtering of the
ectomorph; mesomorph.) dition and the response to treatment. blood may be carried out by a dialysis

270
 END STAGE

ENDOSCOPES

A typical flexible fibre-optic endoscope

consists of a bundle of light- SOME COMMON TYPES HOLD SHIFT KEY AND
OF ENDOSCOPE TO KEEP CORNER
THEIR USES RADIUS
transmitting fibres. At one end is the Instrument Region Endoscope type
head (featuring a viewing lens and
steering device) and a power source. Cystoscope Bladder Flexible or rigid
The tip has a light, a lens, and an
Bronchoscope Bronchi (main airways of the lungs) Flexible or rigid
outlet for air or water. Side channels
enable attachments to be passed to Gastroscope Oesophagus, stomach, and duodenum Flexible
the tip. In some endoscopes the tip
may contain a camera that transmits Colonoscope Colon (large intestine) Flexible E
a picture electronically to a screen. A
rigid endoscope is a straight, narrow Laparoscope Abdominal cavity Rigid
viewing tube that has a light source Arthroscope Knee joint Rigid
attached to it.

Route of endoscope FLEXIBLE ENDOSCOPE

(gastroscope)

Endoscope Power cable Eyepiece

Steering
Oesophagus control

Port for
Instrument instruments
Liver control

Stomach Tip of
endoscope

Procedure for endoscopy

The endoscope is inserted through a
natural opening (here, the mouth during
gastroscopy); the patient may be sedated.
A tiny camera at the tip of the endoscope
relays an image of the area under
investigation via a monitor and eyepiece. Monitor
Minor procedures, such as biopsy (removal
of a tissue sample for analysis), may be
carried out using very fine surgical
instruments passed down the endoscope.

Instrument
control
Mouthguard Blood
Eyepiece pressure
cuff

271
 ENEMA

machine. The term “end stage” is used ENERGY STORAGE AND USE Engelmann’s disease
in relation to many conditions, includ- In general, the energy liberated from A rare, progressive, inherited form of
ing cancer, advanced kidney failure, and the breakdown of food is stored as bone dysplasia (a growth abnormality).
chronic lung diseases. chemical energy in ATP (adenosine tri- In affected individuals, the bones become
phosphate) molecules. The stored abnormally long and thick, which usually
enema energy is then available to power pro- results in abnormal stature and, some-
A procedure in which fluid is passed cesses that consume energy, such as times, in delayed walking (see walking,
into the rectum through a tube that has muscle contraction or the repair and delayed). There may also be muscle
been inserted into the anus. An enema maintenance of body structures. wasting, pain or weakness in affected
may be performed as a treatment, to limbs, delayed puberty, and hypogonadism
prepare the intestine for surgery, or as energy requirements (underactivity of the testes or ovaries).
E an aid to diagnosis. The amount of energy needed by an in- The disease is inherited in an auto-
WHY IT IS DONE dividual for cell metabolism, muscular somal dominant pattern (see genetic
An enema may be given to clear the activity, and growth. This energy is pro- disorders) and affects more males than
intestine of faeces, either to relieve con- vided by the chemical breakdown of fats, females. It is usually diagnosed in the
stipation or in preparation for intestinal carbohydrates, and proteins supplied by first few years of life. There is no
surgery. Enemas may also be used to food in the diet and by stored nutrients specific treatment available, although
administer medicine, such as corticosteroid in the liver, muscles, and adipose tissue. nonsteroidal anti-inflammatory drugs may
drugs in the treatment of the inflamma- ENERGY EXPENDITURE be given to relieve pain.
tory bowel condition ulcerative colitis. A Energy is needed to maintain the heart-
barium enema is used to diagnose dis- beat, lung function, and constant body engorgement
orders of the large intestine (see barium temperature.The rate at which these pro- Overfilling of the breasts with milk.
X-ray examinations). cesses use energy, while the body is at Engorgement is common a few days
HOW IT IS DONE rest, is called the basal metabolic rate after childbirth, when the milk supply
Anaesthesia is not required, although (BMR). Any actions, such as movement arrives quickly and forcibly. Engorge-
the procedure may cause slight discom- or food digestion and absorption, increase ment causes the breasts and nipples to
fort because the fluid stretches the energy expenditure above the BMR. become swollen and tender, and can
intestine. The patient lies on his or her An individual’s energy requirement make breast-feeding difficult. The prob-
side with the hips raised on a pillow. A increases during periods of growth and lem can be relieved by expressing milk.
catheter (flexible tube), with a soft, well- during pregnancy and breast-feeding.
lubricated tip, is gently inserted into the ENERGY AND BODY WEIGHT enhancement
rectum and the enema fluid, warmed to When more energy is ingested (in the The process of augmentation. The term
prevent a sudden contraction of the form of food) than is used by the body, may be used of improvements made to
intestine, is slowly introduced through the surplus is stored and there is usually body structures or functions, or may
it. Treatment doses are often packaged a gain in weight. When less energy is mean increasing the clarity of images in
with their own applicators. consumed than is spent, weight is usu- diagnostic imaging methods. For exam-
ally lost as the stores are used up. (See ple, immunoenhancement is the process
energy also nutrition; obesity.) by which the body’s immune response is
The capacity to do work or effect physi- increased by the use of antibodies (pro-
cal change. Nutritionists use the term to enflurane teins made by the immune system).
refer to the fuel content of a food. A liquid mixed with oxygen and inhaled
There are many different forms of as a vapour to induce and help to main- enkephalins
energy, including light, sound, heat, tain general anaesthesia (see anaesthesia, A group of small protein molecules
chemical, electrical, and kinetic, and general). Rarely, enflurane may cause produced in the brain and by nerve end-
most of them play a role in the body. arrhythmia (an abnormality of the ings elsewhere in the body (in the
For instance, the retina (the light- rhythm or rate of the heartbeat; see digestive system and adrenal glands, for
sensitive inner layer at the back of the arrhythmia, cardiac). example). Enkephalins have an analgesic
eye) converts light energy to electrical (painkilling) effect and are also thought
nerve impulses, making vision possi- engagement to affect mood. They are similar to end-
ble. The body’s muscles use chemical The descent of the head of the fetus into orphins but have a slightly different
energy obtained from food to produce the mother’s pelvis. In a woman’s first chemical composition and are released
kinetic energy, movement, and heat. pregnancy, engagement usually occurs by different nerve endings.
MEASUREMENT by the 37th week but in subsequent
Energy is measured in units called cal- pregnancies it may not occur until enlarged prostate gland
ories and joules. Because these units are labour begins. Rarely, engagement fails to See prostate, enlarged.
extremely small, more practical units occur. This may happen, for example, if
used in dietetics (nutritional science) the baby’s position in the uterus is enophthalmos
are the kilocalorie (kcal, 1,000 calories) abnormal; if the baby’s head is too big A sinking inwards of the eyeball. Enoph-
and kilojoule (kJ, 1,000 joules). Carbo- for the mother’s pelvis; or if there is a thalmos is most commonly caused by
hydrates and proteins provide 4 kcal per condition known as placenta praevia (an fracture of the eye socket or shrinkage
gram (g), whereas fats provide 9 kcal abnormal positioning of the placenta of the eye due to the formation of scar
per g (see metabolism). across the opening of the uterus). tissue following injury.

272
 ENTRAPMENT NEUROPATHY

ENT enteritis in the bloodstream they can cause

The abbreviation for ear, nose, and Inflammation of any part of the intestine, septicaemia (blood poisoning) and
throat (see otorhinolaryngology). particularly the small intestine. Enteritis infective endocarditis (inflammation of
may be due to infection, particularly the membrane lining the inside of the
Entamoeba giardiasis and tuberculosis, or to Crohn’s heart). The infections are usually treat-
A genus of amoebae (see amoeba), disease. Enteritis usually causes diar- ed with antibiotic drugs.
some of which are parasites of the rhoea. (See also colitis; gastroenteritis.)
human digestive tract. enterocolitis
Worldwide, ENTAMOEBA HISTOLYTICA is the enteritis, regional A combination of enteritis (inflamma-
most serious cause of amoebic disease, Another name for Crohn’s disease. tion of the small intestine) and colitis
particularly in tropical areas. It is respon- (inflammation of the colon). Possible
sible for amoebiasis (amoebic dysentery), enterobacteria causes include inflammatory bowel dis- E
a disease in which the tissues of the A group of rod-shaped, gram-negative orders such as Crohn’s disease.
intestinal lining are destroyed, causing (see Gram’s stain) bacteria that live in
the formation of ulcers in the intestines; the human or animal intestine (the enteropathic
and abscesses may form in the liver. principal part of the digestive tract, A term used to describe any condition
ENTAMOEBA GINGIVALIS is found in the which extends from the exit of the or organism related to disease of the
mouths of humans and is associated stomach to the anus). intestine (the main part of the digestive
with periodontal disease (any disorder Some types of enterobacteria live tract, extending from the exit of the
of the tissues that surround and support harmlessly in the intestine. Several other stomach to the anus). Enteropathic bac-
the teeth) and gingivitis (inflammation types, however, cause intestinal diseases, teria, for example, are species that may
of the gums). ENTAMOEBA COLI is a harm- with symptoms of diarrhoea and/or cause intestinal disease; enteropathic
less intestinal parasite. vomiting. Certain types are also responsi- arthritis is joint inflammation associated
ble for urinary infections such as cystitis, with inflammatory bowel disease.
enteral feeding which may occur when bacteria from
A type of feeding that involves intro- the intestines gain access to the urethra. enteropathy, gluten
ducing nutrients directly into the Examples of common enterobacteria See coeliac disease.
intestines via a tube passed either include ESCHERICHIA COLI, SALMONELLA,
through the abdominal wall or through YERSINIA, ENTEROBACTER, and SHIGELLA. enterostomy
a nostril and down the throat. Food An operation in which a portion of
may be provided in a partially broken- enterobiasis small or large intestine is joined to
down form so that it does not need to The medical term for threadworm infesta- another part of the gastrointestinal tract
be digested before being absorbed in tionof the intestines. or to the abdominal wall. For example,
the intestines. Enteral feeding is a use- when part of the colon (large intestine)
ful method of feeding people with enterocele is brought through an incision in the
intestinal disorders, particularly inflam- A type of hernia in which part of the abdominal wall to allow the discharge
matory bowel disorders such as Crohn’s small intestine protrudes through a of faeces into a bag attached to the skin,
disease. (See also feeding, artificial.) weakened area of the upper vaginal the operation is called a colostomy;
wall. An enterocele may develop when when the ileum (the last section of the
enteric the muscles in a woman’s vaginal small intestine) is used, the procedure
Relating to or affecting the intestine canal become stretched, damaged, or is called an ileostomy.
(the main part of the digestive tract, weakened by any of the following:
which extends from the exit of the pregnancy, childbirth, surgery, or aging. enterotoxin
stomach to the anus). Pelvic floor exercises may help to A type of toxin released by certain bacte-
improve the condition, but surgery may ria that inflames the intestinal lining,
enteric-coated tablet be needed to tighten the muscles. In leading to diarrhoea and vomiting.
A tablet whose surface is covered some cases, hysterectomy (removal of the Enterotoxins cause the symptoms of
with a substance that is resistant to the uterus) may be the best treatment. (See cholera and staphylococcal food poison-
action of stomach juices. Enteric-coated also hernia repair.) ing (see staphylococcal infections). (See
tablets pass undissolved through the also endotoxin; exotoxin.)
stomach into the small intestine, where Enterococcus
the covering dissolves and the contents A genus of gram-positive (see Gram’s Entonox
are absorbed. Such tablets are used stain) bacteriaof the Streptococcaceae A brand name for a mixture of nitrous
either when the drug might harm the family. Enterococci are normally found oxide and oxygen used to produce pain
stomach lining (as may occur with cer- in the human or animal intestine relief without loss of consciousness.
tain corticosteroid drugs) or when the (the principal part of the digestive
stomach juices may affect the efficacy of tract, which extends from the exit of entrapment neuropathy
the drug (as with sulphasalazine). the stomach to the anus). A condition, such as carpal tunnel syn-
They rarely cause problems in the drome, in which local pressure on a
enteric fever intestine, but urinary tract infections, nerve causes muscle pain, numbness,
An alternative name for typhoid fever or caused by enterococci entering the ure- and weakness in the area of the body
paratyphoid fever. thra, are common. If the bacteria spread supplied by that nerve.

273
 ENTROPION

entropion cleation is the removal of an eyeball Punishing a child for bedwetting, how-
A defect of the eyelids in which the while leaving the other structures in ever, will not help, and may actually
edges of the lids turn inwards, causing place in the eye socket. worsen the problem by making the
the lashes to rub against the cornea (the child anxious.
transparent dome that forms the front enuresis, nocturnal Alarm systems, known as buzzer and
of the eyeball) and the conjunctiva (the The medical term for bedwetting. It is a pad systems, that involve placing a
membrane that covers the white of common condition in children, and humidity-sensitive pad in the child’s
the eye and the inside of the eyelid). boys are slightly more likely than girls bed are available. The child is woken
CAUSES to be affected. The problem tends to by the alarm if urine is passed and
Entropion may be congenital (present run in families. eventually learns to wake before start-
from birth), especially in overweight CAUSES ing to pass urine.
E babies. In addition, it is common in Usually, enuresis results from slow The drug desmopressin is a synthetic
elderly people, due to weakness of the maturation of nervous system func- form of antidiuretic hormone (see ADH)
muscles around the lower eye, allowing tions concerned with bladder control. that may occasionally be given to redu-
the lower lid plate to turn inwards. It may also result from psychological ce the amount of water that is excreted
Entropion of the upper or lower lid may stress. In a small number of bedwetters, by the kidneys. Desmopressin is useful
also be caused by scarring, such as that there is a physical cause, such as a on the occasional nights when a child
due to trachoma. structural abnormality of the urinary needs to stay dry, such as when staying
COMPLICATIONS AND OUTLOOK tract. Diabetes mellitus or a urinary tract overnight with friends.
Entropion in babies does not disturb the infection may cause bedwetting in a
eye and usually disappears within a few child who was previously dry. In cases environmental medicine
months. In later life, entropion can due to physical problems, the child also The study of the effects on health of
cause irritation, conjunctivitis, damage to has difficulty with daytime bladder natural environmental factors, such as
the cornea, or problems with vision. control (see incontinence, urinary). climate, altitude, sunlight, and the pres-
Surgery to correct entropion can pre- INVESTIGATION AND TREATMENT ence of various minerals. Environmental
vent such conditions. If a child wets the bed persistently, tests, medicine overlaps somewhat with occu-
including urinalysis, may be performed pational medicine, in which the effects
ENT surgery to rule out a physical cause. For bedwet- on people of their working environ-
The abbreviation for ear, nose, and ting that is not caused by a physical ments are studied.
throat surgery (see otorhinolaryngology). disorder, treatment starts with training CLIMATE
the child to pass urine regularly during The symptoms of particular types
enucleate the day. Systems such as rewarding the of illness may be affected by certain
To remove an organ, a tumour, or child for each dry night (for example, climates. For example, sufferers from
another structure surgically in such a by putting stars on a chart) are often chest disorders, such as chronic bronchi-
way that it comes out cleanly and successful. Getting the child to go to the tis and asthma, usually obtain some
completely. A common example of enu- toilet just before bed may be helpful. relief from their symptoms in a warm,

THE GROWING IMPORTANCE OF ENVIRONMENTAL MEDICINE

Large areas of the world are

naturally hostile to humans
and were, in the past, avoided.
Today, exploitation of natural
resources has lured people
into these regions and has
highlighted the importance
of environmental medicine.

Key

Desert regions

Cold regions with average

winter temperature
below –23˚C
Mountain regions
above 3,000 m

274
 EPENDYMOMA

relatively dry climate. Most respiratory ferent chemical structure. It is this

complaints, in contrast, are more com- structure that determines the specific THE ACTION OF ENZYMES
mon during the winter. reaction regulated by the enzyme.
An enzyme is a protein that acts as
ALTITUDE Every cell in the body produces a catalyst for a chemical change in
Although mountainous regions have various types of enzymes; different sets the body (that is, it greatly speeds
much less atmospheric pollution, they of enzymes occur in different tissues, up the rate at which the change
are not necessarily beneficial to health reflecting their specialized functions. occurs). The change may be a small
because the air becomes thinner as alti- For example, the pancreas produces the modification to the structure of a
tude increases. People with a chest con- digestive enzymes lipase, protease, and substrate (the particular chemical
dition who ascend in a few days from amylase, and among the numerous on which the enzyme acts) in a body
sea level to 1,500 m may find that their enzymes produced by the liver are some tissue, the splitting of a substrate,
breathing difficulty worsens. Above that metabolize drugs. or the joining of two substrates. E
about 3,000 m, breathing becomes dif- In order to function properly, many
ficult even for healthy people. Rapid enzymes need an additional compon-
ascent from sea level to 3,600 m or ent, known as a coenzyme, which is
higher carries a risk of altitude sickness often derived from a vitamin or mineral.
(see mountain sickness), which can cause INDUCTION AND INHIBITION
Substrate
sleeplessness, nausea, coma (a state of Enzyme activity is influenced by many
unconsciousness and unresponsiveness factors. One of these factors is the
Enzyme
to stimuli), or death. action of drugs. Liver enzyme activity
Sustained life seems to be impossible is increased by certain drugs, such as
above 6,000 m because at that level the barbiturate drugs, which affect the rate The shape of an enzyme determines
blood cells increase in number to com-
pensate for the lack of oxygen. This
at which other drugs are metabolized
by the liver cells. This effect, which is
1combine
its activity. Each enzyme molecule will
only with a particular substrate
increase puts strain on the heart and called enzyme induction, is responsi- that has molecules of a complementary
shape.
causes a predisposition to thrombosis ble for a variety of important drug
(abnormal blood clotting). interactions (see drug).
SUNLIGHT Conversely, many drugs inhibit or
Fair-skinned people who live in sunny block enzyme action. Some antibiotic
climates may suffer ill effects from drugs destroy bacteria by blocking bac- Combined
substrate
repeated exposure to sunlight (see terial enzymes while leaving human and enzyme
sunlight, adverse effects of), including enzymes unaffected. Similarly, some
premature wrinkling of the skin and an anticancer drugs act by blocking enzyme
increased risk of cataract (loss of trans- activity in tumour cells, affecting nor- When the enzyme and substrate
parency of the lens of the eye). There is mal body cells to a lesser degree. 2chemical
combine, their interaction causes a
change within the substrate. In the
also an increased risk of developing skin ENZYMES AND DISEASE
cancers, such as malignant melanoma Measuring enzyme levels in the blood example shown here, the chemical is split
into two products.
(see melanoma, malignant) and basal cell can be useful in diagnosing certain
carcinoma, as well as the precancerous disorders. For example, the level of
condition solar keratosis. These risks heart muscle enzymes is raised follow-
have been increased by damage caused ing a myocardial infarction (heart attack)
by environmental pollutants to the pro- because the damaged heart muscle
tective layers of ozone in the upper releases enzymes into the bloodstream,
atmosphere. Health risks from sunlight and muscle enzyme levels are raised in Products
may be reduced by protection of the muscular dystrophy.
Enzyme
skin, such as by using sunscreens. Many inherited metabolic disorders,
MINERALS including phenylketonuria, galactosaemia, After the chemical reaction has ended,
Variations in the distribution of certain and G6PD deficiency, are caused by defects 3 the enzyme molecule remains unchanged
and can move on to combine with another
minerals in the environment are known in, or deficiencies of, enzymes. Abnor-
substrate molecule and repeat the process.
to have an effect on health. For example, mal enzymes or levels can be detected
there is a higher-than-average incidence in tests on blood or other body fluids.
of cancer in areas where the radioactive ENZYMES AND TREATMENT
gas radon is emitted from granitic rocks. Enzymes can play a valuable role in eosinophil
In contrast, there is a lower-than-average treating certain conditions. Pancreatic A type of leukocyte (white blood cell) that
incidence of tooth decay (see caries, enzymes may be given to aid digestion plays a role in allergic responses (see
dental) in populations in regions where in people who have malabsorption related allergy) and fighting parasitic infections.
the water has a high fluoride content. to pancreatic disease.
Enzymes such as streptokinase and ependymoma
enzyme alteplase (see tissue-plasminogen activator) A rare brain tumour of the glioma type
A protein that regulates the rate of a are used to treat acute thrombosis and (arising from supporting glial cells in
chemical reaction in the body. There are embolism (conditions that cause block- the nervous system) that occurs most
thousands of enzymes, each with a dif- age of blood vessels) by dissolving clots. commonly in children.

275
 EPHEDRINE

ephedrine epidemiology The outlook varies from gradual im-

A drug that mimics the effects of the The branch of medicine that is con- provement in mild cases to progressive
neurotransmitter noradrenaline (norep- cerned with the occurrence and distri- disease in the most severe cases.
inephrine). Ephedrine is prescribed as a bution of disease, including infectious
decongestant drug to treat nasal conges- diseases (such as cholera or influenza) epididymal cyst
tion. It may also be used to treat some and noninfectious diseases (such as A harmless, usually painless, swelling in
cases of low blood pressure that are due cancer and heart disease). the epididymis (the coiled tube at the
to drug actions or disease. In epidemiological studies, the mem- back of the testis). Small cysts are fairly
bers of a population are counted and common in men over the age of 40 and
epicanthic fold described in terms of such variables as need no treatment. Rarely, they enlarge
A vertical fold of skin extending from race, sex, age, social class, and occupa- or become tender, causing discomfort.
E the upper eyelid to the side of the nose. tion. The incidence and prevalence of the In such cases, it may be necessary for
Epicanthic folds are common in East disease of interest are then determined. the cysts to be surgically removed.
Asian people but rare in other races, These observations may be repeated at
except in babies, in whom they usually regular intervals in order to detect epididymis
disappear as the nose develops. Abnor- changes over time. The result is a stat- A long, coiled tube that runs along the
mal epicanthic folds are a feature of istical record that may reveal links back of the testis and connects the vasa
Down’s syndrome. If desired, the folds can between particular variables and distrib- efferentia (small tubes leading from the
be removed by cosmetic surgery. ution of disease. testis) to the vas deferens (the sperm
In comparative epidemiological stud- duct that leads to the urethra). Sperm
epicardium ies, two or more groups are chosen. For cells, which are produced in the testis,
The outermost of the three layers that example, in a study of the link between mature as they pass slowly along the
form the wall of the heart. The epicar- smoking and lung cancer, one group epididymis, until they are capable of fer-
dium is a smooth membranous structure may consist of smokers and the other of tilizing an egg, and they are then stored
that envelops the myocardium (the mus- nonsmokers; the proportion with can- until ejaculation takes place.
cle layer of the heart). cer in each group is calculated. In such Disorders of the epididymis include
cases, the epidemiologist is careful to epididymal cysts (fluid-filled swellings in
epicondyle make the two groups as identical as the epididymis) and epididymo-orchitis
Any bony outgrowth to which tendons possible in all other relevant respects, (inflammation of the testis and epi-
are attached (for example, at the lower and will carefully match factors such as didymis). Infection or injury can block
end of the humerus (upper-arm bone) age, sex, and weight. the epididymis; if both testes are
where it forms part of the elbow joint). affected, infertility may result.
Overuse of muscles, leading to repeated epidermis
tugging on the tendons, can result in The thin outermost layer of the skin.
pain and inflammation at an epicondyle LOCATION OF THE EPIDIDYMIS
(see epicondylitis). epidermoid cyst
The epididymis runs
A harmless nodule under the skin’s sur- along the back of the
epicondylitis face that contains yellow, cheesy material. testis and links the
Painful inflammation of an epicondyle, The terms epidermoid cyst and sebaceous vasa efferentia to the
and specifically one of the bony promi- cyst are often used interchangeably. vas deferens.
nences of the elbow at the lower end of
the humerus (upper-arm bone). Epi- epidermolysis bullosa
Vas deferens
condylitis is the result of overuse of the A group of rare, inherited conditions,
forearm muscles, which causes repeated varying widely in severity, in which
Vasa
tugging on the tendons at their point of blisters appear on the skin after minor efferentia
attachment to the bone. injury or occur spontaneously.
Epicondylitis that affects the promi- CAUSES
nence on the outer elbow is called tennis Epidermolysis bullosa is caused by a
elbow. When the prominence on the genetic defect that may show either an
inner elbow is affected the condition is autosomal dominant or an autosomal
called golfer’s elbow. recessive pattern of inheritance (see
genetic disorders).
epidemic DIAGNOSIS AND TREATMENT
A term applied to a disease that for the The conditions can be diagnosed by
majority of the time is rare in a commu- means of a skin biopsy (the removal
nity but that suddenly spreads rapidly to of a small sample of tissue for micro-
affect a large number of people. scopic analysis).
Epidemics of new strains of influenza There is no specific treatment for the
are common, occurring periodically condition, but injury to the skin should
when the influenza virus changes to a be avoided and protective measures Testis
form to which the population has no should be taken to prevent the rubbing Scrotum Epididymis
resistance. (See also endemic.) of affected areas when blisters appear.

276
 EPILEPSY

epididymitis epigastric hernia seizures. Some people experience an

See epididymo-orchitis. A hernia (protrusion of an organ or tis- aura (a peculiar “warning” sensation)
sue) through a weakened area in the shortly beforehand. In some cases, a
epididymo-orchitis upper central abdominal wall. The her- stimulus such as a flashing light trig-
Acute inflammation of a testis and epi- nia may appear as a lump in the centre gers a seizure. Epileptic seizures may
didymis (coiled tube that runs along the of the upper abdomen, between the occur more frequently during times of
back of the testis). Epididymo-orchitis base of the sternum (breastbone) and illness or stress.
causes acute pain and swelling at the the navel. (See also hernia repair.) TYPES
back of the testis, and, in severe cases, Epileptic seizures can be classified into
swelling and redness of the scrotum. epiglottis two broad groups: generalized and
The inflammation is caused by infec- The flap of cartilage lying behind the partial seizures.
tion. Often, there is no obvious source tongue and in front of the entrance to Generalized seizures These seizures E
of the infection, but sometimes the the larynx (voice box). The epiglottis is cause loss of consciousness and may
cause is a bacterial urinary tract infection usually upright to allow air to pass affect all areas of the brain. There are
that has spread via the vas deferens (the through the larynx and into the rest of two main types of generalized seizure:
sperm duct leading to the urethra) to the respiratory system. During swallow- tonic–clonic (formerly grand mal) and
the epididymis. ing, it tilts downwards to cover the absence (petit mal) seizures.
Treatment is with antibiotic drugs. If entrance to the larynx, preventing food During a tonic–clonic seizure, there
there is an underlying urinary tract and drink from being inhaled into the may initially be an aura, then the body
infection, its cause needs to be investi- trachea (windpipe). becomes stiff and consciousness is lost.
gated. (See also orchitis.) Breathing may be irregular or may stop
epiglottitis briefly, then the body jerks uncon-
epidural anaesthesia A potentially life-threatening infection trollably. The episode usually ends
A method of administering pain relief causing inflammation and swelling of spontaneously after a few minutes. The
in which a local anaesthetic (see anaes- the epiglottis (the flap of cartilage at the person may be drowsy and disorien-
thesia, local) is injected into the epidural back of the tongue that closes off tated for a few hours afterwards,
space (the space around the membranes the windpipe during swallowing). The however, and may have no memory
that surround the spinal cord) in the swollen epiglottis obstructs breathing of the event. Prolonged tonic–clonic
middle and lower back. Epidural anaes- and can cause death by suffocation if seizures are potentially life-threatening.
thesia numbs the nerves that supply the the condition is not treated promptly. Absence seizures occur mainly in
chest and lower body. The technique is Epiglottitis is now rare due to the children. Periods of altered conscious-
widely used to relieve pain during and routine immunization of infants against ness last for only a few seconds and
after surgery, as well as during childbirth. HAEMOPHILUS INFLUENZAE, the bacterium there are no abnormal movements of
that causes the condition. the body. This type of seizure may occur
hundreds of times daily.
epilepsy Partial seizures These seizures are caused
A tendency to have recurrent seizures. by abnormal electrical activity in a
Seizures are defined as transient neuro- more limited area of the brain. They
logical abnormalities that are caused may be simple or complex.
by abnormal electrical activity in the In simple partial seizures, conscious-
brain. Human activities, thoughts, and ness is not lost and an abnormal
emotions are normally the result of the twitching movement, tingling sensa-
regulated and orderly electrical excita- tion, or hallucination of smell, vision, or
tion of nerve cells in the brain. During a taste occurs, lasting several minutes.
seizure, a chaotic and unregulated elec- In one type of partial seizure, called
Vertebra
trical discharge causes various physical temporal lobe epilepsy, conscious contact
and mental symptoms. with the surroundings is lost. The suf-
Spinal cord CAUSES ferer becomes dazed and may behave
In many people with epilepsy, the oddly. Typically, the person remembers
Epidural space cause is unclear, although a genetic little, if anything, of the event.
factor may be involved. In other cases, DIAGNOSIS
Skin Catheter
seizures may be the result of brain In order to make a diagnosis, a doctor
damage from a head injury; birth trau- needs as much information as possible
Administering an epidural anaesthetic
The anaesthetic is injected into the epidural space ma; brain infection (such as meningitis about the seizures. The patient may not
(the region surrounding the spinal cord within the or encephalitis); brain tumour; stroke be able to recall the events, so an accu-
spinal canal). (damage to part of the brain caused by rate account from a witness may be
an interruption to its blood supply); necessary. Examination of the nervous
epidural space drug or alcohol intoxication; or a meta- system is normally carried out between
The space between the outer membrane bolic disorder. seizures. An EEG (a method of recording
of the spinal cord and the walls of the SYMPTOMS the activity of the brain), CT scanning or
vertebral canal that surround it. (See Many people who suffer from epilepsy MRI of the brain, and blood tests may
also epidural anaesthesia.) do not have any symptoms between also be carried out.

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 EPILOIA

TREATMENT Affected people should also advise their

While a seizure is happening, any family, friends, and colleagues what to LOCATION OF EPIPHYSES
witnesses should make the surrounding do if a seizure occurs.
Each epiphysis is
area safe (for example, by removing situated at an end of a
hazardous objects) and ensure that the epiloia long bone of the body
person can breathe while unconscious. See tuberous sclerosis. and is separated from
Clothing around the neck should be the shaft of the bone
loosened, and a soft item, such as a epinephrine by an area called the
folded piece of clothing, should be An alternative name for adrenaline. epiphyseal plate.
placed under the head. Otherwise,
witnesses should simply let the attack EpiPen
E run its course. Once the convulsions A brand name for an assembled needle
Epiphysis

have stopped, the person should be and syringe containing a dose of adren- Epiphyseal
plate
placed in the recovery position. A person aline (epinephrine) that is used for
having a seizure should never be rapid administration to prevent or treat
restrained, and should never have any- life-threatening allergic reactions (see
thing put into his or her mouth. anaphylactic shock). The EpiPen is
Anticonvulsant drugs usually stop or designed for people who are prone to
reduce the frequency of recurrent such reactions to use on themselves; it Shaft of bone
seizures. The drugs may have unpleasant delivers the adrenaline directly into a
side effects, however, so the doctor will muscle, usually a thigh muscle.
take care to find the one drug that Anyone known to be at risk of an
works best for that patient. With very anaphylactic reaction should carry an
severe epilepsy, a combination of drugs EpiPen with them at all times and be
Epiphyseal
may be needed to control seizures. If no taught how to administer it. An affected plate
seizures occur after two or three years person’s family, as well as other close
of treatment, and depending on their contacts, such as teachers, colleagues,
cause, the doctor may suggest reducing and friends, should also be aware of Epiphysis
or stopping the drug treatment. how to use the EpiPen.
Women who are taking anticon-
vulsant drugs and are planning a epiphora
pregnancy will need to have their treat- See watering eye. condition called epiphysitis), may retard
ment reviewed before conceiving. They the growth of the affected bone and
may need to change to another drug to epiphyseal fracture cause it to become deformed.
reduce the risk of a fetal abnormality. A fracture (break) at the point where
Stopping treatment is not usually an the epiphysis (the end section of a long epiphysis, slipped
option because seizures can be pro- bone) meets the diaphysis (the main See femoral epiphysis, slipped.
foundly damaging to the fetus. shaft of the bone). This type of break
Surgery may be considered if a sin- may affect the subsequent growth of episcleritis
gle area of damage to the brain is the fractured bone. A localized patch of inflammation
causing the seizures and drug treat- that affects the outermost layers of
ment has not proved effective. epiphyseal plate the sclera (white of the eye) in an area
OUTLOOK The disc that separates the epiphysis (the immediately underneath the conjunctiva
Epilepsy that develops during child- end section of a long bone) from the dia- (the transparent membrane that covers
hood may sometimes disappear soon physis (the main shaft of the bone). the sclera).
after adolescence. During the period of growth, the epi- Episcleritis is usually of unknown
Affected adults can enjoy relatively physeal plate is composed of cartilage cause and mainly affects middle-aged
normal lives, but may be restricted in (connective tissue formed of collagen). men. It may, at times, be a complication
their choice of work. For example, it is This cartilage is gradually replaced by of rheumatoid arthritis. The inflammation
inadvisable for people with epilepsy to bone as a result of ossification, a process may cause a dull, aching pain and there
have occupations involving heights or by which cartilage cells multiply and may be photophobia (abnormal sensitiv-
operating dangerous machinery. In absorb calcium to develop into bone. ity of the eyes to light).
addition, there are certain restrictions The disorder usually disappears by
on driving vehicles (see driving, health epiphysis itself within a week or so, but it may
and). People with epilepsy are legally The end section of a long bone (such as recur. Symptoms may be relieved by
required to contact their vehicle licens- the femur in the legs, or the humerus in using eye-drops or ointment containing
ing agency, who will explain the the arms) that is separated from the dia- a corticosteroid drug.
relevant restrictions. physis (the main shaft of the bone) by
Many people with epilepsy carry a the epiphyseal plate. episiotomy
special card, tag, or bracelet, such as Problems that affect the epiphysis or A surgical procedure in which an inci-
those produced by Medic-Alert, which the epiphyseal plate during the period sion is made in the perineum (the tissue
states that they have the condition. of growth, such as inflammation (a between the vagina and the anus) in

278
 ERCP

order to facilitate the delivery of a baby. subjected to more trauma, consists of reactivated. Epstein–Barr virus is one of
After delivery, the severed tissues are many layers including a dead outer layer the few viruses with a proven role in
stitched back together. of cells that is constantly being shed. the development of cancerous tumours.
WHY IT IS DONE Structures that are not lined with In Africa, it is associated with Burkitt’s
An episiotomy is advisable if the peri- epithelium are the blood vessels, the lymphoma, and in Southeast Asia it is
neum fails to stretch over the baby’s lymph vessels (see lymphatic system), associated with cancer of the naso-
head and/or a large perineal tear is like- and the inside of the heart, which are pharynx (see nasopharynx, cancer of).
ly. The procedure prevents ragged tears lined with endothelium, and the chest Epstein–Barr virus may also cause lym-
that would be more painful, more diffi- and abdominal cavities, which are lined phomas to develop in patients who have
cult to repair, and more likely to lead to with mesothelium. undergone transplant surgery.
complications. Episiotomy is usually Other disorders that are associated
necessary in a forceps delivery, because with Epstein–Barr virus include some E
the instruments occupy additional space cases of acute hepatitis. In people with
in the vagina, and in a breech delivery, in AIDS, the virus may lead to the develop-
which there is little opportunity for ment of a condition called oral hairy
gradual stretching of the perineal tissues. Squamous cells Squamous leukoplakia; this condition is character-
In most cases, however, the naturally ized by roughened, white patches on
elastic vagina should not have to be cut the sides of the tongue.
to allow a normal delivery.
Cuboidal cells
Erb–Charcot disease
epispadias A rare condition resulting from spinal
A rare congenital (present from birth) Cuboidal cord damage due to syphilis (a sexually
abnormality in which the opening of transmitted bacterial infection). The
the urethra (the tube through which Cilia symptoms include numbness, a sensa-
urine is excreted from the bladder) is tion of pins and needles, and muscle
not in the glans (head) of the penis but weakness in the legs.
is on its upper surface. In some cases,
the penis also curves upwards. Surgery Erb’s palsy
is carried out during infancy, using tis- Columnar cells Weakness or paralysis of the muscles in
sue from the foreskin to reconstruct the the upper arm and shoulder. Erb’s palsy
urethra. (See also hypospadias.) results from damage to the upper roots
Columnar of the brachial plexus (a collection of
epistaxis nerve trunks formed from nerve roots
Types of epithelium
A medical term for nosebleed. The cells of the epithelium vary in shape and size near the top of the spine). Such an
according to function. The three basic types are injury may occur during birth if excess
epithelioma squamous, cuboidal, and columnar. pressure is applied to the baby’s head
A noncancerous tumour arising from during a difficult delivery, causing the
the epithelium, the tissue that covers the epoetin fifth cervical root of the spinal cord to
outer surface of the body and forms A genetically engineered preparation of be damaged. It may also result from a
the membranous lining of internal the hormone erythropoietin, which is road traffic accident, particularly in
organs). In some cases, an epithelioma produced by specialized cells in the kid- motorcycle riders, when an impact
may become cancerous, in which case neys and stimulates the bone marrow to forces the head and neck to one side
it becomes known as a carcinoma. produce red blood cells. and severely strains the nerves on the
Epoetin may be used in the treatment opposite side. Erb’s palsy is character-
epithelium of anaemia (a reduced level of the oxy- ized by an arm that is rotated inwards at
The layer of cells that covers the entire gen-carrying pigment haemoglobin in the shoulder and hangs limp down one
surface of the body and lines most of the blood) due to the lack of erythropo- side of the body.
the structures within it. Epithelial cells etin that occurs in kidney failure. It is also
vary in shape according to their func- used to boost the level of red blood cells ERCP
tion. There are three basic shapes: before surgery; the patient donates blood The abbreviation for endoscopic retro-
squamous (thin and flat), cuboidal, and to be used during or after the surgery grade cholangiopancreatography, which
columnar. These structures may vary beforehand. Epoetin may also be used as is an X-ray procedure used for examin-
further. For example, in the respiratory an alternative to blood transfusions in ing the biliary system and the pancreatic
tract, epithelial cells bear brushlike fila- major orthopaedic (bone) surgery. duct. ERCP is used mainly when other
ments called cilia that create a current in imaging techniques, such as ultrasound
the surrounding fluid. This current pro- Epstein–Barr virus scanning, CT scanning, or MRI, fail to pro-
pels dust particles from inhaled air back A virus that belongs to the herpesvirus vide sufficiently detailed images of
up the bronchi (the large air passages in family.The Epstein–Barr virus (EBV) may these body structures.
the lungs) and the trachea (windpipe). cause glandular fever (see mononucleo- HOW IT IS DONE
Most internal organs lined with sis, infectious); after the initial infection, An endoscope (a flexible viewing tube
epithelium are covered with only a sin- the virus remains dormant in the cells with a lens and a light attached) is
gle layer of cells, but the skin, which is of the immune system and may later be passed down the oesophagus, through

279
 ERECTILE DYSFUNCTION

the stomach, and into the duodenum ergot eruption of teeth

(the upper part of the small intestine). A A product of CLAVICEPS PURPUREA, a fungus The process by which developing teeth
catheter (a fine, flexible tube) is passed that grows on rye and various other grow from the jawbone, breaking through
through the endoscope into the common cereals. Ergot contains poisonous alka- the gum to project into the mouth.
bile duct and pancreatic duct. Finally, a loids (nitrogen-containing substances), DECIDUOUS TEETH
contrast medium (a substance opaque to some of which have medicinal proper- Deciduous teeth (milk teeth) usually begin
X-rays) is introduced through the cath- ties when taken in controlled doses. to appear at about six months of age. All
eter to make the pancreatic duct and the The drugs ergotamine, used in the 20 deciduous teeth have usually erupted
biliary system visible on X-rays. treatment of migraine, and ergometrine, by three years (see teething).
If a disease or disorder is detected given to control blood loss following PERMANENT TEETH
during the procedure, it can sometimes childbirth, miscarriage, or abortion, are Permanent teeth (which are also known
E be treated at the same time. For exam- both produced from ergot. as secondary teeth) usually begin to
ple, it may be possible to relieve a appear at about six years of age.The first
blockage due to a gallstone. ergotamine permanent molars erupt towards the
A drug used to treat migraine. It works back of the mouth and appear in addi-
erectile dysfunction by constricting the dilated blood vessels tion to the deciduous teeth. The
Inability to achieve or maintain an erec- around the brain. Side effects of ergota- eruption of permanent teeth nearer the
tion; commonly known as impotence. mine include nausea, vomiting, muscle front of the mouth is preceded by reab-
cramps, and abdominal pain. It is now sorption of the roots of the deciduous
erection used infrequently, having been largely teeth, which causes the teeth to become
The hardness, swelling, and elevation of replaced by drugs such as sumatriptan. loose so that they fall out. Eventually,
the penis that occurs in response to sex- permanent teeth replace all of the
ual arousal or physical stimulation. The erosion deciduous teeth.
erectile tissue of the penis becomes en- The destruction and loss of surface Wisdom teeth (the third molars)
gorged with blood as the blood vessels tissue through physical or chemical usually erupt between the ages of 17
within it dilate. Muscles around the ves- processes (see cervical erosion; erosion, and 21. In some people, however, they
sels then contract and keep blood in the dental; gastric erosion). never appear; in others, the wisdom
penis, thereby maintaining the erection. teeth are impacted (blocked from erup-
erosion, dental ting) because of insufficient space in
erection, disorders of Loss of enamel from the surface of the jawbone (see impaction, dental).
Conditions in which the erection of the a tooth (see teeth) due to attack by
penis is disrupted. Such conditions in- plaque acids or other chemicals.The first eruptive phase
clude total or partial failure to attain or sign of enamel loss is a dull, frosted The phase in the course of a condition
maintain an erection (see impotence), appearance. As the condition progresses, such as chickenpox in which skin lesions,
persistent erection in the absence of sex- smooth, shiny, shallow cavities form. for example spots or blisters, break out.
ual desire (see priapism), and curving of Erosion of the outer surfaces of the
the penis during erection (see chordee). front teeth is most frequently caused by erysipelas
excessive intake of acidic fruit juices A disorder, caused by a streptococcal
ergocalciferol and carbonated drinks. Erosion of the infection, that produces inflammation and
An alternative name for vitamin D2 (see inner surfaces of the molars may be a blistering of the face and is associated
vitamin D). result of regurgitation of stomach acid, with a high fever and malaise. Erysipelas
as occurs in people suffering from acid most often affects young children and
ergometer reflux or bulimia. Erosion may be com- elderly people. Treatment is with peni-
A machine that measures and records bined with, and may also accelerate, the cillin drugs. (See also cellulitis.)
the amount of physical work undertaken processes of abrasion (mechanical wear-
by the body and the body’s response to ing away of teeth) and attrition (wearing erythema
a controlled amount of exercise. An down of the chewing surfaces). These A term meaning redness of the skin.
ergometer makes continuous record- problems may result in extensive dam- Disorders in which skin redness is a fea-
ings, both during and after activity, of age to the teeth. (See also caries, dental.) ture include erythema multiforme, erythema
heart rate and rhythm (using an ECG); nodosum, erythema ab igne, lupus erythe-
blood pressure; rate of breathing; and eroticism matosus, and erythema infectiosum
volume of oxygen taken in from the air. The character and emotive nature of (also known as fifth disease).
sexual excitement. Sexual arousal may Erythema can have many causes, such
ergometrine be stimulated by erotic thoughts, by as blushing, hot flushes, sunburn, and
A drug given after childbirth, miscarriage, touching the erogenous zones, and by a inflammatory, infective, or allergic skin
or abortion to reduce the loss of blood variety of other sensations (such as the disorders such as acne, dermatitis, eczema,
from the uterus (womb). Ergometrine look and feel of certain clothes). erysipelas, rosacea, and urticaria.
works by causing blood vessels in the
uterine wall to contract, thereby reduc- eruption erythema ab igne
ing bleeding. The drug is often given in The process of breaking out, as of a skin Red, mottled skin that may also be dry
combination with oxytocin, which stim- rash or a new tooth. (See also eruption of and itchy. Erythema ab igne is caused by
ulates uterine contractions. teeth; eruptive phase.) exposure to strong direct heat, such as

280
 ERYTHEMA NODOSUM

ERUPTION OF TEETH

The top diagrams show the approximate ages at which in the lower diagrams. Blue denotes erupting teeth; grey
particular deciduous teeth usually appear. The ages at which denotes erupted deciduous teeth; white denotes erupted
specific types of permanent teeth usually appear are shown permanent teeth.

Deciduous teeth
The full deciduous set (left) consists of eight
incisors, four canines, and eight molars.
They usually start erupting at six months.

E
Permanent teeth
The full set of permanent teeth (below)
6 to 10 months: 8 to 12 months: 9 to 16 months: 13 to 19 months: 16 to 23 months: 23 to 33 months: consists of eight incisors, four canines,
lower central upper central lateral incisors first molars canines second molars eight premolars, and twelve molars.
incisors incisors They usually start erupting at six years.

6 to 7 years: 6 to 8 years: 7 to 9 years: 9 to 12 years: 10 to 12 years: 10 to 12 years: 11 to 13 years: 17 to 21 plus:

first molars central incisors lateral incisors canines first premolars second premolars second molars third molars

when an individual has been sitting too ties), that is sometimes accompanied by ter or form raised, pale-centred weals
close to a fire. The condition is most generalized illness. Erythema multiforme known as target lesions. People suffer-
common in elderly women. means “skin redness of many varieties”. ing from erythema multiforme may
Dryness and itching can often be CAUSES have a fever, sore throat, headache,
relieved by use of an emollient (soothing Erythema multiforme can develop as an and/or diarrhoea.
cream). The redness fades in time but adverse reaction to certain drugs or it In a more severe form of erythema
may not disappear entirely. may accompany certain viral infections multiforme, known as Stevens–Johnson
(for example, herpes simplex) or bacterial syndrome, the mucous membranes of
erythema infectiosum infections (such as streptococcal infec- the mouth, eyes, and genitals are all
See fifth disease. tions). Other possible causes of erythema affected and become ulcerated.
multiforme are pregnancy, vaccination, TREATMENT
erythema marginatum and radiotherapy. However, about half of Treatment for erythema multiforme
A pink rash that appears and disappears all cases occur for no apparent reason. depends on the underlying cause. Any
spontaneously and that may affect any SYMPTOMS causative drug treatment will be with-
area of the body except the face. Erythe- A symmetrical rash of red, frequently drawn and any underlying condition
ma marginatum is a characteristic sign itchy, spots erupts on the skin of the will be treated if possible. Corticosteroid
of rheumatic fever. limbs and, occasionally, on the face and drugs may be given to reduce the
the rest of the body. The spots may blis- inflammation. People suffering from
erythema migrans Stevens–Johnson syndrome are also
A red, circular rash that occurs as a given analgesic drugs (painkillers) and
result of infection with Lyme disease. may need intensive care.
Erythema migrans first appears at the
site of a bite from an infected tick. erythema nodosum
The rash then expands, over a period of A condition characterized by reddish-
days or weeks, to form a large, round purple, tender swellings on the legs.
patch. Erythema migrans is most com- Erythema nodosum is usually associated
monly found on the thighs, groin, or with another illness.
trunk, or in the armpit. CAUSES
The most common cause of erythema
erythema multiforme nodosum is a streptococcal infection of
The rash of erythema multiforme
Acute inflammation of the skin, and The spots of this rash are usually itchy. They may
the throat. However, the condition is
sometimes of the mucous membranes (the form into target lesions (concentric rings of different also associated with other diseases,
thin, moist tissue that lines body cavi- shades of red around a pale centre). mainly tuberculosis and sarcoidosis, and

281
 ERYTHEMATOUS

may occur as a reaction to some drugs, triggered by heat. Attacks of the condi- vessels towards the heart. This action
particularly sulphonamide drugs, penicillin tion can be relieved by elevating the creates a blood-free area, so surgery on
drugs, and salicylate drugs. Sometimes affected limb and applying something the limb can be performed more easily.
there is no apparent cause. cold, such as an ice pack, to it. No spe- The patient is anaesthetized (see
SYMPTOMS cific treatment is available, but aspirin anaesthesia), then the Esmarch’s ban-
The swellings, which may range from may relieve the condition in some cases. dage is wrapped from the fingers or
1 to 10 cm in diameter, are shiny and toes upwards. An inflatable tourniquet
tender and occur on the fronts of the erythromelia (a device used to compress blood ves-
shins, the thighs, and, less commonly, Diffuse erythema (redness) and atrophy sels) is then applied to the upper arm or
the arms. Joint and muscle pains and (wasting) of the skin of the lower limbs. thigh to stop blood from returning to
fever also usually occur. The cause of erythromelia is unknown. the limb. The Esmarch’s bandage is
E TREATMENT removed, leaving the inflated tourni-
Successful treatment of any underlying erythromycin quet in position during surgery.
condition clears the swellings. Bed rest, An antibiotic drug used in the treatment
analgesic drugs (painkillers), and, occa- of skin, chest, throat, and ear infections. esotropia
sionally, corticosteroid drugs may also be Erythromycin is given to people with An alternative term for a convergent
necessary. The condition usually sub- these conditions who are allergic to squint, in which one eye looks directly
sides within about a month. penicillin drugs. In addition, it is particu- at an object while the other eye turns
larly useful in the treatment of pertussis inwards. (See also exotropia.)
erythematous (whooping cough) and legionnaires’ dis-
Characterized by erythema (redness of ease. The drug may be taken in tablet ESR
the skin). form, liquid form, or intravenously. The abbreviation for erythrocyte sedi-
Possible adverse effects include nausea, mentation rate, which is the rate at
erythrasma diarrhoea, and an itchy rash. which erythrocytes (red blood cells) sink
A bacterial skin infection, caused by the to the bottom of a test tube.
organism CORYNEBACTERIUM, that affects erythrovirus WHY IT IS DONE
the groin, armpits, and skin between A virus formerly known as parvovirus. The ESR is increased if the level of
the toes. Raised, irregularly shaped, dis- Infection with a strain of erythrovirus fibrinogen (a type of protein) in the
coloured patches appear in the affected causes fifth disease in humans. blood is raised. Fibrinogen is raised in
areas. Erythrasma is most common in response to a range of illnesses, includ-
people who have diabetes mellitus. The escape beat ing inflammation, especially when this
condition generally clears up following An automatic heartbeat that occurs after is caused by infection or by an auto-
a course of treatment with the antibiot- an abnormally long pause in the heart immune disease. The ESR is also
ic drug erythromycin. rhythm. An escape beat is therefore a increased if levels of antibodies (proteins
delayed beat that terminates a longer manufactured by the immune system)
erythrocyte cycle than normal. are very high, as occurs in multiple
Another name for a red blood cell. myeloma. ESR is therefore useful for
eschar helping to diagnose these conditions as
erythroderma A scab that forms on the surface of well as in monitoring their treatment.
See exfoliative dermatitis. skin that has been subject to damage, HOW IT IS DONE
for example by a burn. Whole blood collected from the patient
erythrogenic toxin is mixed with anticoagulant (a chemical
A poisonous protein produced by strep- Escherichia coli (E.coli) that prevents the blood from clotting)
tococcal bacteria that causes the red A bacterium (see bacteria) that is nor- in a test tube. In one method, the blood
rash in scarlet fever. mally found in the intestines but can is left undisturbed at a constant temper-
cause illness under some circumstances. ature for one hour. The red blood cells,
erythromelalgia Types of E. COLI are often the cause of which can be seen as a dark red clump,
A rare condition, also known as Ger- traveller’s diarrhoea, which is usually a settle to the bottom of the tube, leaving
hardt–Mitchell disease, that principally mild illness. Bacteria that enter the the clear, straw-coloured plasma at the
affects the extremities of the body, bladder through the urethra are a com- top. The ESR is the number of milli-
most commonly the feet. Erythrome- mon cause of urinary tract infections. metres the red cells fall in one hour.
lalgia usually first appears in middle Some strains of E.COLI, however, can
age. It may be associated with poly- cause serious food-borne infections essential amino acids
cythaemia (an increase in the total red that may result in haemolytic–uraemic The nine amino acids required for pro-
cell mass of the blood), thrombocytosis syndrome (a condition in which red tein synthesis, growth, and develop-
(an increase in the number of platelets blood cells are destroyed and kidney ment, that cannot be made by the body
in the blood), gout (a metabolic disor- function becomes impaired). and must be obtained in the diet.
der that causes attacks of arthritis), and
neurological disease. Esmarch’s bandage essential fatty acids
Erythromelalgia is characterized by A broad rubber bandage that is The fatty acids that cannot be synthe-
severe attacks of burning pain and mot- wrapped around the elevated limb of a sized by the body and must therefore be
tled redness of the skin; it may be patient to force blood out of the blood obtained in the diet.

282
 EUPHORIA

essential food factors ethics, medical acitretin, etretinate is also occasionally

Any substances that are essential for See medical ethics. used in the treatment of other disorders
normal functioning of the body but that cause excessive skin thickening,
cannot be synthesized by the body ethinylestradiol such as ichthyosis. It reduces the produc-
itself, so must be obtained through the A synthetic form of the female sex hor- tion of keratin, the protein that forms
diet. Examples of essential food factors mone estradiol. Ethinylestradiol is most the hard, outer layers of the skin.
are most vitamins and minerals and often used in oral contraceptives, in Etretinate can cause liver damage and
essential amino acids. which it is combined with a progesto- a rise in blood fats. The drug must not
gen drug. Rarely, it is used in hormone be taken during pregnancy because it
essential hypertension replacement therapy. can cause damage to the fetus.
Hypertension (high blood pressure) that
occurs without known cause. ethmoidal sinus eucalyptus oil E
One of the air-containing spaces in the A substance distilled from the leaves of
estradiol ethmoid bone behind the nose (see sinus, eucalyptus trees. Because of its aromatic
The most important oestrogen hormone, facial). smell and refreshing taste, it is used as a
which is essential for the healthy func- flavouring. It is also used in cough and
tioning of the female reproductive ethmoid bone cold remedies, when it may be applied
system and for breast development. In A bone that forms part of the floor of as a rub, inhaled as vapour, or incorpor-
its synthetic form, estradiol is used to the cranium (skull) and contributes ated in tablets.
treat the symptoms and complications to the roof of the nasal cavity and to the There is little evidence that eucalyp-
of the menopause (see hormone replace- orbits (eye sockets). The olfactory nerves, tus oil has any curative properties,
ment therapy) and to stimulate sexual which are responsible for smell, pass although it may relieve symptoms.
development in female hypogonadism through holes in part of the ethmoid
(underactivity of the ovaries). bone called the cribriform plate. eugenics
The science that is based on the
estriol ethosuximide improvement of the human race and
One of the oestrogen hormones. Estriol is An anticonvulsant drug used in the treat- the quality of human life through the
the predominant oestrogen produced ment of absence (petit mal) seizures principles of genetics. Modern eugenics
during pregnancy. Synthetic estriol is (see epilepsy). Ethosuximide may cause is primarily concerned with the study
prescribed to treat the symptoms and nausea and vomiting and, in rare cases, (and, where possible, the elimination)
complications of the menopause (see affects the production of blood cells in of genetic disease (see genetic disorders).
hormone replacement therapy) as well as bone marrow (see anaemia, aplastic).
to stimulate sexual development in Eulenburg’s disease
female hypogonadism (underactivity of ethyl alcohol A rare, nonprogressive, inherited disor-
the ovaries). Another name for ethanol, the alcohol der, also called congenital paramyotonia,
in alcoholic drinks. in which there is prolonged contraction
estrone of muscle fibres (see myotonia) when
An oestrogen hormone. Synthetic estrone ethyl chloride the patient is exposed to the cold. The
is used to treat the symptoms and A colourless liquid that is used as an muscles of the limbs, eyelids, and
complications of the menopause (see analgesic drug (painkiller). Ethyl chlo- tongue may be affected. Eulenburg’s
hormone replacement therapy). ride is applied to the skin as a spray disease shows an autosomal dominant
to numb an area before minor surgery pattern of inheritance (see genetic disor-
ESWL is carried out or to relieve muscle pain. ders) and may be caused by a disorder
The abbreviation for extracorporeal The substance is also used in the treat- of potassium metabolism.
shock wave lithotripsy. ment of larva migrans, a hookworm
infestation. eunuch
ethambutol A man whose testes (see testis) have
A drug used in conjunction with other etidronate, disodium been removed or destroyed so that he is
drugs to treat tuberculosis. Ethambutol A bisphosphonate drug used to treat sterile and lacks male hormones. A male
rarely causes side effects, but it may bone disorders (see bone, disorders of), who has been castrated before puberty
sometimes result in inflammation of the such as Paget’s disease and osteoporosis. will have broad hips, narrow shoulders,
optic nerve, leading to blurred vision. Disodium etidronate works by reducing and undeveloped male secondary sexual
the activity of bone cells, thereby halt- characteristics (such as a small penis, a
ethanol ing the progress of the disease. Side feminine distribution of body hair, and
The chemical name for the alcohol that effects of the drug are generally mild. a high-pitched voice).
is present in alcoholic drinks.
etretinate euphoria
ether A retinoid drug, chemically related to A state of confident wellbeing. Euphoria
A colourless liquid that produces un- vitamin A, that is used mainly in the is a normal reaction to personal success,
consciousness when inhaled. Ether was treatment of severe psoriasis (a skin dis- but it can also be induced by certain
the first general anaesthetic (see anaes- ease characterized by thickened patches drugs, including prolonged use of
thesia, general) to be introduced. of red, inflamed skin). Also known as corticosteroid drugs. Euphoria that has

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 EUSTACHIAN TUBE

no rational cause may be a sign of mania because their adenoids are larger and bleed easily. The haemolysis (red cell
or of brain disease, or damage from more likely to cause a blockage if they destruction) causes jaundice (yellowing
head injury (particularly damage to the become infected and partly because of the skin and the whites of the eyes).
frontal lobes), dementia, brain tumours, children’s eustachian tubes are shorter A blood transfusion may be needed
or multiple sclerosis. than those of adults. in the early stages of the condition. Cor-
ticosteroid drugs may be prescribed to
eustachian tube euthanasia control haemolysis and platelet destruc-
The passage that runs from the middle The use of medical knowledge to end a tion. In severe cases, the spleen may be
ear into the back of the nose, just above life painlessly in order to relieve suffer- removed (see splenectomy). The anti-
the soft palate (part of the roof of the ing.Voluntary euthanasia refers to action bodies may eventually disappear after
mouth).The eustachian tube is lined with taken to end life at the patient’s own several months or years.
E a smooth, moist, mucous membrane. request. In the UK, it is illegal to take
FUNCTION active measures to end a person’s life; evening primrose oil
The eustachian tube acts as a drainage however, the withdrawal of treatment An oil extracted from the seeds of
channel from the middle ear and main- that would prolong life may be consid- the plant OENOTHERA BIENNIS, commonly
tains hearing by opening periodically to ered under some circumstances. called evening primrose. The oil con-
regulate air pressure. The lower end of tains an anti-inflammatory substance
the tube opens during swallowing and euthyroid known as gamolenic acid and is believed
yawning, allowing air to flow up to the A term used to describe a person whose by some to be of benefit in treating
middle ear, equalizing the air pressure thyroid gland is functioning normally. eczema and premenstrual syndrome.
on both sides of the eardrum. The term “euthyroid” is used especially
DISORDERS to refer to someone who has been suc- eversion
When a viral infection, such as a cold, cessfully treated for either hypothyroidism Turning outwards. The term is used
causes blockage of the eustachian tube, (underactivity of the thyroid) or hyper- medically to describe a type of ankle
equalization cannot occur, resulting in thyroidism (overactivity of the thyroid). injury or deformity in which the foot is
severe pain and temporary impairment turned outwards.
of hearing. A person with a blocked Evan’s syndrome
eustachian tube who is subjected to An uncommon autoimmune disorder in evidence-based medicine
rapid pressure changes may suffer from which the body wrongly makes two The use of medical or surgical treat-
barotrauma (pressure damage to the antibodies (immune system proteins): ments that have been evaluated for
eardrum and other structures). Glue ear one that attacks healthy red blood cells effectiveness and safety by clinical
(the accumulation of secretions in the (see anaemia, haemolytic) and one that research. The research involves random-
middle ear) or chronic otitis media (mid- destroys platelets (tiny cells in the ized controlled trials and often includes
dle-ear infection) may occur if the tube blood that play a vital role in blood meta-analysis, in which the results from
is blocked, preventing adequate drain- clotting). The spleen is usually the main several trials are combined.
age from the middle ear. site of cell destruction.
These conditions, which often result The anaemia can cause tiredness and Evista
in partial hearing loss, are much more pallor, and the deficiency of platelets A brand name for raloxifene, a drug
common in children. This is partly may lead to bruising and a tendency to that is prescribed for the prevention
and treatment of osteoporosis in post-
menopausal women.
ANATOMY OF THE EUSTACHIAN TUBE
evoked potential
The eustachian tube connects the Inner ear
middle ear with the back of the
The electrical signal generated when a
nose. The tube is divided into two sensory area, such as a nerve, a muscle,
separate parts: the uppermost part or the retina (the light-sensitive inner
runs through a bony canal and the layer at the back of the eye), is stimulated.
lower part is lined with cartilage. Tests to record evoked potentials are
used to diagnose problems affecting the
Middle ear conduction of signals along sensory
nerves. (See also evoked responses.)

Eustachian tube evoked responses

The tracing of electrical activity in the
brain in response to a specific external
Ear canal stimulus. The evoked responses proce-
Nasopharynx
dure is similar to that for an EEG
(back of throat) (electroencephalography).
Tympanic The technique is used to check the
membrane
(eardrum) functioning of various sensory systems
(such as sight, hearing, or touch). The
information obtained can be used to

284
 EXERCISE

reveal abnormalities caused by inflam- exanthema never be attempted without the advice
mation, pressure from a tumour, or A skin eruption or rash, or a disease in of a doctor, dietitian, or nutritionist
other disorders, and to help confirm a which a skin eruption or rash is a because it can result in serious nutri-
diagnosis of multiple sclerosis. prominent feature, such as measles, tional deficiencies.
scarlet fever, or roseola infantum.
Ewing’s sarcoma excoriation
A rare malignant form of bone cancer. exchange transfusion Injury to the surface of the skin or to a
Ewing’s sarcoma arises in a large bone, A treatment for haemolytic disease of the mucous membrane (the thin, moist tissue
usually the femur (thigh bone), tibia, newborn, a severe disorder resulting that lines body cavities) caused by phys-
(shin), humerus (upper-arm bone), or from rhesus incompatibility between a ical abrasion, such as scratching.
a pelvic bone, and spreads to other pregnant mother and her baby and
areas at an early stage. The condition is causing destruction of red blood cells in excrescence E
most common in children between ten the baby. This condition leads to dan- Any abnormal raised growth on the sur-
and 15 years of age. gerously high levels of the pigment face of the body, such as a wart.
SYMPTOMS bilirubin in the baby’s blood as well
A bone affected by Ewing’s sarcoma is as severe anaemia (a reduced level of the excretion
painful and tender. It may also become oxygen-carrying pigment haemoglobin The discharge of any waste material
weakened and fracture easily. Other in the blood). Exchange transfusion from the body. Examples of such waste
symptoms include weight loss, fever, is used to treat both these symptoms material are the by-products of diges-
and anaemia (a reduced level of the by replacing the infant’s blood with tion, waste products from the repair of
oxygen-carrying pigment haemoglo- rhesus-negative donor blood. tissues, and excess water.
bin in the blood). ORGANS OF EXCRETION
DIAGNOSIS AND TREATMENT excimer laser The kidneys excrete urine, which con-
The sarcoma can be diagnosed by X-rays A computer-controlled laser used to tains excess nitrogen (as urea), together
and biopsy (removal of a small sample reshape the cornea (the transparent with excess water, salts, some acids, and
of tissue for microscopic analysis). If dome that forms the front of the eye- most drugs. The liver excretes bile,
cancer is found, the whole skeleton is ball). The laser removes very thin layers which contains waste products and bile
examined by X-rays and radionuclide of tissue from the corneal surface (see pigments formed from the breakdown
scanning, and the lungs viewed by CT LASIK; PRK). The technique is used to of red blood cells. Some of the bile is
scanning, to determine if, and how far, correct myopia (shortsightedness), hyper- passed from the body in the faeces. The
the cancer has spread. metropia (longsightedness), and some large intestine excretes undigested food,
Treatment of Ewing’s sarcoma is other vision disorders. some salts, and excess water in the form
with radiotherapy and anticancer drugs. of faeces. The lungs discharge carbon
The outlook depends on how far the excision dioxide and water vapour into the air.
cancer has spread. The surgical cutting out of diseased Sweat glands excrete salt and water onto
tissue, such as a breast lump or gan- the surface of the skin as a method of
examination, physical grenous skin, from surrounding healthy regulating the body’s temperature.
The part of a medical consultation in tissue. (See also excisional biopsy.)
which the doctor looks at, feels, and lis- exencephaly
tens to various parts of the patient’s excisional biopsy A developmental defect of the cranium
body. A physical examination is used A type of biopsy that involves the (skull) in which part of the bone is
to assess the patient’s condition or to removal of an entire area of affected absent, leaving the brain exposed or
gather information to help the doctor tissue, together with a margin of adja- allowing it to protrude. This defect is
make a diagnosis. cent healthy tissue, for microscopic incompatible with survival.
Most physical examinations include analysis in a laboratory.
palpation (feeling with the hands), by exenteration
which the doctor examines relevant exclusion diet The surgical removal of all organs and
areas of the body for signs such as A dietary programme that is used to soft tissue in a body cavity, usually to
swelling, tenderness, or enlargement identify a particular food allergy or food arrest the growth of a cancer. Exentera-
of organs. In some cases, percussion of intolerance. Food is initially limited to a tion is sometimes used in ophthalmology
the chest, or other parts of the body, very restricted choice until symptoms when the eye and the contents of the
may be performed by tapping with the improve; test foods, such as milk, are eye socket are removed.
fingers and then listening to the sound then reintroduced one at a time, at
produced. Auscultation (listening with a intervals of several days, to see if there exercise
stethoscope) may be used to listen to is an adverse reaction. The reintroduc- Any physical activity performed to
blood flow through the arteries and tion of such a test food is known as a improve health. Exercise may be taken
sounds made by the heart and lungs. food challenge. for recreation or to correct a physical
Other aspects of the examination may Individuals on an exclusion diet are injury or deformity (see physiotherapy).
involve taking the patient’s pulse or asked to keep a daily record of their TYPES OF EXERCISE
blood pressure, examining his or her symptoms from at least a week before Different types of exercise have differ-
eyes and ears, and assessing the strength starting the diet until the end of the ent effects on the body. Some forms
and coordination of the muscles. programme. An exclusion diet should (aerobic exercises) improve the fitness

285
 EXERCISE ECG

of the cardiovascular and respiratory improve flexibility. For further informa- Exercise can help to relieve the symp-
systems; some forms improve flexi- tion on the effects of exercise, see the toms of peripheral vascular disease as
bility; some increase muscular strength; illustrated box below. well as of some psychological dis-
and some improve physical endurance. BENEFITS OF EXERCISE orders, particularly depression. Regular
During aerobic exercise, such as There is an association between high weight-bearing exercise (such as run-
jogging or swimming, the heart and levels of aerobic exercise and a low inci- ning) increases bone density, making
lungs work faster and more efficiently dence of coronary artery disease. Regular the bones stronger; hence osteoporosis is
to meet the muscles’ increased demand aerobic exercise usually leads to reduced less common in people who have exer-
for oxygen. Regular aerobic exercise blood pressure. It also increases levels of cised throughout their adult lives. Such
improves the condition of both the high density lipoprotein (HDL) in the exercise also increases muscle mass and
cardiovascular and respiratory systems. blood, which is thought to help protect strengthens the muscles and ligaments.
E Exercises such as weight training against atherosclerosis (the accumulation It can therefore help to prevent or ease
increase muscle strength and endurance. of fatty deposits on artery walls) and lower back pain and can make the liga-
Activities such as yoga and pilates myocardial infarction (heart attack). ments less susceptible to strains.

THE EFFECTS OF EXERCISE

Exercise produces many changes The muscles

in different body organs. Muscles As the muscles flex and relax,
there is a rise in the chemical Flexed
receive an increased blood flow muscle
because of their greater energy activity within muscle cells. The
rate at which the cells consume
requirements, and the heart oxygen and glucose increases.
and lungs work faster and more
efficiently to keep the body Relaxed muscle
tissues well supplied with blood.
These changes are controlled
by the release of the chemicals
adrenaline and noradrenaline from
the sympathetic nervous system.

The heart and

The lungs circulation
The rate and depth of breathing The heart beats
increase to ensure a sufficient faster and more
flow of oxygen from the lungs powerfully to
into the blood. This increase in increase the blood
breathing also helps to remove flow to the working
additional carbon dioxide ECG printout showing heart
muscles. Blood
produced by the muscle cells rate at rest
vessels in the
during exercise. intestines, liver,
stomach, and
Bones kidneys narrow so
Regular exercise helps to maintain the that more blood is
strength and density of the bones and directed away from
so prevents or slows the development these areas and to
of the bone disease osteoporosis. Heart rate during exercise the muscles.

COMMON TYPES OF EXERCISE

Aerobic Isometric Isotonic Isokinetic

Aerobic exercise is activity in Isometric exercise is exercise Isotonic exercise is exercise with Isokinetic exercise involves
which the body continuously without movement, in which movement, in which muscle both isotonic and isometric
needs to take in additional one group of muscles exerts tension is more or less constant exercise. The muscles move
oxygen to meet the muscles’ steady pressure against either and the body works against its reasonably heavy loads, but
increased demands. Regular an immovable object or an own weight or external weights. are also put through their
aerobic exercise improves opposing group of muscles. Isotonic exercise includes weight full range of movement.
the performance of the It is an effective means of training and calisthenics Isokinetics combines strength
cardiovascular and respiratory increasing muscle strength, (repetitious movements with little training with some aerobic
systems. Jogging, swimming, but does not exercise the or no equipment). It increases exercise, but requires
and cycling are examples of cardiovascular system or help muscle strength, size, and specialist equipment.
aerobic exercise. in muscular endurance. endurance.

286
 EXOSTOSIS

RISKS exhalation exophthalmic goitre

In some circumstances, vigorous exer- The medical term for the process of An alternative name for the thyroid
cise may pose a number of health risks. breathing out (see breathing). gland disorder Graves’ disease.
For example, people who are out
of condition but attempt strenuous exhaustion exophthalmos
activity may suffer injury and put Extreme mental or physical tiredness in Protrusion of one or both eyeballs
themselves at increased risk of a heart which a person lacks energy. The state caused by a swelling of the soft tissues
attack. Professional sportsmen, such as of exhaustion may come about as a within the eye socket.
footballers, may have an increased risk result of overactivity or prolonged
of osteoarthritis in later life because of insomnia (difficulty in falling or staying
the repeated minor damage to struc- asleep) or it may be a symptom of a
tures such as the knee and the cervical mental or physical disorder, such as anx- E
area of the spine. iety, stress, severe anaemia, or prolonged
labour. (See also heat exhaustion.)
exercise ECG
The use of electrocardiography (see exhibitionism
ECG) to assess the function of the heart The habit of deliberately exposing the
when it is put under the stress of exer- genitalia as a deviant sexual act. This
cise. Exercise ECG is usually carried out type of behaviour is almost always
when a patient is suspected of having confined to men. Psychotherapy or
coronary artery disease. The procedure behaviour therapy may help to treat per-
Appearance of exophthalmos
involves raising the heart rate by exer- sistent offenders. The staring appearance in exophthalmos is caused
cising, usually on a treadmill with an by swelling of the soft tissue in the eye socket,
adjustable gradient or on an exercise existential psychotherapy which pushes the eyeball forwards.
bicycle. The heart’s electrical activity is An uncommon form of psychotherapy in
then recorded for analysis. which emphasis is placed on sponta- CAUSES
neous interactions and feelings rather Exophthalmos is most commonly associ-
exercise tests than on rational thinking. The psy- ated with Graves’ disease, which also
Any of a variety of tests in which exer- chotherapist is involved in the therapy causes thyrotoxicosis (overactivity of the
cise is used as a means of deliberately to the same extent as the patient. thyroid gland). Other causes include an
stressing the heart and the lungs. The eye tumour, an aneurysm (ballooning of an
use of exercise tests enables doctors to exocrine gland artery), or inflammation behind the eye.
assess an individual’s level of health A gland that secretes substances through SYMPTOMS
and fitness. (See also cardiac stress test; a duct (a tube or passage) either onto Exophthalmos may restrict eye move-
exercise ECG.) the inner surface of an organ or the ment and cause double vision. In severe
outer surface of the body. Examples of cases, increased pressure in the socket
exfoliation exocrine glands include the salivary may restrict blood supply to the optic
Flaking off, shedding, or peeling from a glands and the sweat glands. The release nerve, causing blindness. The eyelids
surface in scales or thin layers, as in of exocrine secretions can be triggered may be unable to close, and vision may
exfoliative dermatitis. by a hormone or a neurotransmitter. (See become blurred due to drying of the
also endocrine gland.) cornea (the transparent dome that forms
exfoliative dermatitis the front of the eyeball).
A skin disorder characterized by severe exogenous TREATMENT AND OUTLOOK
inflammation, redness, and scaling of A term referring to a disease or disorder In exophthalmos due to thyroid disease,
the skin over most of the body. Exfolia- that has a cause external to the body. treatment of the thyroid disorder may
tive dermatitis may be the result of an Examples are infection, poisoning, or relieve the exophthalmos; however, exo-
allergic response to a drug (see allergy) injury. (See also endogenous.) phthalmos may persist even if thyroid
or it may be due to worsening of a pre- function returns to normal.
existing skin condition such as psoriasis exomphalos With early treatment, normal vision
or eczema. The condition sometimes A rare birth defect in which a mem- is usually restored. Occasionally, surgery
occurs in lymphoma and leukaemia. branous sac containing part of the may be required to relieve pressure on
In exfoliative dermatitis, there is a intestines protrudes through the navel. the eyeball and optic nerve.
widespread rash, accompanied by severe In mild cases of exomphalos, only one
flaking of the skin, which results in in- or two loops of intestine protrude; in exostosis
creased loss of water and protein from severe cases, most of the abdominal The most common type of noncan-
the surface of the body. Protein loss may organs are exposed. An affected infant cerous bone tumour, in which there is an
cause oedema (the accumulation of fluid may also have intestinal malformation. outgrowth of bone tissue. Exostosis
in tissues) and muscle wasting. Further Exomphalos is sometimes diagnosed develops most commonly at one end of
possible complications include heart before birth by ultrasound examination. the femur (thigh bone) or the tibia
failure and infection. The treatment of The condition is treated using surgery, (shin). The condition may be due to
exfoliative dermatitis, and the outlook, the success of which depends on the hereditary factors or to prolonged pres-
depend on the cause. extent of the defect. sure on a particular bone.

287
 EXOTOXIN

SYMPTOMS expire or external bleeding. It can also be

In most cases, exostosis produces no To exhale (breathe out air from the performed during surgery to create a
symptoms. Often it is recognized only lungs). The term also means “to die”. blood-free area for the procedure. (See
after an injury, when it appears as a also Esmarch’s bandage.)
hard swelling. Occasionally, the tumour expired gas
presses on a nerve, causing pain or Any gas that has been expelled from the exstrophy of the bladder
weakness in the affected area. lungs. Expired gas usually contains a A rare birth defect in which the bladder
DIAGNOSIS AND TREATMENT high proportion of carbon dioxide. It is inside-out and is open to the outside
Diagnosis can be confirmed by X-rays. may also contain other substances, such of the body through a space in the
The tumour may be surgically removed as alcohol and carbon monoxide, that are lower abdominal wall. There are also,
if it is causing symptoms or for cos- carried in the circulation. usually, other defects, such as epispadias
E metic reasons. in males (in which the opening of the
exploratory surgery urethra is on the upper surface of the
exotoxin Any operation carried out to investigate penis) and failure of the pubic bones to
A poison, released by certain types of or examine part of the body to discover join at the front. Untreated, an affected
bacteria (including tetanus bacilli and the extent of known disease or to estab- child constantly leaks urine.
diphtheria bacilli), that enters the blood- lish a diagnosis. Advances in imaging, Surgical treatment involves recon-
stream and causes widespread effects such as MRI (a technique that produces structing the bladder and closing the
around the body. Exotoxins are among cross-sectional or three-dimensional abdominal wall. If the bladder is very
the most poisonous substances known. images of body structures), have redu- small, it is removed and the urine
Infections by tetanus, diphtheria, and ced the need for exploratory surgery. diverted (see urinary diversion).
some other bacteria that release life-
threatening exotoxins can be prevented exposure extensor
by immunization with vaccines consisting A term used to describe the effects on Any muscle that moves a joint in order to
of detoxified exotoxins. Treatment of the body of being subjected to very straighten a limb. An example of an
such infections usually includes adminis- low temperatures, or to a combination extensor muscle is the triceps muscle in
tration of antibiotic drugs and an antitoxin of low temperatures, wetness, and high the arm, which straightens the elbow.
to neutralize the exotoxin. (See also winds. The primary danger in these
endotoxin; enterotoxin.) conditions is hypothermia (a sharp fall external cardiac massage
in body temperature). Rhythmic pressure applied to the chest
exotropia The term is also used to describe sub- in order to maintain circulation if a per-
An alternative term for a divergent jection to radiation, to environmental son’s heart has stopped beating. The
squint, in which one eye is used for pollutants, or to infectious diseases. lower breastbone is squeezed repeatedly
detailed vision and the other is directed with the heels of the hands, in order to
outwards. (See also esotropia.) expressing milk compress the heart (see cardiac mas-
A technique sometimes used by women sage). External cardiac massage may be
expectorants who are breast-feeding, for removing used in first aid, as part of cardiopul-
Cough remedies that encourage expect- milk from the breasts. The technique monary resuscitation.
oration (the coughing up of sputum). may be needed if the woman’s breasts
are overfull (see engorgement). A woman external fixation
expectoration may also want to express milk so that it The insertion of pins through the skin
The coughing up and spitting out of can be given to the baby in her absence to hold together parts of a broken bone
sputum (phlegm). (See also cough.) or so that an infant who is unable to (see fracture). The pins are held in place
feed at the breast (due to prematurity, by an external metal frame. Usually, the
expiratory reserve volume for example) can still benefit from breast affected limb can be used within a few
The extra volume of air expired in the milk. Milk can either be expressed by days; the frame and pins are removed
fullest possible exhalation; this amount hand or using a breast pump. The milk under anaesthesia when the bone has
is in addition to the volume that is nor- may also be frozen for later use. healed. (See also internal fixation.)
mally expelled when a person is at rest.
The expiratory reserve volume may be expressive dysphasia external haemorrhoids
measured in pulmonary function tests. A type of dysphasia (disturbance in the Haemorrhoids (dilated veins) that form
ability to use and/or understand words) around the outside of the anus. Haem-
expiratory stridor in which the person can understand orrhoids are commonly known as piles.
An abnormal noise that is heard when a others and knows what he or she The condition is sometimes associated
person exhales. Expiratory stridor may wishes to say, but has difficulty putting with internal haemorrhoids, those that
occur if the vocal cords are partially thoughts into words. (See also aphasia; develop higher up inside the anal canal.
obstructing the flow of air or if there is speech; speech disorders; speech therapy.) If the blood in an external haemorrhoid
an obstruction in the trachea (the wind- clots, the resulting swelling is termed a
pipe) or bronchi (see bronchus), which exsanguinate perianal haematoma. This condition is
are the main airways to the lungs. To remove, withdraw, or deprive the very painful but usually disappears
Expiratory stridor may occur either body of circulating blood. Exsanguina- within about five days. (See also haem-
alone or with inspiratory stridor. tion usually results from severe internal orrhoidectomy; internal haemorrhoids.)

288
 EXTRINSIC ALLERGIC ALVEOLITIS

extracorporeal circulation Teeth are usually extracted with dental extrapyramidal disease
Circulation of blood outside the body forceps, which are designed to grasp Any of a group of disorders that are the
through a machine that temporarily the root of the tooth. When gentle but result of damage to, or degeneration of,
assumes an organ’s functions. Examples firm pressure is applied, the blades cut parts of the extrapyramidal system (nerve
of extracorporeal circulation include through the periodontal ligaments (the pathways that link motor nerve nuclei
the use of a heart–lung machine, during tough, fibrous membranes supporting within the brain). Extrapyramidal dis-
open heart surgery, to keep blood mov- the tooth in its socket), the socket is eases disrupt the execution of voluntary
ing around the body and carry out gradually expanded, and the tooth movements; these diseases are charac-
carbon dioxide–oxygen exchange, and is removed. Occasionally the root frac- terized by uncontrollable movements,
extracorporeal dialysis. tures during this procedure and may changes in muscle tone, and postural
need to be removed separately. disturbances. Examples of extrapyram-
extracorporeal dialysis In difficult extractions, for example if idal disease include Huntington’s disease, E
Haemodialysis performed through an the tooth is impacted, if the crown is Parkinson’s disease, and some types of
artificial kidney to remove the sub- missing, or if the roots are very curved, cerebral palsy.
stances that are normally excreted in the some gum and bone may need to be
urine (see dialysis). removed from around the tooth before extrapyramidal system
the tooth is extracted and the gum is A network of nerve pathways that links
extracorporeal gas exchange sutured (stitched). the surface of the cerebrum (main mass
A technique in which blood is diverted COMPLICATIONS of the brain) with motor nerve nuclei
out of the body and through an “artifi- Most extractions take place without in the basal ganglia, and parts of the
cial lung” to aid respiration. It involves a complications. If bleeding does not brainstem. This system influences and
procedure called extracorporeal mem- stop after extraction of a tooth, sutur- modifies electrical impulses sent from
brane oxygenation (ECMO), in which ing of the tissue around the socket may the brain to initiate movement in
blood is passed over an artificial mem- be necessary. skeletal muscles.
brane and takes up oxygen, and the Occasionally, if a blood clot (see Damage or degeneration of compo-
removal of waste carbon dioxide. Extra- blood clotting) fails to form in the empty nents in the extrapyramidal system
corporeal gas exchange is used to treat tooth socket, or if the blood clot is dis- may be caused by extrapyramidal disease.
severe respiratory failure, in addition to lodged, dry socket (infection in the tooth It may also occur as a side effect of tak-
mechanical ventilation. socket) develops. ing phenothiazine drugs.
extracorpuscular extradural haemorrhage extrasystole
A term meaning “situated or occurring Bleeding into the space between the A contraction of the heart that is inde-
outside the corpuscles (minute bodies or inner surface of the skull and the exter- pendent of the heart’s normal rhythm.
cells)”. Extracorpuscular refers particu- nal surface of the dura mater (the outer Extrasystole arises in response to an
larly to the environment outside the layer of the meninges, the protective electrical impulse in a part of the heart
blood cells (for example, it may be used covering of the brain). other than the sinoatrial node (see
for agents that attack red blood cells CAUSE ectopic heartbeat).
from outside; see anaemia, haemolytic). Extradural haemorrhage most com-
monly occurs as a result of a heavy extrauterine pregnancy
extraction, dental blow to the side of the head that An alternative term for an ectopic preg-
The removal of one or more teeth by fractures the skull (see skull, fracture of) nancy.
a dentist. and ruptures an artery running over the
WHY IT IS DONE surface of the dura mater. extravasation
Dental extraction may be performed SYMPTOMS The leakage and spread of fluid, usually
when a tooth is severely decayed or too A haematoma (a collection of clotted from blood vessels or lymph vessels, into
badly broken to be repaired or when an blood) forms and enlarges, increasing the surrounding tissues. Extravasation
abscess (see abscess, dental) has formed. pressure inside the skull. Symptoms has a variety of causes, including injury,
Teeth may also be removed if there is result several hours or sometimes even burns, and inflammation.
dental crowding or malocclusion (an days after the injury. These symptoms
incorrect bite); if they are loose due may include headache, drowsiness, extravascular
to severe gum disease; or if they are vomiting, paralysis affecting one side of Situated or occurring outside the vessels.
preventing another tooth from erupting the body, and seizures. The term refers particularly to the blood
through the gum (see eruption of teeth). If left untreated, extradural haemor- vessels (see circulatory system) and lymph
HOW IT IS DONE rhage may be life-threatening. vessels (see lymphatic system). Extravascu-
For most extractions, local anaesthesia is DIAGNOSIS AND TREATMENT lar fluid is fluid that exists outside the
used (see anaesthesia, dental). A general CT scanning or MRI (techniques that pro- circulation, in the body tissues.
anaesthetic (see anaesthesia, general) may duce cross-sectional or three-dimensional
be used to extract badly impacted wis- images of body structures) are used to extrinsic allergic alveolitis
dom teeth (see impaction, dental), to confirm the diagnosis. Treatment may Inflammation and thickening of the
extract several teeth at once, or for consist of craniotomy (drilling holes in tiny air sacs in the lungs that is caused
extremely anxious or disabled patients the skull), draining the blood clot, and by an allergy to inhaled organic dusts
or young children. clipping shut the ruptured blood vessel. (see alveolitis).

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 EXTRINSIC ASTHMA

extrinsic asthma Most exudates are a result of inflamma- light-sensitive inner layer at the back of
Any form of asthma precipitated by an tion. In inflamed tissue, the small blood the eye) and nerve cells that convert this
environmental factor. Extrinsic asthma vessels widen and tiny pores in the ves- image into electrical impulses. These
is usually due to an allergy to a foreign sel walls enlarge, allowing fluid and impulses are carried by the optic nerve to
substance, such as inhaled particles, cer- cells (mainly white blood cells) to escape. the visual cortex (an area on the back
tain foods, or a particular drug. surface of the brain concerned with
exudation cyst vision) for interpretation.
extrinsic factor A cyst (a fluid-filled lump or swelling) The eyes work in conjunction with
An alternative name for vitamin B12. formed when an existing body cavity one another, under the control of the
fills with fluid due to exudation. A hydro- brain.They align themselves on a partic-
extrovert cele (fluid-filled swelling in the scrotum) ular object so that a clear image of the
E A person whose main interest is in other is an example of an exudation cyst. object is formed on each retina. If nec-
people and the outside world. Extroverts essary, the eyes may sharpen the image
are active, sociable, and have many inter- exudative retinitis by altering focus using an automatic
ests. (See also introvert; personality.) See Coat’s disease. process called accommodation, which
changes the shape of the lens.
exudation eye EYEBALL
The discharge of fluid from blood vessels The organ of sight.The eye is a complex The eyeballs lie in pads of fat within the
into surrounding tissues. Exuded fluid organ, consisting of a series of structures bony orbits (eye sockets) that provide
(exudate) contains cells and protein. that focus an image on to the retina (the protection from injury. Each eyeball is

ANATOMY OF THE EYE

The eye is a complex organ that focuses light rays to form an body alters the shape of the lens to adjust the focus.
image on the retina, the light-sensitive inner layer at the back The retina has millions of nerve cells that respond to light;
of the eyeball. The cornea and lens focus the rays. The pupil they convert the image into a pattern of nerve impulses,
controls the amount of light entering the eye and the ciliary which are transmitted to the brain via the optic nerve.

Choroid Sclera

Cornea

Retina

Iris

Optic nerve
Lens

Movement of the eye

Movement of each eyeball occurs as the
Vitreous humour result of contraction of one or more of the
muscles attached around it. There are six
of these muscles, each of which pulls the
eye in a specific direction.

Iris Pupil Ciliary body Pupil

Fat
Bony eye socket

Superior rectus Lacrimal

Lacrimal muscle ducts
ducts
Lacrimal gland
The external eye Lacrimal
Behind the sac
Iris
transparent cornea
is the fluid-filled Lateral rectus Inferior
front chamber of the muscle rectus
muscle
eye. At the back of
this is the iris, with Inferior oblique
muscle
the round pupil in
the centre. Sclera

290
 EYE, EXAMINATION OF

moved by six delicate muscles. The eye network of blood vessels, the choroid the muscles that normally move the eye
has a tough, white outer layer known as plexus, lies immediately under it. The to the remaining conjunctival mem-
the sclera. At the front of the sclera, choroid is continuous at the front with brane (see conjunctiva) or to a plastic
the cornea (a transparent, thin-walled the ciliary body and the iris; these three implant placed in the eye socket.
dome) serves as the main “lens” of the parts constitute the uveal tract. Often called “glass eyes”, artificial
eye and does most of the focusing. CONJUNCTIVA AND EYELID eyes were once made of glass; now an
Behind the cornea is a shallow cham- The eyeball is sealed off by a trans- easily mouldable plastic material is used.
ber filled with watery fluid (called the parent, flexible membrane called the
aqueous humour), at the back of which conjunctiva, which is attached to the skin eye-drops
is the iris (the coloured part of the eye) at the corners of the eye and forms the Medication in solution that is used in
with its pupil (circular opening), which inner lining of the eyelids. The conjunc- the treatment of eye disorders or to aid
appears black. Tiny muscles alter the tiva contains mucus-secreting glands. in their diagnosis. Examples of drugs E
size of the pupil in response to changes These, together with the meibomian given in this form are antibiotic drugs,
in light intensity in order to control the glands in the eyelids (which secrete an antihistamine drugs, drugs used either to
amount of light entering the eye. oily fluid), provide the tear film that dilate (widen) or constrict (narrow) the
Behind the iris, and in contact with protects the cornea and conjunctiva. pupil, the circular opening in the centre
it, is the crystalline lens, which is sus- Blinking, a protective reflex, helps to of the iris, and corticosteroid drugs.
pended by fibres from a circular ring of spread the tear film evenly over the A specified number of eye-drops are
muscle: the ciliary body. Contraction of cornea to enable clear vision. applied to the inside of the lower eyelid
the ciliary body changes the shape of after the lid has been drawn down
the lens, enabling fine focusing. eye, artificial using the tip of a clean finger. Blinking
The main cavity of the eye contains a A prosthesis used to replace an eye helps to spread the medicated solution
clear gel (the vitreous humour) and is that has been surgically removed. An evenly around the eyeball.
located directly behind the lens. On the artificial eye is worn purely for cosmetic
inside of the back of the eye is the retina, and psychological reasons and fits neat- eye, examination of
a complex structure of nerve tissue that ly behind the eyelids into the cavity An inspection of the structures of the
is extremely sensitive to light.The retina from which the natural eye was eyes, either as part of a vision test or to
requires a constant supply of oxygen removed. Some movement of the artifi- make a diagnosis when an eye disor-
and glucose. To meet this need, a thin cial eye may be achieved by attaching der is suspected.

DISORDERS OF THE EYE

Many eye disorders are minor, but some a result of injury to the eye or infection its own tissues), such as ankylosing
can cause loss of vision unless treated. elsewhere in the body. spondylitis and sarcoidosis.
(See also disorders of the cornea box;
disorders of the retina box.) Impaired blood supply Degeneration
Narrowing, blockage, or inflammation of Macular degeneration of the retina is
Congenital defects retinal blood vessels may cause visual loss. common in elderly people, as is cataract.
Squint (misalignment of the eyes) may
be congenital (present at birth). Other Tumours Focusing disorders
examples of congenital defects are Malignant melanoma of the choroid is the Myopia (shortsightedness), hypermetropia
nystagmus (uncontrollable, jerky eye most common cancerous tumour of the (longsightedness), and astigmatism are
movements), albinism (absence of eye. Retinoblastoma (a cancer of the retina) relatively common. Presbyopia is a pro-
pigment in the iris), and developmental most commonly affects children. Basal cell gressive, age-related loss of the ability
defects affecting the cornea and retina. carcinoma affects the eyelid and may result to focus at close range. Amblyopia (poor
A rare birth defect is microphthalmos from excessive exposure to sunlight. vision in one eye unrelated to structural
(abnormally small size of one or both abnormality) is often due to squint.
eyes). Cataract (opacity of the lens) can Nutritional disorders
sometimes be seen in newborn infants. Various vitamin deficiencies affect the eyes. Other disorders
Vitamin A deficiency may lead to xeroph- Glaucoma (increased pressure within the
Infection thalmia (corneal and conjunctival eyeball), can lead to permanent visual
Conjunctivitis(inflammation of the dryness), night blindness, or, eventually, loss. In retinal detachment, the retina lifts
conjunctiva) is the most common eye keratomalacia (corneal softening and away from the eye’s underlying layer.
infection. Trachoma (a persistent disease disintegration).
of the cornea or conjunctiva) or severe INVESTIGATION
bacterial conjunctivitis can impair Autoimmune disorders
vision. Corneal infections can lead to Uveitis (inflammation of the iris, choroid, An ophthalmoscope and slit-lamp are
blurred vision or corneal perforation if and/or ciliary body) may be caused by used to view the eye.Vision is evaluated
not treated early. Endophthalmitis infection or an autoimmune disorder (in using Snellen charts and refraction tests.
(infection within the eye) can occur as which the body’s immune system attacks

291
 EYE, FOREIGN BODY IN

WHY IT IS DONE Colour vision is occasionally checked eye, foreign body in

Eye examinations are used to determine because loss of colour perception is a Any material on the surface of the eye
the cause of visual disturbance or of sign of certain disorders of the retina or under the eyelid, or an object that
other symptoms relating to the eye. (the light-sensitive inner layer at the penetrates the eyeball.
They are also used to assess whether back of the eye) or of the optic nerve CAUSES
corrective devices, such as glasses or (which transmits impulses from the Particles of dust are the most common
contact lenses, are necessary. Eye tests retina to the brain). In order to check type of foreign body to enter the eye.
are essential to discover certain serious for abrasions or ulcers, the conjunctiva Occasionally, a fragment of metal, plas-
eye disorders, such as glaucoma (in (the transparent membrane covering tic, or wood may be deflected into the
which the fluid in the eye is at abnor- the white of the eye and inside of the eye. Rarely, an object travelling at high
mally high pressure), because such eyelids) and the cornea (the transparent speed may penetrate the eyeball.
E disorders may be symptomless in the dome that forms the front of the eye- SYMPTOMS AND COMPLICATIONS
early stages and only detectable during ball) may be stained with fluorescein A foreign body may cause irritation,
an eye examination. (an orange dye). redness, increased tear production, and
HOW IT IS DONE Applanation tonometry (measurement blepharospasm (uncontrollable closure
An eye examination usually begins with of the pressure within the eye) is an and squeezing of the eyelid). Some for-
a physical inspection of the eyes, the essential test for glaucoma. eign bodies left within the eyeball may
eyelids, and the surrounding skin. Eye EQUIPMENT release damaging substances into the
movements are usually checked and the The ophthalmoscope is an instrument eye, resulting in blindness. Other for-
examiner looks for squint (misalign- used to examine the inside of the eye, eign bodies may remain intact but cause
ment of the eyes). particularly the retina. infection that can lead to loss of sight.
Visual acuity (sharpness of vision) in The slit-lamp microscope, with its Sympathetic ophthalmitis is a rare condi-
each eye is investigated using a Snellen illumination and lens magnification, tion that may threaten sight even in the
chart, the standard eye test wall chart. allows for examination of the conjunc- uninjured eye.
Refraction testing (using lenses of differ- tiva, the cornea, the front chamber of TREATMENT
ent strengths) may then be performed the eye, the iris (the coloured part of the Foreign bodies on or in the conjunctiva
to determine precisely what glasses or eye) and the lens (the component that (the transparent membrane covering
contact lenses, if any, are required. is responsible for focusing). the white of the eye and lining the
An investigation of the visual fields To obtain a full view of the lens and inside of the eyelids) can usually be
(the extent of peripheral vision) may the structures behind it, the pupil (the flushed out with water. However, med-
also be carried out, especially in sus- circular opening in the centre of the ical attention is needed if the object has
pected cases of glaucoma or a variety of iris) must be widely dilated by using penetrated the eyeball. The doctor may
neurological conditions. special eye-drops. drop fluorescein (an orange dye) into
the eye to reveal the presence of any
corneal abrasions or sites of penetration.
CONDUCTING AN EYE EXAMINATION Ultrasound scanning or an X-ray of the eye
may also be performed.
In an eye examination, the ophthalmologist
checks the external appearance, eye
Anaesthetic eye-drops may be applied
movement, visual acuity, visual field, and and a spatula used to remove an object
colour vision. The eyes are checked for the from the cornea (the transparent dome
presence of a squint, abrasions, and ulcers. that forms the front of the eyeball). The
Applanation tonometry and a refraction eye may then be covered with a patch.
test may also be carried out. Antibiotic drugs may be prescribed to
fight infection.
Blood Optic
vessel disc
eye injuries
Eye injuries may be caused by a blow to
the eye or penetration of a foreign body
Applanation

Z tonometry
Measurement of the
pressure within the
eye is a test for
(see eye, foreign body in). However, the
eye often escapes serious injury because
it is protected by the surrounding bone
D A glaucoma.
and the rapid blink reflex.
A blow to the eye may cause tearing
Snellen chart of the iris (the coloured part of the eye)
F X H This chart is used or the sclera (the white of the eye), with
P T N D to check the visual collapse of the eyeball and potential
acuity of each eye;
X A Z F N the patient’s ability blindness. Minor injuries may lead to
View of retina through ophthalmoscope H T X U D F to read letters of a vitreous haemorrhage (bleeding into
The retina (the inner back surface of the eye) is U Z N D F X T
different sizes from the gel-filled cavity behind the lens);
examined to assess its health and to detect the A P H T X Z N U
the same distance hyphaema (bleeding into the front
presence of disorders such as retinopathy. is assessed.
chamber of the eye); retinal detachment;
or injury to the trabeculum (the chan-

292
 EYE TUMOURS

nel, which drains fluid from the eye), gland), blepharitis (inflammation of the (inflammation of the eyelid margins),
which can lead to glaucoma (a sudden edge of the eyelid), and a stye (a small or conjunctivitis (inflammation of the
increase in fluid pressure in the eyeball). abscess at the root of one of the lashes). conjunctiva, the transparent membrane
Injuries to the centre of the cornea Certain disorders affect the shape and that covers the whites of the eye).
(the transparent dome that forms the position of the eyelids. These include
front of the eyeball) impair vision by entropion (in which the eyelid margin eye teeth
causing scarring. Damage to the lens turns inwards), ectropion (in which the A common name for the canine teeth.
(the component of the eye responsible eyelid margin turns outwards), and pto-
for focusing) may cause a cataract (loss sis (in which the eyelid droops down, eye tumours
of transparency) to form. covering all or part of the eye). Tumours of the eye are rare. However,
Myokymia (twitching of the eyelid) is when eye tumours do occur, they are
eyelashes common, and usually caused by fatigue. usually painless and cancerous. E
Hairs that are arranged in rows at the Blepharospasm (prolonged contraction TYPES AND TREATMENT
edge of each eyelid and normally curve of the eyelid) is usually due to a condi- Retinoblastoma This is a cancerous
outwards. The purpose of the eyelashes tion such as photophobia (abnormal tumour of the retina (the light-sensitive
is to prevent dust and debris from sensitivity of the eyes to sunlight) or a inner layer at the back of the eye) that
entering the eye. The lashes become foreign body. The skin of the eyelid is a may occur in one or both eyes and most
finer and fewer as a person ages. common site for a basal cell carcinoma. often affects children. Retinoblastoma
Growth in an abnormal direction may be treated by radiotherapy, laser
may be due to injury to the eyelid or, eyelid, drooping treatment, or cryosurgery (freezing), but
more commonly, to an infection. See ptosis. the eye may have to be removed to
Severe blepharitis (inflammation of the prevent spread of the tumour.
lid margins) may destroy the roots of eyelid surgery Malignant melanoma This form of cancer
the lashes. Trachoma, an infection in See blepharoplasty. occurs in the choroid (the layer of tissue
which the lid can be distorted by scar- between the retina and the sclera, the
ring, may lead to trichiasis, in which eye, painful red white of the eye) and usually affects
the lashes turn inwards and rub against A common combination of eye symp- middle-aged or elderly people.There are
the cornea (the transparent dome that toms that may be due to any of various no symptoms in the early stages, but
forms the front of the eyeball). eye disorders. the tumour eventually causes retinal
Conjunctivitis (inflammation of the detachment and distortion of vision.
eye, lazy conjunctiva, the transparent membrane Small malignant melanomas can be
A popular term for amblyopia (in which covering the white of the eye) is the destroyed by laser treatment, but the eye
normal vision has failed to develop in most common cause of redness and irri- may need to be removed to prevent
an otherwise healthy eye). The term tation in the eye. Uveitis (inflammation spread of the tumour.
“lazy eye” also refers to a convergent of the iris, choroid, and/or ciliary body) Secondary eye tumours If cancer else-
squint (in which one eye turns inwards). is a common cause of dull, aching pain; where in the body spreads to the eye,
this may be due to swelling in the front secondary tumours develop. Symptoms
eyelid part of the eye and spasm in muscles depend on a tumour’s location and
A fold of tissue at the upper or lower around the iris (the coloured part of the growth rate. Secondary eye tumours
edge of an orbit (eye socket). The eye- eye). The redness is caused by widening may be controlled by radiotherapy;
lids are held in place by ligaments of blood vessels around the iris. however, the primary tumour will need
attached to the socket’s bony edges. Another cause of pain and redness in to be treated separately.
They consist of thin plates of fibrous one eye is acute closed-angle glaucoma Basal cell carcinoma This is the most
tissue (called tarsal plates) covered by (a sudden increase in pressure within common type of tumour of the eyelid. It
muscle and a thin layer of skin. The the eyeball). The pain is severe and may may be caused by excessive exposure to
inner layer is covered by an extension of be accompanied by nausea, vomiting, sunlight. The tumour usually has a
the conjunctiva (the transparent mem- and blurred vision. Increased blood flow crusty central crater and a hard rolled
brane that covers the white of the eye). in the surrounding blood vessels causes edge. In the early stages, a basal cell
Along the edge of each lid is a row of redness in the white of the eye. carcinoma of the eyelid may be treated
eyelashes. Immediately behind the eye- There are additional causes of painful by surgery, radiotherapy, or cryosurgery.
lashes are the openings of ducts that red eye including keratitis (inflammation If the tumour becomes large, the eyelid
lead from the meibomian glands, which of the cornea, the outer protective layer may need to be removed.
secrete the oily fluid in tears. of the eye), which usually occurs as a
The eyelids act as protective shutters, result of a corneal ulcer, and a foreign
closing almost instantly as a reflex action body in the eye (see eye, foreign body in).
if anything approaches the eye. They
also spread the tear film across the eye-strain
cornea (the transparent dome that forms A common term used to describe ach-
the front of the eyeball). ing or discomfort in or around the eye.
DISORDERS Eye-strain is usually due to a headache
Disorders affecting the eyelids include caused by fatigue, tiredness of muscles
a chalazion (a swelling of a meibomian around the eye, sinusitis, blepharitis

293
 FABRY’S DISEASE

facet joint infection. Sinusitis (inflammation of the

F
A type of joint found in the spine, air spaces in the facial bones) can cause
formed by the process (bony projec- pain around the eyes and in the cheek
tion) of one vertebra fitting into a bones. The onset of mumps can cause
hollow in the vertebra above. Facet pain in the cheeks before swelling is
joints allow a degree of movement apparent; the pain is in front of and/or
between vertebrae, which gives the below the ears. Pain from a boil in the
spine its flexibility. nose or ear may also be felt in the face.
Problems with the teeth and jaws are
facial nerve another common cause of facial pain.
The seventh cranial nerve, which arises Such problems include severe tooth
Fabry’s disease from structures in the brainstem and decay (see caries, dental), an abscess (see
A rare inherited disorder caused by a sends branches to the face, neck, sali- abscess, dental), impacted wisdom teeth
F deficiency of alpha-galactosidase A, an vary glands, and outer ear. (see impaction, dental), or partial dislo-
enzyme (a protein that acts as a catalyst) The facial nerve performs both motor cation of the jaw (see jaw, dislocated).
necessary for the metabolism of certain and sensory functions. It controls the Damage to one of the nerves that
lipids (fats) in the body. Without the neck muscles and those of facial expres- supply the face can also produce severe
enzyme, lipid molecules accumulate in sion; it stimulates the secretion of saliva; pain. Conditions resulting from nerve
the tissues, especially in the nerves, and it conveys sensory information damage include the stabbing pain that
heart, and kidneys. from the tongue and from the outer ear. precedes the rash of herpes zoster
Fabry’s disease is inherited as an Damage to the facial nerve results (shingles) and the intermittent shoot-
X-linked recessive trait (see genetic dis- in weakness of the facial muscles (see ing pain of trigeminal neuralgia, which
orders) and therefore affects males facial palsy) and, in some cases, loss of usually affects the cheek, lip, gum, or
more commonly than females. chin on one side and is often brought
SYMPTOMS on by touching the face or chewing.
Among the first symptoms to develop, LOCATION OF THE A disorder elsewhere in the body
FACIAL NERVE
often in childhood, are pain and dis- may cause referred pain in the face. For
comfort in the hands and feet as a Arising from the brainstem, the facial example, in angina pectoris (chest pain
result of damage to the peripheral nerve has branches that connect due to impaired blood supply to the
nerves. As the condition progresses, to the outer ear, tongue, salivary heart muscle), pain may also be felt in
heart and kidney function may become glands, and muscles of facial the jaw. During a migraine headache,
impaired. Female carriers usually show expression in the neck and face. pain may also occur on one side of the
only mild symptoms. face. Facial pain that occurs for no
TREATMENT AND OUTLOOK Brain apparent reason may occasionally be a
Hand and feet pain is treated with car- Facial nerve symptom of depression.
bamazepine. Sufferers usually survive TREATMENT
into adulthood but are at risk from Analgesic drugs (painkillers) can pro-
strokes, heart attacks, and kidney damage. vide temporary relief from pain, but
severe or persistent facial pain requires
face-lift Outer
ear medical attention.
A cosmetic operation to smooth out
wrinkles and lift sagging skin on the facial palsy
face to make it look younger. The effect Tongue Weakness of the facial muscles as a
is achieved by making an incision near result of damage to, or inflammation
or along the hairline on each side of Salivary
of, the facial nerve. The condition is usu-
the face, lifting the skin off the face, glands ally temporary and affects only one
and then removing the excess skin. The Muscle side of the face.
edges of skin are then stitched back CAUSES
together within the hairline. Facial palsy is most often due to Bell’s
Some bruising of the face is com- palsy, which occurs for no known rea-
mon following the procedure, and taste. Such damage is probably most son. Less commonly, the condition is
there may be some discomfort. Stitches often due to a viral infection but may associated with herpes zoster (shingles)
are removed three to five days after the also occur in stroke. affecting the ear and facial nerve. Facial
operation. In most cases, the scars, palsy may also result from surgical
which fade within about a year, are facial pain damage to this nerve, or compression
hidden by natural crease lines or by Pain in the face may be due to any one of the nerve by a tumour.
the hair. The effect of a face-lift usually of a variety of causes or may occur for SYMPTOMS
lasts about five years. no known reason. Facial palsy usually develops suddenly.
In a few cases, satisfactory healing CAUSES The eyelid and the corner of the mouth
does not occur because blood accumu- Injury to the face, such as by blows or on one side of the face droop, and there
lates under the skin or because of cuts, is a common cause of facial pain. may be pain in the ear on that side. The
infection that leads to severe scarring. Facial pain is also commonly due to ability to wrinkle the brow or to close

294
 FAECES

the eye may be lost, and smiling is dis- The sufferer may aggravate existing Treatment of faecal impaction is with
torted. Depending on which nerve physical problems or even inflict self- enemas or, in cases where these are
branches are affected, the sense of taste injury. In Ganser’s syndrome, symptoms ineffective, by manual removal of the
may be impaired or sounds may seem are psychological. Factitious disorders faecal mass.
to be unnaturally loud. differ from malingering, in which a
TREATMENT person claims to be ill for a particular faecal incontinence
In many cases, facial palsy clears up purpose (for example, in order to See incontinence, faecal.
without treatment. Pain can be relieved obtain time off work).
by taking analgesics (painkillers), and faecalith
exercising the facial muscles may aid factor V A small, hard piece of impacted faeces
recovery. It may be necessary to tape One of the blood proteins that main- that forms in a diverticulum (a sac in
the eyelid shut at bedtime in order to tains the balance between the blood the wall of the intestine). A faecalith is
avoid the risk of corneal abrasion. clotting too easily or too slowly after harmless unless it forms a blockage at
Bell’s palsy may be treated with an injury. About 5 per cent of the pop- the entrance to the sac, which causes F
corticosteroid drugs to reduce inflam- ulation have an inherited mutation in diverticulitis, or to the appendix, which
mation and speed recovery. Re-routing the gene controlling factor V produc- causes appendicitis.
or grafting of nerve tissue may help tion, known as factor V Leiden. They
people suffering from palsy caused by are at increased risk of deep-vein faecal occult blood test (FOBT)
an injury or a tumour. thrombosis (see thrombophilia), partic- A test, also known as a stool guaiac
ularly if taking the oral contraceptive test, that is used to check for the pres-
facial spasm pill or going on long aircraft journeys. ence of hidden blood in the faeces (see
An uncommon disorder in which the occult blood, faecal). FOBT is a screening
muscles that are supplied by the facial factor VIII test that may be carried out because
nerve twitch frequently. Facial spasm, One of the blood proteins involved in such bleeding may be one of the earli-
which predominantly affects middle- blood clotting. People with haemophilia est indications of colorectal cancer (see
aged women, is of unknown cause. have a reduced level of factor VIII in colon, cancer of; rectum, cancer of). One
their blood and, consequently, have a example of a commonly used brand of
facial tic tendency to abnormal bleeding and to FOBT is Hemoccult.
See facial spasm. prolonged bleeding when injured.
People with severe haemophilia re- faecal vomiting
facies quire regular treatment with concentrates The vomiting of matter that resembles
A term used to denote facial expres- of factor VIII. This treatment reduces faeces, either in appearance or odour
sion, which is often used as a guide to the bleeding tendency and allows the or both. Faecal vomiting is a symptom
a person’s health. For example, the typ- affected person a normal quality of life. of serious intestinal obstruction (see
ical facies seen in a child with enlarged intestine, disorders of).
adenoids is open-mouthed because of factor IX
difficulty breathing through the nose. A protein in blood that plays an impor- faeces
The term “facies” may also be used tant role in the clotting mechanism. Waste material from the digestive tract
to refer to a particular surface of a A deficiency of factor IX causes a that is solidified in the large intestine
body structure, part, or organ. rare genetic bleeding disorder known as and expelled through the anus. Faeces
Christmas disease. are composed of indigestible food resi-
facioscapulohumeral dystrophy due (dietary fibre), dead bacteria, dead
An autosomal dominant genetic disorder fad cells shed from the intestinal lining,
that causes muscle weakness and wasting. See food fad. intestinal secretions such as mucus,
The condition first appears in childhood bile from the liver (which is the sub-
or adolescence. The muscle wasting faecal fistula stance that gives faeces their brown
chiefly affects the face, shoulder girdle, See fistula. colour), and water.
arms, and later the pelvis and legs. Examination of the faeces plays an
faecal impaction important part in the diagnosis of dis-
factitious disorders A condition in which a large mass of orders of the digestive tract, such as
A group of disorders in which a pa- hard faeces cannot be evacuated from malabsorption. Samples of faeces may be
tient’s symptoms mimic those of a true the rectum. It is usually associated with examined physically for their colour,
illness but which have been invented long-standing constipation. Faecal im- odour, consistency, or for the presence
by, and are under the control of, the paction is most common in very of blood. A special test, known as a fae-
patient. There is no apparent cause young children and in elderly people, cal occult blood test (FOBT), is used to
other than a wish for attention; the especially those who are bedridden. detect concealed blood in the faeces
desire to assume the role of a patient The main symptoms are an intense (see occult blood, faecal). Microscopic
may be an escape from everyday life in desire to pass a bowel movement; pain examination may be carried out to
order to be cared for and protected. in the rectum, anus, and centre of the detect pus, parasites, or microorgan-
The most common disorder of this abdomen; and, in some cases, watery isms. Chemical tests may be performed
type is Munchausen’s syndrome, which is faeces that are passed around the mass to assess the excretion of fat. (See also
characterized by physical symptoms. (and may be confused with diarrhoea). faeces, abnormal.)

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 FAECES, ABNORMAL

faeces, abnormal Fahrenheit scale CAUSES

Faeces that differ from normal in their A temperature scale in which the melt- Episodes of fainting are often due to a
colour, odour, consistency, or content. ing point of ice is 32º and the boiling vasovagal attack – an episode in which
Abnormal faeces may be an indication point of water is 212º. On this scale, overstimulation of the vagus nerve
of a disorder of the digestive system or normal body temperature is 98.6ºF, (which controls vital organs such as the
a related organ, such as the liver. A which is equivalent to 37º Celsius (C). lungs and heart) causes slowing of
change in the character of faeces, how- To convert a temperature in Fahrenheit the heartbeat and a fall in blood pres-
ever, is most often the result of a to its Celsius equivalent, subtract 32 sure, thereby reducing the flow of
change in diet. and multiply by 0.56 (or 5/9). To blood to the brain. Attacks are usually
Diarrhoea (frequent passage of liquid convert a Celsius temperature to preceded by sweating, nausea, dizzi-
or very loose faeces) may simply be due Fahrenheit, multiply by 1.8 (or 9/5) ness, and weakness, and are commonly
to anxiety. However, it may be the result then add 32. (See also Celsius scale.) the result of pain, stress, shock, a stuffy
of an intestinal infection (see gastro- atmosphere, or prolonged coughing.
F enteritis), an intestinal disorder (such as Fahr’s disease Fainting may also result from postural
ulcerative colitis or Crohn’s disease), or A rare, degenerative neurological dis- hypotension (low blood pressure), which
irritable bowel syndrome. Loose stools may order that is characterized by the may occur when a person stands still
also be an indication of malabsorption appearance of abnormal calcium depos- for a long time or stands up suddenly.
(impaired absorption of nutrients by its and is associated cell loss in certain This problem is common in elderly
the small intestine). areas of the brain. Fahr’s disease may be people, in those with diabetes mellitus,
Constipation (infrequent passage of familial, in which it shows either an and in those taking antihypertensive
very hard faeces) is generally harmless. autosomal recessive or autosomal dom- drugs or vasodilator drugs.
Constipation that develops unexpec- inant pattern of inheritance (see genetic TREATMENT
tedly, however, may be caused by a disorders). In many cases, however, the In most cases, recovery from fainting
disorder of the large intestine, such as cause of the disorder is unknown. occurs when normal blood flow to the
cancer (see colon, cancer of). Symptoms of fahr’s disease include brain is restored. This restoration usu-
Pale faeces may be caused by diarrh- progressive dementia (deterioration in ally happens within minutes because
oea, a lack of bile in the intestine as a brain function) and the loss of acquired the loss of consciousness results in the
result of bile duct obstruction, or a dis- motor skills. Increased muscle stiffness person falling into a lying position,
ease that causes malabsorption (such and restricted movements may also which restores the flow of blood to the
as coeliac disease). In malabsorption, the develop. Possible complications include brain. Medical attention is required in
paleness is caused by the high fat con- athetosis, characterized by slow, invol- cases of prolonged unconsciousness or
tent of the faeces. This type of faeces untary, writhing movements, or chorea, repeated attacks of fainting.
may be oily, foul-smelling, and difficult characterized by irregular, rapid, jerky
to flush away. movements. There may also be gradual faith-healing
Dark faeces may result from taking deterioration of eyesight. The supposed ability of certain people
iron tablets. If the faeces are black, Individual symptoms of Fahr’s dis- to cure disease by a healing force inex-
however, there may be bleeding in the ease are treated where possible, but plicable to science.
upper digestive tract. there is no cure.
Faeces that contain excessive mucus falciparum malaria
are sometimes associated with constipa- failure to thrive The most severe form of malaria,
tion or with irritable bowel syndrome. Failure of expected growth in an infant which is caused by the parasitic proto-
Enteritis, dysentery, or a tumour of the or toddler, usually assessed by compar- zoan PLASMODIUM FALCIPARUM.
intestine (see intestine, tumours of) may ing the rate at which a baby gains
also lead to the passage of excess weight with measurements on a stan- fallen arches
mucus, often accompanied by blood. dardized growth chart. One of the causes of flat-feet. Fallen
Blood in the faeces differs in appear- An undiagnosed minor illness such arches can develop as a result of weak-
ance depending on the site of bleeding. as a urinary infection may be the ness of the muscles that support the
Bleeding from the stomach or duo- cause; in some cases, failure to thrive arches of the foot.
denum is usually passed in the form of suggests a more serious disorder such
black, tarry faeces (see melaena). Blood as congenital heart disease or kidney fail- fallopian tube
from the colon is red and is usually ure. Emotional or physical deprivation One of the two tubes that extend from
passed at the same time as the faeces. can result in failure to thrive, especially the uterus to each ovary. The fallopian
Bleeding from the rectum or anus, if the child is undernourished or neg- tube transports eggs and sperm and is
which may be due to tumours or to lected. A child who fails to grow at the where fertilization takes place.
haemorrhoids (piles), is usually bright appropriate rate needs to undergo tests STRUCTURE
red. Occasionally, however, it may not to determine the cause. (See also The funnel-shaped fallopian tube is
even be visible (see occult blood, faecal). growth, childhood; child development.) about 10 cm long. It opens into the
(See also rectal bleeding.) uterus at one end. The other end, which
fainting is divided into fimbriae (fingerlike pro-
faeces, blood in the Temporary loss of consciousness due jections), lies close to the ovary. The
See faeces, abnormal; occult blood, faecal; to reduced blood flow to the brain. The tube has muscular walls lined by cells
rectal bleeding. medical term is “syncope”. with cilia (hairlike projections).

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 FAMILIAL HYPERCHOLESTEROLAEMIA

fallout mammography result is one that sug-

LOCATION OF THE See radiation hazards. gests breast tissue is healthy when, in
FALLOPIAN TUBES
fact, a breast cancer is present.
falls in the elderly
Situated in the pelvis,
each tube extends The tendency to fall over increases false positive
from the upper part steadily with age. This increased proba- A test result that wrongly suggests that
of the cavity of the bility of falling is due to a gradual a certain disease or condition is pre-
uterus to an ovary. slowing down of reflex actions; an sent. For example, a false positive
elderly person who trips is frequently mammography result appears to reveal a
Ovarian ligament too slow to prevent a fall. breast cancer, but subsequent tests do
Uterus CAUSES not find any evidence of disease.
Fallopian tube Falls may simply be accidents, which
are commonly the result of obstructions false pregnancy
on the ground (such as loose floor cov- See pregnancy, false. F
erings), or they may be caused by
medical problems. Various medical con- false teeth
ditions that are common in elderly See denture.
people increase the risk of falls. Exam-
ples of such conditions are poor sight, false vocal cord
walking disorders, cardiac arrhythmia (an One of two folds of tissue in the larynx
irregular heartbeat), hypotension (low (voice-box) that are situated above the
blood pressure), and Parkinson’s disease true vocal cords but which are not
Cilia
(a movement disorder). Taking sleeping involved in the production of speech.
drugs or tranquillizer drugs may also
Fimbriae increase the risk of falls. Falls sometimes famciclovir
Ovary herald the onset of a serious illness, An antiviral drug used to treat viral
such as pneumonia. infections such as herpes zoster (shin-
Broad ligament of uterus
COMPLICATIONS gles) and genital herpes simplex . Minor
Broken bones (see fracture) are a com- side effects can include nausea, vomit-
mon complication of falls, especially in ing, and headache.
FUNCTION women. Not only do women have more
The fimbriae take up the egg after it is falls, but they are also more likely to familial
expelled from the ovary. The beating suffer fractures because the strength of A term applied to a characteristic or
cilia and muscular contractions propel their bones may be reduced through disorder that runs in families, that is, it
the egg towards the uterus. After sexual osteoporosis (loss of bone density). occurs in more members of a particu-
intercourse, sperm swim up the fallo- Falls may sometimes have serious lar family than would be expected
pian tube from the uterus. The lining of indirect consequences in elderly peo- from the occurrence in the population
the tube and its secretions sustain the ple. Anyone who falls and lies on the as a whole. An example of a familial
egg and sperm, encouraging fertiliza- floor for more than an hour, especially characteristic is male-pattern baldness
tion to take place, and nourish the egg if it is cold, may develop hypothermia (see alopecia); an example of a familial
until it reaches the uterus. (low body temperature). A fall, or the disorder is hyperlipidaemia (abnormally
DISORDERS fear of falling, can also have adverse high levels of fats in the blood).
The fallopian tube may become in- psychological effects, causing a once
flamed, usually as a result of a bacterial active person to become demoralized familial adenomatous polyposis
sexually transmitted infection (see pelvic and housebound. (FAP)
inflammatory disease); this can, in some PREVENTION See polyposis, familial adenomatous.
cases, lead to infertility. Ectopic pregnancy Falls may be prevented by taking com-
(the development of an embryo outside mon-sense measures such as ensuring familial cystinuria
the uterus) is another serious disorder that floors are free of clutter, good See cystinuria.
that most commonly occurs in a fallo- lighting is available, suitable footwear
pian tube. This arises when there is a is worn, floor coverings and wiring are familial goitre
delay in the passage of the fertilized safe, and handrails are secure. For See goitre.
egg along the tube, usually as a result elderly people who live alone, personal
of scarring or blockage. Implantation alarms are available that can be worn familial hypercholesterolaemia
occurs in the fallopian tube wall, but it round the neck at all times; in the An inherited disorder of lipoprotein
is too thin to sustain growth, and as the event of a fall the alarm button can be metabolism (see fats and oils) that is
pregnancy progresses, the tube may pressed to summon help. characterized by a high level of the fatty
rupture and cause internal bleeding.The substance cholesterol in the blood. An
pregnancy must be terminated. false negative individual suffering from familial hyper-
A test result that wrongly suggests that cholesterolaemia lacks the low density
Fallot’s tetralogy a particular disease or condition is not lipoprotein receptors in the liver that
See tetralogy of Fallot. present. For example, a false negative remove excess cholesterol from the

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 FAMILIAL MEDITERRANEAN FEVER

blood. The condition shows an auto- family planning Fantasy can give the illusion that wish-
somal dominant pattern of inheritance The deliberate limitation or spacing of es have been met. In this sense, it
(see genetic disorders). births. Strategies for family planning provides satisfaction and can be a
Raised levels of cholesterol in the include the different methods of con- means of helping people to cope when
blood lead to the early development of traception. (See also birth control.) reality becomes too unpleasant. Fan-
atherosclerosis (an accumulation of fatty tasy can also stimulate creativity.
deposits on the inner walls of the arter- family therapy Psychoanalysts believe that certain
ies), coronary artery disease, and other A form of psychotherapy, designed to fantasies are unconscious and represent
vascular diseases. Treatment, which must help someone with mental health primitive instincts; these fantasies are
continue long term, is with lipid-lower- problems, that is aimed at the whole presented to the conscious mind in the
ing drugs, including statins, along with a family rather than just the individual form of symbols.
diet that is low in cholesterol and a sufferer. The therapist arranges regular
weight-reduction regime. meetings with the family to encourage farmer’s lung
F discussion and understanding and to An occupational disease affecting the
familial Mediterranean fever find out what feelings lie behind the lungs of farm workers. Farmer’s lung is
An inherited condition that affects cer- way family members deal with each a type of allergic alveolitis, in which
tain Sephardic Jewish, Armenian, and other in everyday life. The main theory affected people develop hypersensitivity
Arab families. The cause of familial behind family therapy is that improv- (an excessive reaction of the immune
Mediterranean fever is unknown. Symp- ing the functioning of the family unit system) to certain moulds or fungi
toms usually begin between the ages of will benefit the individual’s health. that grow on hay, grain, or straw. The
five and 15 years, and include recurrent causative organisms thrive in warm,
episodes of fever, abdominal and chest famotidine damp conditions, and outbreaks are
pain, and arthritis. Red skin swellings An H2 receptor antagonist drug that pro- most common in areas of high rainfall.
sometimes occur, and affected people motes healing of peptic ulcers and SYMPTOMS
may also suffer from psychiatric prob- reduces inflammation of the oesopha- Symptoms typically develop about six
lems. Attacks usually last from 24 to 48 gus (see oesophagitis). Famotidine acts hours after exposure to dust contain-
hours but may be longer. Between by suppressing production of stomach ing fungal spores. They include
attacks there are usually no symptoms. acid. Side effects are uncommon, but shortness of breath, headache, fever,
Although there is no specific treat- may include headaches and dizziness. and muscle aches. In acute attacks, the
ment for familial Mediterranean fever, symptoms last for about a day. Repeat-
those known to suffer from the condi- Fanconi’s anaemia ed exposure to spores may lead to a
tion can reduce the incidence of A rare type of aplastic anaemia (see chronic form of the disease, causing
attacks by taking colchicine, a drug that anaemia, aplastic) in which the bone permanent scarring of lung tissues.
is usually used to treat gout. Death may marrow, which normally makes all of DIAGNOSIS AND TREATMENT
eventually occur from amyloidosis, a the types of blood cells, produces Diagnosis of farmer’s lung may involve
complication of the condition. abnormally low numbers of the cells. a chest X-ray; pulmonary function tests;
and blood tests for a specific antibody
familial screening Fanconi’s syndrome to the fungus.
Screening of a family in which one A rare kidney disorder that usually Corticosteroid drugs relieve the symp-
member is affected by an inherited occurs in childhood. In Fanconi’s syn- toms of the condition. Further expo-
disorder. Looking for evidence of in- drome, various important chemicals, sure to the spores of the fungus should
creased susceptibility to a disorder may such as amino acids, phosphate, calcium, be avoided. Complete recovery is likely
involve testing for a specific gene and potassium, are lost in the urine. The if the disease is diagnosed before per-
defect (as is the case for cystic fibrosis), results of these losses include failure to manent lung damage has occurred.
which will also help specialists deter- thrive, stunting of growth, and bone (See also fibrosing alveolitis.)
mine the chances of family members disorders such as rickets.
having an affected child. Possible causes include several rare farmer’s skin
Alternatively, tests may be carried inherited abnormalities of body chem- Premature aging of the skin caused by
out to detect a risk factor for a disor- istry and an adverse reaction to certain prolonged exposure to sunlight. Fea-
der; for example, if a person has a drugs, such as tetracycline that has tures of farmer’s skin include a lack of
heart attack at an early age, his or her passed its “use-by” date. elasticity, wrinkling, dryness, thinning
relatives may be tested for hyper- If an underlying chemical abnormal- (sometimes with thicker areas), and
lipidaemia (high levels of fats in the ity is detected and can be corrected, excessive skin pigmentation.
blood), a condition that increases the the affected child may resume normal
risk of coronary artery disease. growth. Alternatively, a kidney transplant fascia
In addition to being tested for a may be possible. Fibrous connective tissue that surrounds
particular disorder, the relatives of an many structures in the body. One layer
affected person may be offered regular fantasy of the tissue, known as the superficial
check-ups so that any abnormal signs The process of imagining events or fascia, envelops the entire body just
may be detected as early as possible objects that are not actually occurring beneath the skin. Another layer, the
and the necessary treatment started or present. The term also refers to the deep fascia, encloses muscles, forming
without any delay. mental image itself. a sheath for individual muscles and

298
 FATS AND OILS

separating them into groups; it also group of muscles causes obstruction of fat atrophy
holds in place soft organs such as the blood flow; it gives the muscles space Localized loss of fatty tissue beneath
kidneys. Thick fascia in the palm of in which to expand. The procedure is the skin. Fat atrophy can occur at injec-
the hand and sole of the foot have a also sometimes performed as a surgical tion sites in people with type 1
cushioning, protective function. emergency after an injury has resulted (insulin-dependent) diabetes mellitus. A
in muscle swelling or bleeding within particular pattern of fat atrophy also
fasciculation a muscle compartment. develops in some people being treated
Spontaneous, irregular, and usually with antiretroviral drugs for HIV infection
continual contractions of a muscle that fasting or AIDS (see lipodystrophy).
is apparently at rest. Unlike the con- Abstaining from all food and drinking
tractions of fibrillation, fasciculation is only water. In temperate conditions fatigue
visible through the skin. and at moderate levels of physical See tiredness.
Minor fasciculation, such as that activity, a person can survive on water
occurring in the eyelids, is common alone for more than two months; how- fat pad F
and is no cause for concern. However, ever, without consuming either food A localized collection of fatty tissue. Fat
persistent fasciculation with weakness or drink, death usually occurs within pads are normally found in parts of the
in the affected muscle indicates dam- about ten days. body that need cushioning and protec-
age to the nerve cells in the spine that EFFECTS ON THE BODY tion, such as behind the eyeballs,
control the muscle, or to the nerve In the absence of food, the energy that around the kidneys, behind the knees,
fibres that connect the spinal nerves to is needed in order to maintain essential under the heel bone, and in the cheeks
the muscle; motor neuron disease is one body processes is supplied by sub- (especially in infants). Abnormal fat
such disorder. stances stored in the body tissues. About pads may be noncancerous tumours
six hours after the last meal, the body (see lipoma) or may develop in certain
fasciitis starts to use glycogen (a carbohydrate disorders, such as lipodystrophy.
Inflammation of a layer of fascia stored in the liver and muscles). This
(fibrous connective tissue), causing process continues for about 24 hours, fats and oils
pain and tenderness. Fasciitis is usually after which time the body obtains en- Nutrients that provide the body with
the result of straining or injuring the ergy from stored fat and by breaking its most concentrated form of energy.
fascia surrounding a muscle; it most down protein in the muscles. If fasting Fats are the largest group of lipids, and
commonly affects the sole of the foot. continues, the body’s metabolism slows are compounds containing chains of
The condition may occur in people down in an attempt to conserve energy, carbon and hydrogen atoms with very
who suffer from ankylosing spondylitis and the fat and protein stores are con- little oxygen. Chemically, they consist
(a rheumatic disorder affecting the sumed more slowly. mostly of fatty acids combined with
spine) or those with Reiter’s syndrome In the initial stages of fasting, weight glycerol. Fats are usually solid at room
(inflammation of the urethra, conjunc- loss is rapid. It then slows down, not temperature, while oils are liquid.
tivitis, and arthritis). only due to the slowing of the TYPES
Treatment of fasciitis involves resting metabolism, but also because the body Fats and oils are divided into two main
the affected area and protecting it from begins to conserve its salt supply, groups – saturated and unsaturated –
pressure. A local injection of a cortico- resulting in the retention of water in depending on the proportion of
steroid drug may be given. If fasciitis is the tissues. This accumulated fluid hydrogen atoms they contain. If the
part of a widespread disorder of the causes oedema (swelling), which prin- fatty acids contain the maximum possi-
joints, treatment of this condition will cipally affects the legs and abdomen. ble quantity of hydrogen, the fats are
generally improve symptoms. (See also In prolonged fasting, the ability to saturated. If some sites on the carbon
necrotizing fasciitis.) digest food may be impaired because chain are unoccupied by hydrogen,
the stomach stops secreting digestive they are unsaturated. Monounsaturated
fascioliasis juices. Prolonged fasting also halts the fats are unsaturated fats with only one
A disease affecting the liver and bile production of sex hormones, causing site that could take an extra hydrogen
ducts that is caused by infestation with amenorrhoea (the absence of menstru- atom; if many sites are vacant, the fats
the liver fluke species FASCIOLA HEPATICA. ation) in women. are polyunsaturated. Animal fats, such
Fascioliasis is acquired through eating as those in meat and dairy products,
plant food (such as watercress) conta- fat are largely saturated; vegetable fats tend
minated with the larvae of the fluke. A substance that is composed of one or to be unsaturated.
Treatment is with anthelmintic drugs. more fatty acids. Fat is the main form in FAT AND HEALTH
which energy is stored by the body. A The amount and types of fat in the diet
fasciotomy layer of fat, known as adipose tissue, have important implications for health.
An operation to relieve pressure on lies directly beneath the skin and sur- A diet containing a large amount of fat,
muscles by making an incision in the rounds various internal organs. Excess particularly saturated fat, is linked to
fascia (fibrous connective tissue) that amounts of fat are deposited under the obesity and an increased risk of athero-
surrounds them. skin in obesity. (See also fats and oils.) sclerosis (deposition of fat on the walls
Fasciotomy is usually performed to of arteries) and of subsequent coronary
treat compartment syndrome, a painful fatal artery disease and stroke. Other serious
condition in which constriction of a Causing, or ending in, death. disorders related to the consumption

299
 FATTY ACIDS

of excess fat include cancers of the ing, only linoleic acid is truly essential, If, for example, levels of a hormone are
breast, colon, and prostate and type 2 because the body can make the other too high, output of any substance that
diabetes mellitus. two from linoleic acid obtained from stimulates the hormone’s release is
USES IN THE BODY food. (See also nutrition.) inhibited; the result is reduced hor-
Some dietary fats, mainly triglycerides mone production (negative feedback).
(combinations of glycerol and three fatty degeneration The reverse process (positive feedback)
fatty acids), are sources of the fat-solu- A general term describing the accumu- restores the balance if the levels of a
ble vitamins A, D, E, and K and also of lation of fat within the cells of tissues hormone become too low. (See also
essential fatty acids. damaged by disease. endocrine system.)
Triglycerides are the main form of
fat stored in the body. These stores act fatty diarrhoea feeding, artificial
as an energy reserve; they also provide See steatorrhoea. The administration of nutrients other
insulation and a protective layer for than by mouth, usually by way of a
F delicate organs such as the heart and fatty liver tube passed through the nose into the
kidneys. Phospholipids are structural A condition in which fat accumulates stomach or small intestine. If long-
fats found in cell membranes. Sterols, within the liver cells.The most common term artificial feeding is anticipated, a
such as cholesterol, are found in animal cause of fatty liver is excessive consump- tube is inserted directly into the stom-
and plant tissues; they have a variety of tion of alcohol which, if continued, ach or upper small intestine during
functions, and are essential for making eventually leads to cirrhosis. However, if endoscopic surgery (see gastroscopy).
hormones or vitamins. Phospholipids the drinking of alcohol stops, the fat This is called enteral feeding. If the gas-
and sterols are made in the body from clears from the liver. Fatty liver can also trointestinal tract is not functioning,
nutrients provided in the diet. occur in association with obesity, dia- nutrients must be introduced directly
FAT METABOLISM betes mellitus, starvation, and in some into the bloodstream (see infusion,
Dietary fats are first emulsified (re- cases of chronic ill-health. intravenous). This type of feeding is
duced to microscopic particles) by bile known as parenteral nutrition.
salts before being broken down by favism TUBE FEEDING
lipase, a pancreatic enzyme. They are A disorder that is characterized by an Tube feeding may be necessary for
absorbed via the lymphatic system be- extreme sensitivity to the broad bean people who have difficulty swallow-
fore entering the bloodstream. VICIA FABA (fava bean). If an affected per- ing, or gastrointestinal disorders (for
To be carried in the blood, the lipids son eats these beans, a chemical in the example, conditions resulting in malab-
become bound to proteins; in this bean causes rapid destruction of red sorption), or disorders affecting the
state, they are known as lipoproteins. blood cells, leading to a severe type of nervous system or kidneys. Premature
There are four classes of lipoprotein: anaemia (see anaemia, haemolytic). babies often require tube feeding if
chylomicrons; high-density lipopro- Favism is uncommon except in some their suckling reflexes are undeveloped,
teins (HDLs); low-density lipoproteins areas of the Mediterranean. It is a sex- as do critically ill patients due to their
(LDLs); and very low-density lipopro- linked genetic disorder. Affected people increased nutritional requirements.
teins (VLDLs). LDLs and VLDLs contain have G6PD deficiency, a defect in a cer- Food mixtures, or preparations of
large amounts of cholesterol, which tain chemical pathway in their red nutrients, are given through a tube that
they carry through the bloodstream blood cells that normally helps protect is passed through the patient’s nostril
and deposit in tissues; they are some- the cells from injury. and down to the stomach or duode-
times referred to as bad fats. HDLs, Children with a family history of num.There are two methods of feeding:
known as good fats, pick up choles- favism can be screened for the disorder continuous drip feeding, and bolus
terol and carry it back to the liver for at an early age. If the condition is feeding (in which set amounts of nutri-
processing and excretion. High levels found, they must avoid fava beans as ents are given at regular intervals
of LDLs are associated with athero- well as certain drugs, including some throughout the day). In both methods,
sclerosis, whereas HDLs have a antimalarial drugs and antibiotic drugs, the rate of delivery of the food can be
protective effect. (See also nutrition.) that can have a similar effect on their controlled by a pump.
red blood cells. INTRAVENOUS FEEDING
fatty acids Intravenous feeding is usually given
Organic acids, containing carbon, oxy- febrile when large areas of the small intestine
gen, and hydrogen, that are con- Feverish or related to fever. Febrile con- have been damaged by disease or have
stituents of fats and oils. There are more vulsions, for example, occur mainly in been surgically removed. Nutrient prep-
than 40 fatty acids found in nature; young children with high tempera- arations are given and are inserted into
they are distinguished from one anoth- tures (see convulsion, febrile). a large central vein near the heart, via a
er by their constituent numbers of catheter (a thin, flexible tube) that is
carbon and hydrogen atoms. febrile convulsion buried under the skin.
Certain fatty acids cannot be syn- See convulsion, febrile.
thesized by the body and must be feeding, infant
provided by the diet. These substances, feedback A person grows more rapidly in his or
sometimes collectively termed essen- A self-regulating mechanism that con- her first year than at any other time in
tial fatty acids, are linoleic, linolenic, trols certain body processes, such as life. A good diet is essential for healthy
and arachidonic acids. Strictly speak- hormone and enzyme production. growth and development.

300
 FELTY’S SYNDROME

BREAST- OR BOTTLE-FEEDING contains antibodies and white blood cells INTRODUCING SOLIDS
During the first four to six months, that protect the baby against infection. Solids, initially as fruit or vegetable
most of the nutritional requirements of From six months of age, supplementary purees and wheat-free cereals, should
babies are satisfied by milk alone, vitamins A, C, and D should be given to be introduced between four and six
whether by breast-feeding or by bottle- breast-fed babies. (Formula milk already months of age, depending on the
feeding. Both human milk and artificial contains vitamin supplements.) baby’s birth weight, rate of growth, and
milk contain carbohydrate, protein, fat, Cows’ milk should not be given in contentment with feeding. From six
vitamins, and minerals in similar pro- the first year of life. From one year, it months, the baby should be eating true
portions; however, human milk also is safe to feed with full-fat cows’ milk. solids, such as chopped-up meat and
vegetables, and at this stage can start
eating well-cooked eggs. A baby under
FEEDING AN INFANT: INTRODUCING SOLIDS one year should not be given honey or
products containing nuts. Salt and sugar
The age at which an infant should be weaned on to solids depends entirely on the
individual. There is no real need to feed solid foods to an infant below the age of
used in home-prepared meals should be F
kept to a minimum to prevent kidney
six months unless he or she is consistently hungry. The following is a flexible guide: problems and dental decay, respectively.
FEEDING PROBLEMS
Age Time Food A few babies have an intolerance to cer-
tain foods, such as lactose or cows’ milk
4 At second breast- Breast milk/formula. Offer one or two teaspoons of protein (see food intolerance; nutritional
months or bottle-feed pureed fruit or vegetables or rice cereal. disorders). Reactions can include vom-
iting, diarrhoea, or rashes. Difficulties
4 1/2 At second breast- Breast milk/formula. Offer two teaspoons of rice cereal. associated with milk usually appear
months or bottle-feed within the first month; solids should be
At third breast - Breast milk/formula. At third breast - or bottle-feed offer two introduced one by one so that any foods
or bottle-feed teaspoons of vegetable or fruit puree. that cause problems can be identified.
Prolonged crying after feeds may
5 to 6 Early morning Breast- or bottle-feed. mean that the baby needs help bring-
months ing up wind, that artificial milk is not
Breakfast Two teaspoons of rice cereal, followed by breast- or bottle-feed.
Lunch One teaspoon of meat puree with three teaspoons of being digested properly, or that the
vegetables. Offer water instead of milk. baby has colic (see colic, infantile).
Mid-afternoon Mashed banana or other soft fruit, followed by usual milk feed.
felbinac
Dinner Breast- or bottle-feed if the baby is still hungry.
A nonsteroidal anti-inflammatory drug
(NSAID) that is used for the relief of
6 to 7 Early morning Breast- or bottle-feed. pain and inflammation in injuries such
months
Breakfast Two teaspoons of cereal with well-cooked scrambled egg. as sprains or bruising. Felbinac is ap-
Offer breast- or bottle-milk from a cup. plied topically as a gel or aerosol foam.
Lunch Offer minced or mashed food instead of pureed. Give meat Rarely, it may cause localized skin irrita-
or fish with some vegetables, then offer yoghurt and fruit. tion. As some of the drug is absorbed in
Give a drink of water or well-diluted fruit juice. the bloodstream, felbinac should not be
Late afternoon/dinner Meat or cheese sandwich. Milk from a cup. taken by anyone with an adverse reac-
tion to oral (taken by mouth) NSAIDs,
7 to 8 Early morning Offer a drink of water or well-diluted fruit juice instead of milk. such as worsening of asthma.
months
Cereal and hard-boiled egg with wholemeal bread and butter.
Breakfast
A drink of milk. Felty’s syndrome
Lunch Cheese, fish, or minced meat with some vegetables. Pudding A disorder that is characterized by an
or fresh fruit. A drink of water or well-diluted fruit juice. enlarged spleen and an abnormally low
Late afternoon/dinner Meat or cheese sandwich. A drink of milk. white blood cell count. Felty’s syndrome
occurs in some people with rheumatoid
arthritis, but the exact cause is unknown.
9 to 12 Early morning A drink of water or well-diluted fruit juice.
months Symptoms of Felty’s syndrome may
Breakfast Cereal, then well-cooked egg or fish with wholemeal toast include general malaise, fatigue, loss
and butter. A drink of milk.
of appetite, weight loss, anaemia, joint
Lunch Chopped meat, fish, or cheese, with vegetables. Pudding or swelling and stiffness, and recurrent
fresh fruit. A drink of water or well-diluted fruit juice.
infections. Possible signs of the condi-
Late afternoon/dinner Meat or cheese sandwich. A drink of milk. tion include an enlarged spleen and, in
some cases, swollen lymph nodes.
WARNING Avoid eggs, fish, and citrus fruit (including juice) before six months. Nuts should not be given to Treatment is the same as for rheu-
babies under six months, and whole nuts should not be given under five years. Avoid gluten before six months.
Parents should be especially careful about feeding their children foods containing gluten or peanuts because matoid arthritis. Splenectomy (surgical
serious allergies to these products are common. removal of the spleen) may be needed
in some cases.

301
 FEMALE

female femoral hernia with the tibia (shin) to form the knee
An individual with two X sex chromo- A type of hernia that occurs in the joint. The upper end is rounded into a
somes. Females are also characterized groin area, at the point where the ball (the head of the femur) that fits
by the presence of a vagina and vulva femoral artery and femoral vein pass exactly into a socket in the pelvis to
(see sexual characteristics, primary). from the lower abdomen to the thigh. form the hip joint.
Women who are overweight or who The head of the femur is joined to
female catheter have had several pregnancies are at risk the bone shaft by a narrow piece of
A short catheter (flexible tube) that can of femoral hernia because their bone called the neck of the femur,
be inserted into a woman’s bladder abdominal muscles are weakened. which is a common fracture site (see
through the urethra for the purpose of femur, fracture of). At the lower end, the
withdrawing urine. femoral nerve bone is enlarged to form two lumps
One of the main nerves of the leg. The (the condyles) that distribute the
feminization nerve fibres that form the femoral weight-bearing load through the knee
F The development of female secondary nerve emerge from the lower spine joint. On the outer side of the upper
sexual characteristics in a male (such and run down into the thigh, where femur is a protuberance called the
as breast enlargement and fat deposits they branch to supply the skin and greater trochanter.
beneath the skin and loss of facial front muscles of the thigh. The nerve The shaft of the femur is surrounded
hair). The condition is due either to a branches supplying the skin convey by muscles that move the hip and knee
hormonal disorder or to hormone ther- sensation; the branches supplying the joints. The shaft is also well supplied
apy. (See also demasculinization; intersex; muscles stimulate contraction of the with blood vessels; therefore, a fracture
masculinization; sex determination; sexual quadriceps muscle, thereby straighten- can result in considerable blood loss.
characteristics, secondary; testicular femi- ing the knee.
nization syndrome.) Damage to the femoral nerve (which femur, fracture of
impairs the ability to straighten the A break in the femur (the thigh bone).
femoral artery knee) is usually the result of a slipped The symptoms, treatment, and possible
A major blood vessel that supplies oxy- disc in the lumbar region of the spine complications of a fracture depend on
genated blood to the leg. The femoral (see disc prolapse). Damage may also whether the bone has broken across its
artery is formed in the pelvis from the result from a dislocation of the hip or neck (the short section between the
iliac artery, which is the terminal from a neuropathy. top of the shaft and the hip joint) or
branch of the aorta. It then runs from across the shaft.
the groin down the front of the thigh, femur FRACTURE OF NECK OF FEMUR
and passes behind the knee to become The medical name for the thigh bone, This type of fracture, which is often
the popliteal artery, which branches which is the longest bone in the body. called a broken hip, is very common in
again to supply the lower leg. The lower end of the femur hinges elderly people, especially in women
with the bone disorder osteoporosis
femoral epiphysis, slipped (loss of bone density). It is usually
Displacement of the upper epiphysis LOCATION OF THE FEMUR associated with a fall. In a fracture of
(growing end) of the femur (thigh the neck of the femur, the broken bone
The femur extends from
bone). Such displacement is rare; it the hip joint, down the ends are often considerably displaced;
usually affects children between the thigh, to the knee joint. in such cases there is usually severe
ages of 11 and 13, and occurs more pain in the hip and groin, making
often in boys and obese children. There standing impossible. Occasionally, the
is a tendency for the condition to run broken bone ends become impacted
in families. (pushed together). In this case, there is
During normal growth, the epiph- less pain, and walking may be possible.
ysis is separated from the shaft of the Pelvis The diagnosis is confirmed by X-ray.
bone by a plate of cartilage. This area is Greater trochanter If the ends of the bone are displaced,
relatively weak, so a fall or any other an operation is necessary, either to
Neck of femur
type of injury can cause the epiphysis realign the bone ends and fasten them
to slip out of position. If this happens, together, or to replace the entire head
a limp develops, and pain is felt in the Shaft of femur and neck of the femur with an artificial
knee or groin. The leg tends to turn substitute (see hip replacement). If the
outwards, and movements of the hip bone ends are impacted, the fracture
are restricted. Condyles may heal naturally, but surgery may
Surgery is needed to fix the epiphysis still be recommended.
into its correct position; the procedure A possible complication is damage
is usually completely successful. In to the blood supply to the head of the
some cases, however, the other hip may Fibula femur, resulting in the disintegration
also need to be stabilized. However, fol- of the bone in that area (see avascular
lowing the injury and repair, the hip Tibia necrosis). Osteoarthritis may develop in
tends to be more susceptible than nor- the hip joint after fracture of the femur
mal to osteoarthritis. neck. In elderly people, immobility

302
 FERTILITY DRUGS

and surgery may result in complica- fentanyl passage down a fallopian tube towards
tions, such as pneumonia, that are not An opioid analgesic drug that is given the uterus; on thinning of the mucus
directly related to the fracture site. by injection to provide pain relief dur- surrounding the mouth of the cervix, to
FRACTURE OF SHAFT OF FEMUR ing surgery and to enhance general enable sperm to penetrate; and on
Fracture of the bone shaft usually anaesthesia (see anaesthesia, general). changes in the lining of the uterus that
occurs when the femur is subjected to Fentanyl is also used in the form of a prepare it for the implantation of a
extreme force, such as that occurring skin patch to control the severe chron- fertilized ovum.
in a traffic accident. In most cases, the ic pain of conditions such as cancer. These processes, in turn, depend on
bone ends are considerably displaced, In common with other opioid drugs, normal production of gonadotrophins
causing severe pain, tenderness, and fentanyl has side effects that include by the pituitary gland, and of the sex
swelling. With a fractured femoral shaft depressed breathing, constipation, nau- hormones oestrogen and progesterone
there is often substantial blood loss sea, and vomiting. The use of patches by the ovaries.
from the bone. containing fentanyl may be associated Women become fertile at puberty
The diagnosis is confirmed by X-ray. with local irritation of the skin. and remain so (although to a lessening F
The fracture is usually repaired by degree as they become older) until the
surgery in which the fractured ends of ferritin menopause, which usually occurs bet-
the bone are realigned and fastened A complex of iron and protein, found ween 45 and 55 years of age. (See also
together with a metal pin. Sometimes, mainly in the liver and spleen. Ferritin fertility drugs; infertility.)
however, the bone ends can be re- is the principal form in which iron is
aligned by manipulation and surgery is stored in the body. fertility drugs
unnecessary. After realignment, the leg COMMON DRUGS
is supported with a splint and put in ferrous fumarate •Bromocriptine •Cabergoline •Clomifene
traction to hold the bone while it heals. A form of iron given in an oral prepa- •Follicle-stimulating hormone •Gonadorelin
Complications include failure of the ration to treat iron-deficiency anaemia. analogues •Human chorionic gonadotrophin
bone ends to unite or fusion of the Ferrous fumarate can cause diarrhoea, •Luteinizing hormone •Tamoxifen
broken ends at the wrong angle; infec- constipation, and abdominal pain.
tion of the bone; or damage to a nerve A group of hormonal or hormone-
or artery. A fracture of the lower shaft ferrous sulphate related drugs that are used to treat some
can cause permanent knee stiffness. Another name for iron sulphate. types of infertility.
In women, fertility drugs may be
fenbufen fertile period given when the abnormal production
A nonsteroidal anti-inflammatory drug The period during a woman’s menstru- of hormones by the pituitary gland or
(NSAID) that is used to relieve pain al cyclewhen conception is most likely ovaries (see ovary) disrupts ovulation
and stiffness caused, for example, by to occur. The fertile period is usually (the release of an ovum, or egg, from
rheumatoid arthritis, osteoarthritis, and between three and five days in dura- an ovary) or causes mucus around the
gout. Fenbufen is also used to reduce tion, beginning just before ovulation. cervix to become so thick that sperm
pain and to help speed recovery fol- Ovulation occurs about 14 days before cannot penetrate it. Treatment with the
lowing muscle and ligament sprains. a new menstrual cycle begins. drug clomifene, which may continue
In common with many NSAIDs, fen- over a number of months, can help to
bufen can cause irritation of the fertility bring about ovulation in women whose
stomach lining (see gastritis) and may The ability to produce children with- pituitary glands do not produce suffi-
also cause a rash. out undue difficulty. Fertility depends cient hormones for ovulation to occur
on both male and female partners. naturally. If this treatment fails to pro-
fenestration MALE FERTILITY duce ovulation, treatment with follicle-
A surgical procedure in which an arti- A man’s fertility depends on the pro- stimulating hormone (FSH), followed
ficial opening, or window, is created in duction of normal quantities of healthy by an injection of human chorionic
a sheath or a membrane. For example, sperm in the testes (see testis). This abil- gonadotrophin (HCG), may be given
fenestration may involve removal of ity depends on adequate production of in order to stimulate ripening of the
part of the wall of a cyst to prevent gonadotrophin hormones by the pituitary ovum and ovulation. (See also gonado-
fluid reaccumulating. gland, situated at the base of the brain. trophin hormones.)
Fertility in males is also dependent on Treatment with fertility drugs must
fenoprofen the ability to achieve an erection and to be monitored carefully in order to avoid
A nonsteroidal anti-inflammatory drug ejaculate semen into the vagina during overstimulation of the ovaries. Symp-
(NSAID) that is used to relieve pain sexual intercourse. toms of overstimulation may include
and stiffness caused, for example, by Males become fertile at puberty and nausea, vomiting, abdominal swelling,
rheumatoid arthritis, osteoarthritis, and usually remain so, although to a less- and the development of massive ovarian
gout. Fenoprofen is also used to treat ening degree, well into old age. cysts. The condition is potentially life-
muscle and ligament sprains; it reduces FEMALE FERTILITY threatening.
pain and helps to speed recovery. A woman’s ability to conceive depends Fertility drugs are generally less effec-
In common with many NSAIDs, on normal ovulation (the monthly pro- tive in men but may be used when
fenoprofen may cause irritation of the duction of a healthy ovum, or egg, by abnormal hormone production by the
stomach lining (see gastritis). an ovary) and the ovum’s unimpeded pituitary gland or testes interferes with

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 FERTILITY DRUGS

THE PROCESS OF FERTILIZATION

Fertilization occurs when the head of

a sperm penetrates a mature ovum. FERTILE PERIOD
After penetration, the nuclei (which
contain the genetic material) of the Ovulation occurs halfway through the menstrual cycle (13 to 16 days before the
sperm and ovum fuse and the body start of a period), after which the released ovum is available for fertilization for
and tail of the sperm drop off. The about two days. Sperm can also live for about two days, so the peak fertile period
newly fertilized ovum, called a zygote, is about four days (two pre- and two post-ovulation).
then forms an outer layer that is
impenetrable to other sperm. The Menstruation Peak fertile period
zygote undergoes repeated cell
divisions as it passes down the 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

F fallopian tube. By the time it reaches

the uterus, it has grown into a solid
Possible fertile period

ball of cells called a morula. It then

develops an inner cavity with a small Unfertilized ovum dies and is
cluster of cells to one side; this is Follicle matures in ovary Ovulation shed during menstruation
called a blastocyst.
Peak and possible fertile periods
Although the peak fertile period is about four days, sperm can survive and the timing of ovulation.
the possible fertile period may last seven to 12 The illustration shows the peak and maximum
days, due to variations in how long the ovum and possible fertile periods in a 28-day cycle.

Morula Blastocyst
The fertilized ovum (zygote) The morula develops a
divides repeatedly to form a cavity, thereby becoming
Fallopian tube ball of cells (morula). a blastocyst.

Fimbriae

Ovary

Sperm and ovum

A single sperm penetrates the ovum, thereby
Ovum
fertilizing it. To achieve this, the sperm releases A mature ovum is
enzymes that dissolve a path through the released from the follicle Ovarian
ovum’s outer layers. into the fallopian tube. follicle

JOURNEY OF THE SPERM Uterus

When semen is ejaculated into Fallopian tube Sperm

the vagina, as many as 500 million
sperm are released, most of which
are capable of fertilizing an ovum.
But, as they travel upwards
(propelled by their whiplike tails), Ovum Ovary
more than half are killed by acidic
vaginal secretions; many more die Uterus
during the journey up through the Blastocyst
Cervix
cervix and uterus and into the
Uterine
fallopian tubes. The journey can take Vagina
wall
Penis
from less than half-an-hour to five
hours and, in the end, only a few
thousand sperm have survived. Lifespan of sperm Blastocyst
A sperm can live in a fallopian tube for up to The blastocyst embeds in the
48 hours, during which time it is capable of uterine wall (implantation),
fertilizing an ovum. where it develops into an embryo
and also forms the placenta.

304
 FETAL HEART MONITORING

the production of sperm. Low sperm Before birth for reoxygenation and elimination of
production may be treated with gon- To upper body carbon dioxide and other wastes. In
adotrophins (FSH or HCG). (See also Foramen
Ductus rare cases, the foramen ovale or ductus
testosterone.) arteriosus arteriosus fails to close after birth,
ovale
Right causing a congenital heart disorder
fertilization atrium
Left
atrium (see heart disease, congenital).
The union of a sperm and an ovum (egg
cell). In natural fertilization (see the Right
Left
ventricle fetal death
ventricle
illustrated box), the sperm and ovum See stillbirth.
unite in the woman’s fallopian tube From To lower
following sexual intercourse. placenta body/ fetal distress
placenta
Fertilization may also occur as a The physical stress experienced by a
result of semen being artificially intro- After birth fetus during labour as a result of not
duced into the cervix (see artificial To upper body receiving enough oxygen. During each F
insemination) or it may take place in a contraction, the uterus tightens and
Ductus
laboratory (see in vitro fertilization). arteriosus
thus reduces the oxygen supply from
To lungs
closed the placenta to the fetus. If there are
festinating gait Foramen also problems, such as pressure on
ovale
An involuntary style of walking in which closed From the umbilical cord or the mother losing
a person moves, often on tiptoe, with lungs blood, there may be an inadequate
progressively shortening and accelerat- amount of oxygen reaching the fetus.
ing steps. A festinating gait is a feature From lower MONITORING
of an individual suffering from the body
To lower Various monitoring techniques may be
movement disorder parkinsonism. body used during childbirth to detect signs
Fetal heart circulation of fetal distress. A cardiotocograph (see
fetal alcohol syndrome In the fetus, blood passes directly from the right fetal heart monitoring) will record
A rare combination of birth defects atrium of the heart to the left atrium through the whether the baby’s heart rate is slow or
foramen ovale. Another channel, the ductus
that occur as a result of continued, arteriosus, allows blood to pass from the
if it is failing to show normal variabili-
excessive alcohol consumption by the pulmonary artery to the aorta. After birth, both ty. Acidosis (high acidity in the body),
baby’s mother during pregnancy. channels close redirecting blood through the lungs. which indicates that the oxygen supply
The affected baby has diminished to the fetus is inadequate, can be de-
growth, a small head and brain, and Oxygenated and nutrient-rich blood tected in a sample of blood taken from
small eyes. He or she may also have a flows from the mother to the fetus the baby’s scalp. Signs of meconium
cleft palate, a small jaw, heart defects, along a vein in the umbilical cord (fetal faeces) in the amniotic fluid can
and joint abnormalities. As a newborn, before entering the right atrium (upper also be an indication of fetal distress.
the baby sucks poorly, sleeps badly, and chamber) of the heart. Then, instead of DELIVERY
is irritable due to alcohol withdrawal. flowing to the lungs, it bypasses them Fetal distress sometimes occurs as a
Some affected babies die during the by flowing into the left atrium via an temporary episode, but, if acidosis is
first few weeks of life. Those who sur- opening known as the foramen ovale. severe, the distressed fetus may need to
vive may experience delayed mental From there, the blood passes to the left be delivered promptly by caesarean sec-
development and are, to some degree, ventricle (lower chamber), where it is tion, forceps delivery, or vacuum extraction.
mentally and physically handicapped. pumped to the upper parts of the body (See also childbirth.)
to provide the tissues with oxygen.
fetal circulation Blood returning to the heart flows fetal heart monitoring
Blood circulation in the fetus is differ- into the right atrium and from there The use of an instrument to record
ent from the normal circulation after into the right ventricle. In the fetus, the and/or listen to an unborn baby’s
birth (see circulatory system). The fetus blood is only partly deoxygenated at heartbeat during pregnancy and labour.
neither breathes nor eats, so oxygen this stage and has more tissues to sup- WHY IT IS DONE
and nutrients are obtained, via the ply with oxygen. Bypassing the lungs The fetal heart is checked routinely dur-
placenta and umbilical cord, from the again, it flows from the pulmonary ing pregnancy with a fetal stethoscope or
mother’s blood. The other fundamental artery into the aorta, through a channel Doppler ultrasound scanning. Additional
difference in circulation is that blood called the ductus arteriosus. The aorta monitoring is carried out if tests indi-
bypasses the lungs in the fetus. carries the blood to the lower parts of cate that the placenta is not functioning
Oxygen and nutrients enter the fetal the body. From there, completely de- normally or if the baby’s growth is slow.
blood through the placenta, an organ oxygenated blood is carried via the Uterine contractions or other stimuli,
embedded in the inner lining and wall umbilical cord to the placenta, where such as reflex kicking, increase the heart
of the uterus and connected to the carbon dioxide and other waste diffus- rate in a healthy fetus; the midwife or
fetus by the umbilical cord. The mater- es into the mother’s blood. obstetrician can detect this using a fetal
nal and fetal circulations are separated After birth, the foramen and the heart monitor. During labour, monitor-
by a thin membrane in the placenta, ductus arteriosus normally close. Blood ing can detect fetal distress, in which
which allows the exchange of nutri- pumped from the right ventricle passes oxygen deprivation causes abnormali-
ents and waste products. via the pulmonary artery to the lungs ties in the fetal heart rate.

305
 FETAL MOVEMENT

HOW IT IS DONE fetal movement ing; they may include shoes, rubber or
The most simple form of fetal heart Movements made by a developing leather garments, and parts of the body
monitoring involves using a special fetus in the uterus, which can usually such as the feet or ears.
fetal stethoscope. Cardiotocography, a be detected by the mother from bet- Fetishism usually has no obvious
more sophisticated electronic version, ween about the 16th and 20th weeks cause. According to psychoanalysts, the
is a procedure that produces a continu- of pregnancy. Fetal movement at this origin may be a childhood fixation of
ous paper recording of the heartbeat stage may feel like a gentle “flutter” to sexual interest upon some aspect of the
and a recording of the uterine contrac- the mother; later in pregnancy the mother’s appearance. Treatment is neces-
tions. The heartbeat is picked up either fetus becomes more robust in its sary only if the behaviour leads to distress
externally by an ultrasound transducer movements and may kick as it moves or is causing persistent criminal acts.
strapped to the mother’s abdomen or, around in the amniotic sac. Some
as an alternative during labour, inter- fetuses are more active than others. In fetoscopy
nally by an electrode attached to the late pregnancy, to monitor fetal well- A procedure for directly observing a
F baby’s scalp that passes through the being, the number of movements may fetus inside the uterus using a feto-
vagina and cervix. The mother’s uterine be recorded on a “kick chart”. scope, which is a type of endoscope (a
contractions are measured and recorded tubelike viewing instrument). Feto-
by an external pressure gauge strapped fetishism scopy allows a close-up look at the fetus,
to the mother’s abdomen, or by an Reliance on special objects in order to particularly the face, limbs, genitals, and
internal plastic tube inserted through achieve sexual arousal. The objects spine, and is used to diagnose various
the vagina into the amniotic fluid. need not have an obvious sexual mean- congenital abnormalities before birth.

DEVELOPMENT OF THE FETUS

By the 32nd week of pregnancy, the internal

organs of the fetus are almost fully mature and Uterine wall
it is perfectly formed. In most cases, the fetus Placenta Intestine
has turned to lie head-down in the pelvis.
Fetus

Cervix
Umbilical cord

Amniotic sac

Bladder

Fetus in sac Vagina

This MRI scan shows the developing fetus head-down in
the mother’s uterus during the 36th week of pregnancy.
Internal organs (such as the brain) are fully formed.

GROWTH OF THE FETUS FROM 8 TO 40 WEEKS

Between the eighth week and term (the 40th

week), the length of the fetus (from crown to rump)
increases by 20 times and its weight increases by
about 1,700 times.

Week 8 12 16 20 24 28 32 36 40

Length 2.5 cm 7.5 cm 16 cm 25 cm 33 cm 37 cm 40.5 cm 46 cm 51 cm

Weight 2g 18 g 135 g 340 g 570 g 900 g 1.6 kg 2.5 kg 3.4 kg

306
 FIBRILLATION

The technique carries some risks, so it TREATMENT cancers. Unrefined carbohydrate foods,
is performed only when other tests, Drugs such as aspirin, other nonsteroidal including wholemeal bread, cereals,
such as ultrasound scanning, detect an anti-inflammatory drugs, or paracetamol and root vegetables, are very rich in
abnormality. By attaching additional may be given to reduce fevers that are dietary fibre. (See also nutrition.)
instruments, doctors can use the feto- due to infections. Otherwise, treatment
scope to take samples of fetal blood or is directed at the underlying cause; for fibre-optics
tissue for analysis and to perform sur- example, antibiotic drugs are given to The transmission of images through
gical procedures, such as insertion of a treat a bacterial infection. bundles of thin, flexible glass or
catheter into the fetal bladder. (See also plastic threads. Light from a powerful
amniocentesis; chorionic villus sampling.) feverfew external source is conducted along
The common name for the plant TAN- the length of the fibre, without losing
fetus ACETUM PARTHENIUM , which is used in its intensity, by a process known as
The unborn child from the end of the herbal medicine for the treatment of total internal reflection. Fibre-optics
eighth week after conception until headache and migraine. have led to the development of endo- F
birth. For the first eight weeks, the scopes, instruments that enable
unborn child is called an embryo. fibrates structures deep within the body to be
The fetus develops in the mother’s A type of lipid-lowering drug that is used viewed directly.
uterus in a sac filled with amniotic fluid, to treat high blood levels of triglycerides
which cushions it against injury. The or cholesterol. fibrillation
oxygen and nutrients required by the Localized, spontaneous, rapid contrac-
fetus are supplied via the placenta, an fibre, dietary tions of muscle fibres that can affect
organ embedded in the inner wall of The indigestible plant material in food. both skeletal and heart muscle.
the uterus that is attached to the fetus Dietary fibre includes certain types of In skeletal muscle, fibrillation gener-
by the umbilical cord. polysaccharide, cellulose, hemicellu- ally occurs when a nerve supplying a
lose, lignin, and gums and pectins (see muscle is destroyed, causing the mus-
FEV carbohydrates). Humans do not have cle to become weak and waste away.
See forced expiratory volume. the enzymes necessary to digest these Unlike fasciculation (muscular quiver-
substances, so the material passes ing), fibrillation in skeletal muscle is
fever through the digestive system virtually not visible through the skin; instead,
Known medically as pyrexia, elevation unchanged and cannot be used as a the contractions can be detected using
of body temperature above the normal source of energy. an EMG (electromyogram).
level of 37°C in the mouth and 0.6°C Some components of dietary fibre Fibrillation in the heart muscle is
lower in the axilla (armpit). A fever may hold water, thereby adding bulk to the caused by disruption to the spread of
be accompanied by symptoms such as faeces and aiding bowel function. For nerve impulses through the wall of one
shivering, sweating, a headache, thirst, this reason, dietary fibre can be effec- of the chambers of the heart. Either the
unusually rapid breathing, and a flushed tive in treating constipation, diverticular upper chambers (see atrial fibrillation) or
face. Confusion or delirium sometimes disease, and irritable bowel syndrome. the lower chambers (see ventricular fib-
occur with a fever, especially in elderly A high-fibre diet can help to reduce rillation) of the heart may be affected.
people. A high fever may cause seizures blood cholesterol levels. Certain high- The condition can be detected by the
in a child under five years (see convul- fibre foods, such as fruit and vegetables, use of an ECG (electrocardiogram). Fib-
sion, febrile) or coma. are also beneficial in protecting against rillation in heart muscle has the
CAUSES
Most fevers are caused either by
bacterial infections, such as tonsillitis, GOOD SOURCES OF FIBRE (per 100g portion)
or by viral infections, such as influenza. Essential for the efficient working of the digestive system, fibre is usually eaten as
In such cases, proteins called pyrogens fruit or grains. Among the best sources are bran, apricots, prunes, and wholemeal
are released when the white blood bread. Eating sufficient fibre in food can reduce constipation. The recommended
cells fight the microorganisms that are daily intake is 25 to 30 grams.
responsible for the infection (see
Wholemeal flour 9.6
immune system). Pyrogens act on the
temperature-controlling centre in the Dried apricots 24
brain, causing it to raise the tempera- Peanuts 8.1
ture of the body in an attempt to Celery 4.9
destroy the invading microorganisms. Peas 12
Fever may also occur in other
Raisins 6.4
conditions where infection is not
Green beans 7.4
present. Such conditions include dehy-
dration, thyrotoxicosis (a condition that Prunes 16.1
results from overactivity of the thyroid Bran 44
gland), lymphoma (a tumour of the lym-
phatic system), and myocardial infarction 0 5 10 15 20 25 30 35 40 45
(heart attack).

307
 FIBRIN

potential to be serious because it fibroadenomas is not fully understood,

impairs the ability of the chambers to their development in the breast is
contract efficiently. believed to be linked to the sensitivity
of breast tissue to female sex hor-
fibrin mones. The lumps tend to grow more
A substance that is produced in the quickly during pregnancy, probably Uterus
Fibroids
blood during the process of blood due to the increased levels of female
clotting. Fibrin is formed from a dis- sex hormones. Uterine wall
solved protein called fibrinogen. It forms A sample of tissue from the lump is
long filaments that bind clumps of removed and examined to confirm the Location of
platelets and other blood cells into a diagnosis (see biopsy). Fibroadenomas fibroids
mass that plugs the bleeding point, are harmless and do not require treat-
thereby preventing further blood loss. ment unless they become very large or der, causing frequent passing of urine,
F cause discomfort. or on the bowel, causing backache or
fibrinogen constipation. Fibroids that distort the
A protein that is present in blood and fibroadenosis uterine cavity may cause recurrent mis-
which is converted into fibrin during An outdated term for the general carriage or infertility. Rarely, a fibroid
the blood clotting process. lumpiness that is a normal feature may become twisted, resulting in sud-
of some women’s breasts. Cyclical den pain in the lower abdomen.
fibrinolysis changes in hormone levels often lead DIAGNOSIS AND TREATMENT
The breakdown of fibrin, the principal to the appearance of lumps in the Fibroids that do not cause symptoms
component of any blood clot. Fibrin is breasts, and the lumpiness is more are often discovered during a routine
a stringy protein that is formed in obvious before a menstrual period. pelvic examination. Ultrasound scanning
blood as the end product of coagula- Lumpy breasts do not increase the can confirm the diagnosis.
tion (see blood clotting). risk of developing breast cancer. How- Small, symptomless fibroids gener-
Blood also contains a fibrinolytic ever, a new solitary, discrete breast lump ally require no treatment, but regular
system, which is activated in parallel should be assessed by a doctor to rule examination may be needed to assess
with the coagulation system when a out the possibility of breast cancer. growth. Surgery or microwave endome-
blood vessel is damaged. The fibrino- (See also mammary dysplasia.) trial ablation (MEA) is required for
lytic system prevents the formation of fibroids causing serious symptoms. In
clots in undamaged blood vessels, fibrocystic disease some cases, they can be removed with
thereby preventing a blockage in these A term that is used to refer either to a hysteroscope (a tubelike viewing
vessels, and it acts to dissolve a clot the inherited disorder cystic fibrosis instrument with surgical attachments)
once healing of a broken blood vessel or to general lumpiness of the breasts under general anaesthesia (see anaes-
wall has taken place. (see fibroadenosis). thesia, general), leaving the uterus
Thrombosis (abnormal formation of intact. Removal of fibroids usually
blood clots) occurs in situations in fibroid results in regained fertility. Sometimes,
which there is a disturbance in the nor- A slow-growing and noncancerous however, a hysterectomy (removal of the
mal balance between the coagulation tumour that is found in the wall of the uterus) is required.
and fibrinolytic mechanisms. uterus. A fibroid is composed of
Drugs that achieve the effect of smooth muscle and connective tissue. fibroma
fibrinolysis (see thrombolytic drugs) can There may be one or more fibroids, A noncancerous tumour of the cells
be used to treat certain disorders, such and they may range in size from as that form connective tissue. For exam-
as pulmonary embolism and myocardial small as a pea to as large as a grape- ple, a neurofibroma is a tumour of the
infarction, in which blood clots block fruit. Fibroids are common, appearing cells that surround nerve fibres (see
the circulation. most often in women between the neurofibromatosis). Treatment is only
ages of 35 and 45. needed if there are symptoms.
fibrinolytic drugs CAUSE
Another name for thrombolytic drugs, The cause of a fibroid is thought to be fibromyalgia
which are used to dissolve blood clots. related to an abnormal response to oes- Pain and stiffness in the muscles,
trogen hormones. Oral contraceptives that which is often associated with distur-
fibroadenoma contain oestrogen can cause enlarge- bance of sleep. Fibromyalgia is most
A noncancerous fibrous tumour most ment of fibroids, as can pregnancy. common in women aged between 40
commonly found in the breast. Fibro- Decreased production of oestrogen and 60 years. The condition is also
adenomas occur most often in women after the menopause usually causes any known as chronic widespread pain
under the age of 30 and in black fibroids to shrink. (CWP) and was formerly referred to as
women. Multiple tumours may devel- SYMPTOMS fibrositis. Medical investigation usually
op in one or both breasts. In many cases, there are no symptoms. fails to reveal any underlying cause
Fibroadenomas of the breast are If a fibroid enlarges and projects into and, for this reason, some doctors do
painless, firm, round lumps that are the cavity of the uterus, it may cause not recognize fibromyalgia as a medical
usually between 1 and 5 cm in diame- heavy or prolonged periods. A large condition. However, the lives of affected
ter and movable. Although the cause of fibroid may exert pressure on the blad- people are often severely disrupted.

308
 FIBULA

The muscles most commonly affected ated with such conditions, particularly fibula
are those in the neck, shoulders, chest, rheumatoid arthritis and systemic lupus The outer and thinner of the two long
back, buttocks, and knees. There is erythematosus. Other causes of the con- bones of the lower leg. The fibula is
usually no restriction of movement. dition may include radiotherapy of the much narrower than the other lower-
Attacks are generally worse in cold, organs in the chest and treatment with leg bone, the tibia (shin), to which it
damp weather. Exhaustion and dis- anticancer drugs.In many cases, howev- runs parallel and to which it is
turbed sleep are common. er, the cause is unknown; the con- attached at both ends by ligaments. The
Use of analgesic drugs (painkillers), dition is then known as idiopathic pul- top end of the fibula does not reach
hot baths, and massage usually relieves monary fibrosis. the knee, but the lower end extends
pain and stiffness. Antidepressant drugs, SYMPTOMS below the tibia and forms part of the
such as amitriptyline, are often effective Symptoms of fibrosing alveolitis in- ankle joint.
in improving sleep and relieving pain. clude shortness of breath, a persistent The main function of the fibula is to
dry cough, and joint pains. As the con- provide an attachment for the muscles.
fibroplasia dition progresses, breathing becomes It provides little supportive strength to F
The formation of fibrous tissue, which increasingly difficult, especially during the lower leg.
is a process that occurs normally during vigorous exercise. In severe cases, there FRACTURE
the healing of a wound, that may occur is increased risk of respiratory failure The fibula is one of the most commonly
abnormally in some tissues. In one and chronic heart failure. Some people broken bones. A fracture of the fibula
form of the condition, known as retro- with the disorder are more susceptible just above the ankle may occur with a
lental fibroplasia, fibrous tissue develops to lung cancer. severe ankle sprain as a result of a vio-
behind the lens of the eye and causes TREATMENT lent twisting movement. Pott’s fracture is
blindness. This type of fibroplasia is Treatment of the condition involves a fracture at this location combined
usually seen only in newborn prema- corticosteroid drugs combined with with dislocation of the ankle and some-
ture babies and is the result of excessive other immunosuppressant drugs to slow times with fracture of the tibia.
treatment with oxygen. the progress of lung damage. Home To confirm a fracture of the fibula, X-
oxygen therapy may be used to assist rays are taken. In some cases, the lower
fibrosarcoma breathing. For some people, a lung leg is immobilized in a plaster cast to
A rare, cancerous tumour of the cells transplant may be life-saving. allow the bone to heal. If a fracture
that make up connective tissue (the occurs in the middle portion of the
material that surrounds body struc- fibrosis fibula, however, immobilization may
tures and holds them together). A An overgrowth of scar tissue or connec- not be needed. If the fracture is severe
fibrosarcoma may develop from a non- tive tissue. Fibrous tissue may be (especially if it is accompanied by dis-
cancerous fibroma or may be cancerous formed as an exaggerated healing res- location of the ankle), surgery may be
from the start. ponse to infection, inflammation, or necessary to fasten the broken pieces
Treatment of a fibrosarcoma is by injury. Fibrosis may also result from a of bone with pins.
surgical removal and/or radiotherapy. lack of oxygen in a tissue, usually due
However, this may be only temporarily to inadequate blood flow through it
successful if cells from the tumour (in heart muscle damaged by a myocar- LOCATION OF THE FIBULA
have already spread through the blood- dial infarction, for example).
The fibula lies beside the tibia on
stream to initiate growths elsewhere In fibrosis, specialized structures the outside of each lower leg.
in the body. (for example, kidney or muscle cells)
are replaced by fibrous tissue, which
fibrosing alveolitis results in impaired function of the Femur
Inflammation and thickening of the organ concerned. An overgrowth of
Knee joint
walls of the alveoli (the tiny air sacs in fibrous tissue can compress hollow
the lungs; see alveolus, pulmonary) that structures, a situation that occurs in
results in scarring of lung tissue (see retroperitoneal fibrosis, in which the
interstitial pulmonary fibrosis). Fibrosing ureters (tubes draining urine from the
Tibia
alveolitis most frequently occurs in kidneys into the bladder) become
people over the age of 60. blocked. Fibrous tissue formed within
Usually, fibrosing alveolitis is a long- a muscle after a tear causes shortening
term disorder, that develops over of the muscle and disruption of the
months or years. Rarely, an acute form normal contraction of its fibres. The Fibula
occurs that develops rapidly over a few likelihood of further tears occurring
days or weeks. Both forms tend to is increased unless the muscle is
Ankle joint
become progressively worse and are stretched and exercised.
difficult to treat.
CAUSES fibrositis
In some cases, fibrosing alveolitis is A former term for fibromyalgia.
the result of an autoimmune disorder (in
which the immune system attacks the fibrous adhesion
body’s own tissues) and may be associ- See adhesion.

309
 FIFTH DISEASE

A fractured fibula may take up to six figure-of-eight bandage scrotum, becomes very enlarged; in
weeks to heal, depending on its seve- A bandage that is wrapped over itself addition, the skin becomes thick,
rity and the age of the patient. a number of times to resemble the fig- coarse, and fissured, resulting in a con-
ure eight. A figure-of-eight bandage is dition known as elephantiasis.
fifth disease often used in first aid to support the The larvae of another type of worm
An infectious disease that often causes elbows, wrists, knees, and ankles, par- invade the eye, causing blindness (see
a widespread rash. Fifth disease, which ticularly if the joint is to be kept in a onchocerciasis). A third type of larva,
is also known as slapped cheek disease flexed position. which may sometimes be seen and felt
or erythema infectiosum, principally moving beneath the skin, causes
affects children and is caused by a strain filariasis loiasis, characterized by irritating and
of erythrovirus. Erythrovirus is trans- A group of tropical diseases, caused by sometimes painful areas of oedema
mitted in airborne droplets from the various parasitic worms or their larvae, called calabar swellings.
coughs and sneezes of individuals who which are transmitted to humans by DIAGNOSIS AND TREATMENT
F are carrying the infection, but it may insect bites. Adult female worms, which A diagnosis of filariasis is confirmed by
occasionally be transmitted through a may measure anything between 2 and microscopic examination of the blood
blood transfusion. 50 cm, produce many thousands of lar- (see blood tests). The anthelmintic drugs
Many children do not develop symp- vae, which are carried through the diethylcarbamazine or ivermectin gen-
toms; in other children, the rash body in the bloodstream. Blood-suck- erally cure the infection, but they may
appears seven to 14 days after infection. ing insects (primarily certain species of also cause certain side effects, however,
The rash of fifth disease starts on the mosquito) ingest the larvae while feed- such as fever, sickness, muscle pains,
cheeks as separate, rose-red, raised ing on blood from infected people and and increased itching.
spots, which subsequently converge to transmit them by biting others . PREVENTION
give the characteristic appearance of the Filariasis is prevalent in tropical The drug diethylcarbamazine can be
condition. Within a few days, the rash Africa, Indonesia, the South Pacific, given as a preventative measure; and
spreads in a lacy pattern over the limbs, coastal Asia, southern Arabia, Mexico, the use of insecticides and protective
but only sparsely on the trunk. The rash and Guatemala. clothing are useful protection against
is frequently accompanied by mild fever TYPES AND SYMPTOMS insect bites. (See also roundworms;
and generally clears up after approx- Some species of worm live in the lym- insects and disease.)
imately ten days. phatic vessels (see lymphatic system).
Adults, who contract the disease Swollen lymph nodes and recurring fever filling defect
only rarely, tend to be more severely are early symptoms of the disease. In- An abnormal finding on contrast X-rays
affected than children. They may have flammation of lymph vessels results in due to a lesion occupying space within
joint pain and swelling that lasts for up localized oedema (the accumulation of a hollow organ. Normally, in contrast
to two years. Infection may bring a fluid in the tissues, causing swelling). X-rays, a radio-opaque dye (a contrast
temporary halt to the production of After repeated infections, the affected medium) is introduced into a hollow
red blood cells in the bone marrow area, which is commonly a limb or the body structure, such as the intestine,
(known as an aplastic crisis); it can
therefore have serious implications for
people with anaemia. THE CYCLE OF FILARIASIS
The only treatment for the infection
Filariasis is caused
is with drugs to reduce the fever. In by parasitic worms Larvae
most cases, the condition clears up bite spre
and/or their larvae. the the blo ad
within two weeks. However, people at gh od s th
There are several ou tre rou
hr am g
risk of anaemia may need hospital stages in the y t sect an
ho lym

in
kin d
o

ut

treatment. One attack of erythrovirus development of this

d-s he b

d
g

the hatic

confers lifelong immunity. infection as it spreads

of a b nter t
uc

bo
p

through the body.

dy v sels
ee

fight-or-flight response
lo o

v es
ia
Larva

The arousal of the sympathetic part

of the autonomic nervous system, gener-
ally in response to fear. Adrenaline
The new y ano
ingeste

(epinephrine), noradrenaline (norepin-

into

ephrine), and other hormones are

ae
db

released from the adrenal glands and

larv
e m velop
larv

nervous system, leading to a raised

ae er b

ore
e
od ae d
en

heart rate, pupil dilation, and increased

th

ter oo

he
rv
uc

blood flow to the muscles. These la

t

d- bloo s, r
l

su ti c p
responses make the body more effi- ck d a nd pha ich
ing a lym wh
cient in either fighting or fleeing the ins re then In the rms,
ect wo
apparent danger. Prolonged or exces- adult
sive fight-or-flight responses occur as
part of anxiety disorders.

310
 FINGER

and X-rays are taken; the dye outlines OUTLOOK join at hinge joints moved by muscle
the shape of the structure. Anything that Amalgam fillings have a limited life tendons that flex (bend) and extend
protrudes into the cavity of a body and may need to be replaced after (straighten) the finger. The tendons are
structure, such as polyps in the large about ten years. Occasionally, a filling covered by synovial sheaths that con-
intestine or a tumour in the bladder, needs to be replaced sooner if decay tain fluid, enabling the muscles to
will prevent the area from filling with has spread under the filling or the fill- work without friction. A small artery,
the contrast medium, and will produce ing has become dislodged or fractured. vein, and nerve run down each side of
a distorted shape on the X-ray. the finger. The entire structure is
film enclosed in skin with a nail at the tip.
filling, dental A thin, transparent sheet of cellulose DISORDERS
The process of replacing a chipped or acetate or similar material, coated with Finger injuries are common, especially
decayed area of tooth with an inactive a light- or radiation-sensitive emulsion, on lacerations, fractures, and ruptures of
material. The term may also be used to which images such as X-rays are produced. the tendons. Mallet finger is a condition
describe the restorative material itself. The term is also used to describe any thin that occurs when the extensor tendon F
Amalgam, a hard-wearing mixture of layer or coating, such as the covering of along the back of the finger is pulled
silver, mercury, and other metals, is tears on the eyeball. (See also blood film.) away from its attachment after a blow
often used for back teeth. Tiny amounts to the fingertip.
of mercury released from such fillings film badge Infections may occur in the finger
are believed by some to cause health A device that enables hospital staff to pulp at the tip; paronychia (infection of
problems. However, a link has yet to be monitor their exposure to radiation. the tissue around a nail) sometimes
scientifically established. Film badges are worn by people work- follows a minor cut.
If a front tooth is chipped, bonding ing in X-ray and radiotherapy depart- Inflammation that is due to rheuma-
(see bonding, dental), in which plastic or ments. The badge consists of a piece of toid arthritis or osteoarthritis may affect
porcelain tooth-coloured material is photographic film in a holder, which is the joints of the fingers, causing stiff-
attached to the surface of the tooth, worn on the clothing. The film has a ness, pain, swelling, and deformity. In
may be used. fast (sensitive) emulsion on one side addition, the flexor tendons, which
WHY IT IS DONE and a slow emulsion on the other. run along the front of the fingers, may
When enamel is damaged, bacteria can Small doses of radiation blacken only become inflamed and stuck in the
invade the dentine beneath and even- the fast emulsion; higher doses start to tendon sheath, causing a condition
tually attack the pulp (inner tissue blacken the slow emulsion and make known as trigger finger.
containing blood vessels and nerves), the fast emulsion turn opaque. Altered control of the muscles in the
causing the tooth to die. Teeth are walls of the blood vessels and impaired
therefore repaired, where possible, at fimbriae blood supply to the hands and fingers
the first signs of damage to prevent A fringe of threadlike or fingerlike fila- may cause Raynaud’s disease. Dactylitis is
decay. Filling also restores a tooth’s ments, such as those that make up the a spindle-shaped swelling of the fingers
original shape, which is important for ends of the fallopian tubes that open on
appearance and also for a correct bite. to the ovaries (see ovary). During ovula-
tion, the fimbriae guide the egg (see
STRUCTURE OF A FINGER
HOW IT IS DONE
If the filling required is large or in a ovum) into the tube.
The phalanges (finger bones) are
sensitive area, the dentist numbs the joined at hinge joints and moved
surrounding gum with a local anaes- finasteride by tendons.
thetic (see anaesthesia, dental). Any A specific enzyme inhibitor drug that
soft, decayed material is removed with prevents the conversion of testosterone Nail
sharp instruments. A high-speed drill into the more potent male hormone Tip
is used to remove harder material and dihydrotestosterone. Finasteride is used
to shape a hole that will hold the fill- in the treatment of noncancerous en- Ligaments
ing securely. While the dentist works, a largement of the prostate (see prostate,
suction tube placed in the patient’s enlarged); it shrinks the gland, thereby
mouth draws away saliva and produces improving urine flow. It is also used to Phalanges
water to cool the end of the drill. treat male pattern baldness in men. Side
If the pulp is almost exposed, the effects include impotence and reductions
bottom of the cavity is lined with a in libido and semen volume.
sedative paste to protect the sensitive
pulp from pressure and temperature fine tremor
changes. If one or more of the walls of A tremor (an involuntary trembling or
the tooth is missing through extensive oscillating movement) characterized Tendons
decay, a steel band may be placed by very small and rapid vibrations.
around the tooth to support the filling. Ligaments
The dentist then mixes the amalgam or finger
other filling material, and packs it into One of the digits of the hand. Each fin- Artery
the cavity, smoothing the surface. The ger has three phalanges (finger bones),
material hardens over 24 hours. and the thumb has two. The phalanges

311
 FINGER-JOINT REPLACEMENT

that is found in sickle-cell anaemia. Swel- The aims of first-aid treatment in an Acquired fistulas may result from infec-
ling of the fingers is also a rare feature emergency are to preserve life; to pro- tion, injury, or cancer. Fistulas between
of tuberculosis and syphilis. tect the individual from further harm; the intestine and the skin may occur
Clubbing of the fingers is a sign of to provide reassurance; to make the in the inflammatory bowel condition
chronic lung disease or of certain forms victim comfortable; to arrange for Crohn’s disease; these fistulas may allow
of congenital heart disease. Tumours of medical help; and to find out as much the intestinal contents to escape to the
the finger are rare, but they may occur as possible about the circumstances of skin through an opening, in which case
in chondromatosis, a condition that is the accident or injury. they are known as faecal fistulas. Fistulas
characterized by multiple noncancerous Various techniques can be used to of the urinary tract, which open from
tumours of the cartilage. achieve these aims. For example, the the urethra or bladder to the perineum
Congenital finger disorders include recovery position helps to maintain an (the area between the anus and geni-
syndactyly (fused fingers), polydactyly open airway in an unconscious person tals), may be the result of radiotherapy to
(extra fingers), missing fingers, or a who is breathing; artificial respiration is the pelvis, or they may be caused by a
F webbed appearance of the hand that is necessary if a person is not breathing. difficult childbirth. Such fistulas may
caused by a deep membrane between Cardiopulmonary resuscitation is essential cause leakage of urine (see incontinence,
the fingers. if a person is not breathing and has no urinary) or urinary tract infection.
heartbeat. Heavy bleeding, which can Certain types of arteriovenous fistula
finger-joint replacement result in shock, may be controlled by (between an artery and a vein) are sur-
A surgical procedure in which one or applying pressure at appropriate pres- gically constructed to provide ready
more artificial joints (made of metal, sure points. access to the circulation in people who
plastic, or silicone rubber) are used to are having dialysis.
replace finger joints that have been fish oil TREATMENT
destroyed by disease, usually by rheu- A product occurring naturally in some Identifying the cause of a fistula, and
matoid arthritis or osteoarthritis. species of oily fish, such as mackerel. treating it if possible, is the first line of
HOW IT IS DONE Fish-oil preparations, which are rich in action. Some types of fistula close spon-
Usually, several finger joints are treated omega-3 fatty acids, are used as lipid-low- taneously but most need surgery. In
at the same time. An incision is made ering drugs. faecal fistulas, a temporary colostomy
to expose the joint; the ends of the two may be necessary to divert faeces away
diseased bones in the joint are cut fissure from the affected area.
away, along with diseased cartilage. An A cleft or groove, which can be either
artificial joint is then inserted into the normal or abnormal. A dental fissure is fit
bone ends. The finger is immobilized a naturally occurring defect in the ena- See seizure.
in a splint until the wound has healed. mel of a tooth in which tooth decay
After about ten days, the dressings are (see caries, dental) commonly arises. fitness
removed and the patient is encouraged The sylvian fissure is one of the deep The capacity for performing physical
to exercise the fingers and resume nor- folds that separate the temporal lobe of activities without exhaustion. Fitness
mal activities. the brain from the frontal and parietal depends on strength (the ability to
RESULTS lobes. An anal fissure is a tear occurring exert force for pushing, pulling, lift-
Finger-joint replacement is usually in the anal canal. ing), flexibility (the ability to bend,
successful in relieving arthritic pain stretch, and twist through a full range
and enabling the patient to use his or fissure sealant of movements), and endurance (the
her hands again. However, it rarely A substance that is bonded to the biting ability to maintain a certain amount of
restores normal movement. surface of a tooth to seal any naturally effort for a certain period of time).
occurring fissures (clefts or grooves) in HOW FITNESS IS ACHIEVED
fingerprint the enamel and to help prevent tooth Cardiovascular fitness is the precondi-
An impression that is left on a surface decay (see dental caries). Treatment with tion for all other forms of fitness; for
by the pattern of fine curved ridges on fissure sealant may be offered as a pre- this reason, regular aerobic exercise
the skin of the fingertip. These ridges ventive measure to children whose (see aerobics), which makes the body’s
occur in four patterns: loops, arches, molar teeth have recently emerged (see use of oxygen more efficient, is the
whorls, and compounds (which are eruption of teeth). basis of any fitness programme. Speci-
combinations of the other three). No fic activities, such as weight training or
two people (not even identical twins) fistula yoga, can help to develop strength and
have the same fingerprints. An abnormal passage leading from an flexibility when included in a pro-
internal organ to the body surface or gramme (see exercise). Although fitness
first aid connecting two organs. Fistulas may training has cumulative effects that
The immediate treatment of any injury rarely be congenital (present from build up over many months (provided
or sudden illness before professional birth), or they may be acquired as a that there is a sustained increase in
medical care can be provided. Most result of tissue damage. activity levels), the effects are specific
first aid consists of treating minor in- Congenital types include tracheoes- to the muscles used and the ways in
juries and burns, and fractures. Some- ophageal fistulas, branchial fistulas (see which they are used. A variety of activ-
times, however, emergency life-saving branchial disorders), and thyroglossal ities is therefore necessary to achieve
first aid treatment may be needed. fistulas (see thyroglossal disorders). overall fitness.

312
 FLATUS

BENEFITS OF FITNESS The word “fixation” also describes the breathing and coughing very painful,
When the body is fit, the maximum alignment and stabilization of frac- which can increase the risk of chest infec-
work capacity and endurance are in- tured bones. Fixation may be external, tion and lung collapse (see atelectasis).
creased. A fit person has a better as with a plaster cast, or internal, using Emergency treatment involves turn-
chance of avoiding coronary artery dis- pins, plates, or nails introduced surgi- ing the person on to the affected side
ease as well as of preventing the effects cally into the injured area. or firmly strapping the flail segment.
of aging and chronic disease. In severe cases, artificial ventilation is
The strength, endurance, and effi- fixative needed until the chest wall has become
ciency of the heart is also increased by A chemical agent, such as formaldehyde, stable and the ribs have healed.
exercise. A fit heart pumps 25 per cent that is used for the hardening and pre-
more blood per minute when at rest, servation of tissue specimens prior to flat-feet
and over 50 per cent more blood per microscopic analysis (see histology). A condition, usually affecting both feet,
minute during physical exertion, than in which the arch of the foot is absent
an unfit heart. A fit person’s heart nor- fixed pupil and the sole rests flat on the ground. F
mally beats 60 or 70 times a minute; An abnormal pupil (the circular opening The rches normally form gradually as the
an unfit person’s heart beats 80 to 100 in the centre of the iris) that does not supportive ligaments and muscles in
times per minute. react to light or adjust on accommoda- the soles develop; they are not usually
tion (the process by which the eye fully formed until about the age of six.
fitness testing focuses on objects). A fixed pupil may In some people, however, the ligaments
A series of exercises designed to deter- be symptomatic of various eye disor- are lax, or the muscles in the feet are
mine an individual’s level of fitness, ders (see eye, disorders of), such as acute weak, and the feet therefore remain flat.
primarily his or her cardiovascular fit- glaucoma and uveitis, or, rarely, of a brain Less commonly, the arches of the feet
ness and muscle performance. Fitness tumour in which brainstem structures may not form because of a hereditary
testing is often carried out before a that control eye reflexes are compres- defect in bone structure.
person starts an exercise programme to sed. Both pupils being fixed and dilated Flat-feet can be acquired in adult life
evaluate its safety and suitability or to is a sign of brain death. because of fallen arches, sometimes as
monitor progress thereafter. the result of a rapid increase in weight.
A physical examination is usually fixed-rate pacemaker Weakening of the supporting muscles
performed, including measurement of An artificial cardiac pacemaker (a and ligaments of the feet may occur in
body fat, height, and weight. Blood device that sends electrical impulses to certain neurological or muscular dis-
and urine tests may be done, including the heart to maintain a regular heart- eases, such as poliomyelitis.
an analysis of blood cholesterol. The beat) that is set to pace at a single rate In most cases, flat-feet are painless
performance of the heart is measured regardless of the patient’s own heart and require no treatment, although in
by taking the pulse before, during, rate. Fixed-rate pacemakers are still some cases the feet may ache on walk-
and after aerobic exercise such as used in some clinical and diagnostic ing or standing. Arch supports can be
step climbing, riding a stationary bicy- settings, and may be appropriate for worn in the shoes for comfort and
cle, or running on a treadmill. The the elderly. For active people, rate- special exercises can be used to help
more efficient the heart, the slower it responsive pacemakers (see demand strengthen weakened ligaments and
works during exercise and the quicker pacemaker) are often a better choice; muscles. A small number of affected
it returns to normal afterwards. these devices deliver electrical stimuli children require an operation to cor-
Another test involves measuring a as required and at a rate to match the rect the bones in the feet.
person’s overall performance in a stan- patient’s level of activity.
dard exercise. This is most suitable for flatulence
monitoring progress through an exer- flaccid Abdominal discomfort or fullness that
cise programme and for setting goals. Lacking in firmness or characterized is relieved by belching or by passing
The test may be based either on mea- by a loss of muscle tone. wind through the anus. Flatulence is a
suring the distance covered in a fixed feature of many gastrointestinal condi-
time or the time needed to cover a fixed flail chest tions, such as irritable bowel syndrome
distance. (See also aerobics; exercise.) A type of chest injury that usually and gallbladder disorders.
results from a traffic accident or from When an individual is in an upright
fixation violence. In flail chest, several adjacent position, most swallowed air passes
In psychoanalytic theory, the process by ribs are broken in more than one back up the oesophagus to be expelled
which an individual becomes, or re- place, producing a piece of chest wall through the mouth. When a person is
mains, emotionally attached to real or that moves in the opposite way to nor- in a prone position, the air may pass
imagined objects or events that oc- mal as the victim breathes: when the through the intestine and anus instead.
curred during early childhood. If the victim inhales, and the rib cage Gas formed in the intestine is passed
fixations are powerful, resulting from expands, the flail segment moves only through the anus.
traumatic events, they may lead to inwards, and during exhalation it
immature and inappropriate behav- moves outwards. flatus
iour. Regression to these events is The injury may severely impair the Gas, commonly known as “wind”, that
regarded by some analysts as the basis efficiency of breathing and may lead to is passed via the anus. Gas is formed
of certain emotional disorders. respiratory failure and shock. It makes in the large intestine by the action of

313
 FLATWORM

bacteria on carbohydrates and amino

acids in food. The gas consists of hydro- HOW TO USE DENTAL FLOSS
gen, carbon dioxide, and methane. Air
Floss should be used as an adjunct to
may be swallowed while eating and toothbrushing to remove plaque and
enter the stomach or intestine. food particles from gaps between teeth
Large amounts of gas may cause flat- and around gums. Care should be taken
ulence (abdominal discomfort), which to avoid damaging the gum margins,
may be relieved by the passage of wind and floss should never be reused.
or by defaecation (passing faeces).
flatworm
Any species of worm that has a flat-
tened shape. Two types of flatworm are
F parasites of humans: cestodes (tape-
worms) and trematodes (schistosomes,
flukes; see liver fluke; schistosomiasis). Holding the floss taut, guide it gently into
flea bites
1fingerBreak off a generous length of floss (about
50 cm) and wrap the ends around one
of each hand.
2 the gap between the teeth until it reaches
the gum line. Then rub the sides of each tooth
See insect bites. with the floss using an up-and-down motion.

flecainide
An antiarrhythmic drug used in the treat- The sudden appearance of a cloud flossing, dental
ment of tachycardia, atrial fibrillation, of dark floaters, especially if they are The removal of plaque (see plaque, den-
and arrhythmias associated with condi- accompanied by light flashes, suggests tal) and food particles from between
tions such as Wolff–Parkinson–White retinal tear or retinal detachment. A red the teeth using soft nylon or silk thread
syndrome (an abnormality of heart floater that is large enough to obscure or tape. Dental floss may be waxed or
rhythm). Flecainide is given, in the vision is usually caused by a vitreous unwaxed. Flossing should be carried
form of tablets or injection, to people haemorrhage. out as an adjunct to toothbrushing.
who are physically resistant to or intol-
erant of other treatments. The treat- floating kidney flu
ment is always started in hospital. A kidney that is more mobile within See influenza.
Side effects include dizziness, visual the body than usual.
disturbances, and worsening of the flucloxacillin
existing arrhythmia or development of floating ribs A penicillin drug usually used to treat
a new type. In rare cases, nausea, vom- The lowest two pairs of ribs, which are staphylococcal infections.
iting, urticaria (nettle rash), vertigo, and attached to the spine at the back but
jaundice occur. are not attached to the sternum (the fluconazole
breastbone) by cartilage in the same An antifungal drug used in the treat-
flexor way as the other ribs. ment of candidiasis (thrush), a fungal
Any muscle that acts to flex a joint. An infection that commonly affects the
example of a flexor muscle is the biceps flooding vagina or the mouth. Although gener-
muscle, in the upper arm, which con- A technique that is used in behaviour ally well tolerated, fluconazole may
tracts to bend the elbow. therapy for treating many different sometimes cause nausea and diarrhoea.
types of phobias. The method of flood-
flies ing forces the patient to confront the fluctuant
See insects and disease. focus of his or her fear directly and for A term used to describe the movement
prolonged periods. With the support within a swelling when it is examined
floaters of a therapist, the patient is repeatedly by touch. It is a sign that the swelling
Small fragments that are perceived to be confronted with the object or situation contains fluid. The term is often used
floating in the field of vision. Floaters that he or she is afraid of. The aim is to describe an abscess.
move rapidly with eye movement but that, through the process of flooding,
drift slightly when the eyes are still. the patient’s distress should eventually fluid retention
They do not usually affect vision. be reduced. The excessive accumulation of fluid in
The majority of floaters are the result body tissues. Mild fluid retention is a
of shadows cast on the retina by micro- floppy infant common feature of premenstrual syn-
scopic structures in the vitreous humour A description of a baby whose muscles drome, but it disappears with the onset
(the jellylike substance behind the lens lack normal tension or tone causing of menstruation. A more severe case of
of the eye). In older people, the vitreous the limbs to be limp and unresistant to fluid retention may be associated with
humour tends to shrink slightly and gravity(see hypotonia in infants). an underlying heart, liver, or kidney
detach from the retina, often resulting disorder (see ascites; nephrotic syndrome;
in conspicuous floaters, which usually floppy valve syndrome oedema). Diuretic drugs may be used to
decrease over time. See mitral valve prolapse. treat fluid retention.

314
 FOLEY CATHETER

fluke Fluoride is also beneficial to both chil- Flushing may occur during fever or as a
A type of flattened worm, also known dren and adults when it is applied result of embarrassment. Hot flushes are
as a trematode, that may infest humans directly to the teeth as part of dental common at the menopause.
or animals. The two main diseases treatment or used in the form of a
caused by flukes are liver fluke infesta- mouthwash or toothpaste. However, the fluticasone
tion, which occurs worldwide, and ingestion of excess fluoride as the teeth A corticosteroid drug taken in the form
schistosomiasis, a debilitating disease are forming can lead to fluorosis (stain- of an inhaler to control asthma, as a
that is common in tropical countries. ing of the tooth enamel). nasal spray to relieve the symptoms of
allergic rhinitis (see rhinitis allergic),
flunitrazepam fluorosis and as an ointment or cream to treat
A type of benzodiazepine drug that is Mottling or staining of the tooth ena- dermatitis and eczema.
used as a sleeping drug in the treatment mel (see teeth) that is caused by the Side effects are rare, but may include
of insomnia. The effects of flunitrazepam ingestion of excess fluoride as the teeth nosebleeds when the drug is taken as a
may persist into the following day. Pro- are formed. In severe cases of fluorosis nasal spray, candidiasis (thrush) of the F
longed use of this drug may result in the enamel develops brown stains. This mouth and throat when taken as an
dependence (see drug dependence). Also occurs principally in areas in which the inhaler, and skin irritation when taken
known as Rohypnol, or the “date-rape” fluoride level in water exceeds the as an ointment or cream.
drug, flunitrazepam is a controlled drug. recommended level or if additional
supplements are taken. Flynn–Aird syndrome
fluorescein A rare, inherited disorder that is charac-
A harmless orange dye (that glows fluorouracil terized by atrophy (wasting away) of the
green in contact with defective cells An anticancer drug used in the treat- muscles and skin, ataxia (incoordination
when blue light is shone on it) used in ment of cancers of the breast, bladder, and clumsiness), and dementia. Other
ophthalmology to aid the diagnosis of ovaries, and intestine. symptoms of Flynn–Aird syndrome
certain eye disorders. Fluorescein can be include tooth decay (see caries, dental),
applied to the front of the eye to detect fluoxetine stiffness in the joints, retinitis pigmentosa
abrasions of the conjunctiva or cornea. It An antidepressant drug that belongs to (degeneration of the rods and cones
is also given intravenously during fluo- a drug group called selective serotonin of the retina), peripheral neuropathy (a
rescein angiography in order to detect reuptake inhibitors (SSRIs). SSRIs work peripheral nerve disorder), cataracts,
abnormalities of the blood vessels in the by increasing the amount of serotonin and progressive loss of hearing. Flynn–
retina (the light-sensitive inner layer at available in the brain and thus stimu- Aird syndrome shows an autosomal
the back of the eye), which occur in lating brain cells. The most common dominant pattern of inheritance (see
such conditions as macular degeneration adverse effects include restlessness, genetic disorders).
and diabetic retinopathy. insomnia, headache, and diarrhoea.
foam, contraceptive
fluoridation flupentixol See spermicides.
The addition of fluoride to the water An antipsychotic drug used to treat
supply as a means of reducing the inci- schizophrenia and similar illnesses. It is focal point
dence of dental caries (tooth decay). also sometimes prescribed for depres- The point at which light rays converge
Some areas have naturally high levels sion. Side effects of the drug most after passing through a lens. In people
of fluoride in the drinking water; in commonly include blurred vision, with normal vision, light rays from a
other areas, however, fluoride is added nausea, a rapid heartbeat, dizziness, viewed object converge on the light-
to bring the concentration up to the and parkinsonism. sensitive retina after passing through
recommended level. In the UK, deci- the cornea and lens, producing a clear
sions to add fluoride to drinking water flurazepam image. In shortsightedness, the focal
are made by the local authorities. A type of benzodiazepine drug that is point occurs in front of the retina and
used as a sleeping drug in the treat- the image is blurred; in longsighted-
fluoride ment of insomnia. The drug’s effects ness, it occurs beyond the retina, with
A mineral that helps to prevent dental may persist the following day. Pro- the same result.
caries (tooth decay) by strengthening longed use may result in dependence
tooth enamel (see teeth), making it (see drug dependence). foetus
more resistant to acid attacks. Fluoride An alternative spelling for fetus.
may also reduce the acid-producing flurbiprofen
ability of microorganisms in plaque. A nonsteroidal anti-inflammatory drug that Foley catheter
Fluoride that is ingested during the is used particularly to ease the symp- A type of catheter (flexible tube) that
formation of teeth has a lifelong bene- toms of musculoskeletal disorders, is fed through the urethra into the
ficial effect because it is incorporated such as rheumatoid arthritis. bladder and used for the continuous
into the developing tooth substance. In drainage of urine (see catheterization,
the UK, fluoride is added to the water flush urinary). A Foley catheter is kept in
supply, and fluoridation has led to a Reddening of the face, and sometimes place within the bladder by means of a
decrease in the incidence of tooth of the neck, caused by dilation of the balloon at its tip that is inflated with
decay among children. blood vessels near the skin surface. either air or liquid.

315
 FOLIC ACID

folic acid folliculitis

A vitamin that is essential for the pro- Inflammation of one or more hair fol- Posterior fontanelle
duction of red blood cells by the bone licles as a result of a staphylococcal
marrow. Folic acid is contained in a infection. Folliculitis can occur almost
Sagittal suture
variety of foods, particularly liver and anywhere on the skin, but the condition
raw vegetables; adequate amounts are most commonly affects the neck, arm-
usually included in a normal diet. pits, thighs, or buttocks, causing a boil; Coronal suture
During pregnancy, folic acid is very it may also affect the bearded area of
important for fetal growth, the devel- the face, producing pustules (see sycosis Anterior fontanelle
opment of the nervous system, and the barbae). Treatment of folliculitis is with
formation of blood cells. The incidence antibiotic drugs. Because the infection is
of neural tube defects is reduced if a easily spread, careful hygiene is impor-
Location of the fontanelles
woman takes folic acid supplements tant, and an affected individual should
F before conception and during the first wash any clothes worn next to the skin
There are two soft areas on the baby’s skull – the
anterior fontanelle is diamond-shaped, the
12 weeks of pregnancy. daily in boiling water until the condi- posterior fontanelle is triangular.
Folic acid deficiency is a cause of tion has cleared up.
megaloblastic anaemia, which pro- food additives
duces symptoms such as headaches, fomites Any substance that is added to food for
fatigue, and pallor. Deficiency can Inanimate objects (for example, bed the purposes of preservation or to
occur during any serious illness or can linen, clothing, books, or telephone improve its acceptability in terms of
be the result of a nutritionally poor receivers) that are not in themselves taste, colour, or consistency.
diet, especially in people who con- harmful but which may be capable of TYPES AND USES
sume large amounts of alcohol. harbouring harmful microorganisms Additives fall into five main groups:
or parasites and, therefore, of convey- those that preserve food; those that
folie à deux ing an infection from one person to affect texture; those that affect appear-
A French term that is used to describe another. Fomites principally transmit ance and taste; added nutrients, such as
the unusual occurrence of two people respiratory infections, such as influenza. vitamins; and miscellaneous additives,
sharing the same psychotic illness (see The singular form of the word fomites such as rising and glazing agents, flour
psychosis). Often the two people are is “fomes”. improvers, and anti-foaming agents.
closely related and share one or more For further information on the many
paranoid delusions. If the sufferers fontanelle different types of food additives, see
become separated, one of them usually Either one of two membrane-covered the table opposite.
rapidly loses the symptoms, which spaces between the bones of a baby’s Preservatives, such as sodium nitrate,
have been imposed by the dominant, skull. At birth, the skull bones are not are added to food to control the
and genuinely psychotic, partner. yet fully fused, and two soft areas can growth of bacteria, moulds, and yeasts.
be felt through the scalp. These are the Other additives, such as antioxidants,
folk medicine anterior fontanelle, which is diamond- can improve the keeping quality of
Any form of medical treatment that is shaped and usually closes up by age 18 food by preventing any undesirable
based on popular tradition, such as the months, and the posterior fontanelle, chemical changes within it; for exam-
charming of warts or the use of copper which is triangular and closes up with- ple, antioxidants prevent rancidity in
bracelets to treat rheumatism. in the first two months. some foods containing fat.
It is normal for the fontanelles to Additives that improve the texture of
follicle become tense and bulge out when a food include thickeners, emulsifiers,
A small cavity in the body. For exam- baby cries. Persistent tension at other stabilizers, and gelling agents. Lecithin,
ple, a hair follicle is a pit in the skin times, however, may indicate an abnor- which occurs naturally in all animal and
from which a single strand of hair mality, particularly hydrocephalus (the plant cells, is an emulsifier that is added
emerges. Another example is an ovar- accumulation of fluid in the skull). A to margarine to prevent separation.
ian follicle, which is a fluid-filled sunken fontanelle may be a sign of The appearance and taste of many
cavity in the ovary in which an ovum dehydration. If a fontanelle is abnor- foods and drinks may be improved
(egg) develops. mally large or takes a long time to through the use of colourings, flavour-
close, the cause may be a brain abnor- ings, sweeteners, and flavour enhancers.
follicle-stimulating hormone mality or a disorder, such as rickets, Artificial sweeteners, such as saccharin
A gonadotrophin hormone that is pro- affecting the skull bones. Early closure and aspartame, may be used instead of
duced by the pituitary gland and acts on of the fontanelles results in a deform- sugar, especially in products that are
the ovary or testis. In women, follicle- ity called craniosynostosis. aimed at people trying to lose weight.
stimulating hormone (FSH) causes an Occasionally, a third fontanelle is pre- Many colourings are natural (for exam-
egg follicle to start maturing in the sent between the other two; this is a ple, beetroot red).
ovary in the first week of the menstru- feature of Down’s syndrome. Sometimes a RISKS
al cycle, ready for ovulation. In men, baby may have extra bones in the ante- Certain additives may produce an al-
FSH stimulates sperm production in the rior fontanelle, but this is not abnormal. lergic reaction in some individuals,
testes. FSH is given medically to treat These extra bones fuse into the skull although this is relatively rare. Some
certain types of infertility. when the gap between them closes. substances, particularly food colourings

316
 FOOD INTOLERANCE

Immediate reactions, which occur with-

FOOD ADDITIVES in an hour (or sometimes only minutes)
Most additives approved by the EU have been given an E number, which must of eating the trigger foods, include
be listed by type and name and/or by number on food labels. Some examples swelling of the lips, tingling in the
of food additives and foods in which they are used are shown below. Antioxidants mouth or throat, vomiting, abdominal
improve the keeping qualities of certain foods by preventing undesirable chemical distension, abnormally loud bowel
changes. Preservatives also improve keeping quality, but by inhibiting growth of sounds, and diarrhoea. Serious food
microorganisms. Emulsifiers and stabilizers improve the texture of foods. allergies can cause anaphylactic shock,
Sweeteners improve palatability and reduce dental problems associated with which requires immediate self-injection
excess sugar intake. with adrenaline (epinephrine). The only
effective treatment for food allergy is
Additive Comments Often used in avoidance of the offending food. (See
also food intolerance.)
Anti0xidants F
food-borne infection
E300–302 L-ascorbic acid/ascorbates (vitamin C) Fruit drinks Any infectious illness caused by eating
E307 Synthetic alpha-tocopherol Cereal-based baby foods
food contaminated with viruses, bacte-
ria, worms, or other organisms.
E322 Lecithins Low-fat spreads There are two mechanisms by which
food can become infected. Firstly, many
Colours animals that are kept or caught for food
may harbour disease organisms in their
*E102 Tartrazine (yellow/orange)Soft drinks Soft drinks tissues or organs; if meat or milk from
such an animal is eaten without being
*E104 Quinoline yellow (greenish/yellow) Smoked fish
thoroughly cooked or pasteurized, the
E160 Carotenes/Annatto (orange) Cheese organisms may cause illness in their
human host. In the UK, the only com-
Emulsifiers and stabilizers mon infection of this type is food
poisoning. Secondly, food may be conta-
E406 Agar (extracted from seaweed) Ice cream
minated with organisms spread from an
infected person or animal, usually by
E412 Guar gum (extracted from cluster beans) Packet soups flies moving from faeces to food (see
E440 Pectin (occurs naturally in fruits Jams, preserves Food poisoning box overleaf).
and plants) Immunization is available against
certain food- and water-borne infections,
Preservatives such as typhoid fever.
food challenge
*E210–219 Benzoic acid/benzoates Fruit products
The controlled reintroduction into the
*E220–227 Sulphur dioxide/sulphites Meat products diet of a food suspected of causing
*E249–252 Nitrites/nitrates Cooked and cured meats symptoms. Food challenges are usually
attempted after a person has already
Sweeteners been following an exclusion diet.
food fad
*E950 Acesulfame-K Baked goods, dairy products, A like or dislike of a particular food or
confectionery foods that is taken to extremes. A food
*E951 Aspartame Carbonated drinks, fad may lead to undue reliance on, or
sugar substitutes avoidance of, a particular food. Fads are
*E954 Saccharin Sugar substitutes, chewing gum common in toddlers, adolescents, and
people who are under stress. When a
*Warning: may produce reactions in susceptible people food fad becomes obsessive or persis-
tent, however, it may indicate a serious
eating disorder. (See also anorexia ner-
such as tartrazine, may be a contribu- fairly common food allergy in young vosa; bulimia.)
tory factor in behavioural problems in children. Other foods that are com-
children, but this is difficult to confirm. monly implicated in food allergy are food intolerance
nuts (particularly peanuts), wheat, fish, An adverse reaction to a food or an
food allergy shellfish, and eggs. Food allergy is more ingredient of food that occurs each
An inappropriate or exaggerated reac- common in those who suffer from other time an individual eats the substance.
tion of the immune system to a food. forms of allergy or hypersensitivity, such Food intolerance does not have a psy-
Sensitivity to cows’ milk protein is a as asthma, allergic rhinitis, and eczema. chological cause; it is not the result of

317
 FOOD POISONING

FOOD POISONING

Some animals, including cows, pigs, poultry, and shellfish, can be transmitted in this way. Adequate pasteurization of
harbour disease organisms (such as bacteria, viruses, worms, milk and the inspection of meat and fish before they go on
and parasites) in their tissues; these organisms may cause sale prevent most infections and infestations of this type from
infection if meat, fish, or dairy products are consumed raw or occurring. Thorough preparation and cooking of meat, fish,
are improperly cooked. Beef, pork, and fish tapeworm shellfish, poultry, and eggs further reduce the risk of infection.
infestations, salmonella poisoning, and (rarely) brucellosis

FOOD CONTAMINATION

Intestinal infections may be spread from person to The or

g
F person if organisms in faeces contaminate food,
either directly or indirectly. Contamination can occur if a
rso
a
n vi it,
pe eat, fr
u
elsewh anism
the fae ere, c s mu
ce s aus lti
vegetable crops are sprayed with sewage, if flies settle s to as m . ing ply
as uch ill
on faeces and then on food, or if food is handled by a

in ss,
s

ish fo s p

ne
th an
,
ellf ed m
od
person who has not washed his or her hands.

ei dp
or sh minat anis

nte ass
conta ive org

sti n out in
.

es a
Infect

nd
Contaminating organism
The or fli es, o hellf
hands mpl e, s

The photograph (left),

for exa

flies nate
taken through an electron
gan

i
n
microscope, shows a
,

.
up ntam
ck ay a tio
typical Salmonella
ism r sew sh o

pi m nit
ed co
by
bacterium. The organism
sm a rc

e ces d sa
uses its many flagellae
ay ge

ae an
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(whiplike structures) to
i

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move. Salmonella is a h to gie f

ro at h foo hy n
common contaminant of ps as d v s of ms i ay b
. co i a dar d is m
poultry, eggs, and egg nta
min If stan , o rgan s or
d
products and may cause ated, are low ’s han
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severe food poisoning. peopl

food poisoning: and it does not involve or parasites. The illness is more com- unlikely to be heavily contaminated,
the immune system. mon in hot weather. However, but eggs that are kept for
Food intolerance is commonly of Food poisoning is usually suspected more than a couple of weeks should be
unknown cause. Certain foods may be when, for example, several members thoroughly cooked before being eaten.
poorly tolerated as a result of impaired of a household (or customers at a par- Bacteria may also be transferred to food
digestion and absorption, which may ticular restaurant) become ill after from the excrement of infected animals
be associated with disorders of the eating the same food. or people; the bacteria can be transmit-
pancreas or of the biliary system (which BACTERIAL CAUSES ted either by flies or through poor
produce digestive juices to break down The bacteria commonly responsible for personal hygiene.
food). Some individuals have a genetic food poisoning belong to the groups Some types of bacteria cause the
deficiency of a specific enzyme, such SALMONELLA, CAMPYLOBACTER, and E. COLI, formation of toxins, which may be dif-
as lactase (which is required for the certain strains of which are capable of ficult to destroy even after thorough
digestion of lactose, the sugar that multiplying rapidly in the intestines to cooking. For example, the organism
occurs in milk); on drinking milk, cause widespread inflammation. Food CLOSTRIDIUM PERFRINGENS is resistant to
those people with lactose intolerance poisoning may also be caused by LISTERIA heat, and it may survive in precooked
develop abdominal cramps, flatulence, (see listeriosis). foods, such as pies, that have been
and loose stools. Certain farm animals, especially poul- incorrectly stored. Botulism is an un-
try, commonly harbour the bacteria that common, life-threatening form of food
food poisoning are responsible for food poisoning. If poisoning that is caused by a bacterial
A term used to describe any gastro- frozen poultry is incompletely thawed toxin. The foods most likely to cause
intestinal illness of sudden onset that is before being cooked, or if it is botulism are home-preserved fruit,
likely to have been caused by contami- not cooked thoroughly, it is liable to vegetables, and fish.
nated food or water. Most cases of food cause food poisoning. Eggs laid by VIRAL CAUSES
poisoning are caused by contamination affected poultry may also contain dis- The viruses that are most commonly
of food or water by bacteria, viruses, ease-causing bacteria. Fresh eggs are responsible for food poisoning are

318
 FOOT

astrovirus, rotavirus, and a small poisoning by a chemical or bacterial walking; the second function of the
round-structured virus (SRSV), which toxin is suspected, the stomach may be foot is to act as a lever that propels the
affects shellfish. This form of poison- washed out (see lavage, gastric). body forwards.
ing can occur when raw or partly Except for botulism and some cases STRUCTURE
cooked foods have been in contact of mushroom poisoning, most food The largest bone of the foot, the heel-
with water that has been contaminated poisoning is not serious; recovery usu- bone (see calcaneus), is jointed with
by human excrement. ally occurs within about three days. the ankle bone (the talus). The tarsal
OTHER INFECTIVE CAUSES Some strains of E. COLI can seriously bones are located in front of the talus
The protozoan parasite CRYPTOSPORIDIUM damage red blood cells, causing kidney and calcaneus and they are jointed to
(see cryptosporidiosis), which princi- failure (see haemolytic–uraemic syndrome). the five metatarsal bones. The bones of
pally affects farm animals, can be (See also cholera; dysentery; seafood poi- the toes are called the phalanges; the
passed on to humans through drinking soning; typhoid fever.) big toe has two phalanges and all the
water supplies, swimming pools, or by PREVENTION remaining toes have three.
direct contact with infected animals. Some simple measures can virtually Tendons passing around the ankle F
People with HIV infection or AIDS are eliminate the risk of food poisoning. connect the muscles that act on the
particularly susceptible to contracting Hands should always be washed before various bones of the foot and toe. The
this type of food poisoning. food is handled, and fresh fruit and main blood vessels and nerves pass in
NONINFECTIVE CAUSES vegetables should be rinsed in clean front of and behind the inside of the
There are a number of noninfective water. Cutting boards and implements ankle to supply the foot. The under-
causes of food poisoning including that have been used for raw meat surface of a normal foot forms a
poisonous mushrooms and toadstools should be washed with hot water be- natural arch that is supported by liga-
(see mushroom poisoning), fresh fruit fore being used for other foods. Meat, ments and muscles. Fascia (fibrous
and vegetables contaminated with high poultry, and eggs must be cooked thor- tissue) and fat form the sole of the
doses of insecticide, and chemical poi- oughly. Raw and cooked foods should foot, which is covered by a layer of
soning from some foods, such as fruit be stored well apart in the refrigerator, tough skin.
juice, that are stored in containers and raw meat should be kept in the DISORDERS
made partly from zinc. coldest part. Advice should be sought Injuries to the foot often result in frac-
Certain foods, such as puffer fish, when preparing unfamiliar foods. ture of the foot bones (the metatarsals
considered a delicacy in Japan, or cas- and phalanges). The calcaneus may
sava, a staple food in many tropical foot fracture following a fall from a height
countries, can also cause moderate to The foot has two vital functions. The on to a hard surface.
lethal poisoning if improperly cooked first of these functions is to support Congenital foot abnormalities are
or prepared. the weight of the body in standing or fairly common and include club-foot
SYMPTOMS (see talipes), flat-feet, and claw-foot. A
The onset of symptoms depends on the bunion is a common deformity of the
cause of poisoning. Symptoms usually ANATOMY OF THE FOOT foot in which a thickened bursa (fluid-
develop within 30 minutes in cases of filled pad) lies over the joint at the base
An adult has 26 bones (about one
chemical poisoning, between one and eighth of the total number in the of the big toe.
12 hours in cases of bacterial toxins, entire skeleton) in each foot. The Corns are small areas of thickened
and between 12 and 48 hours with calcaneus is attached to the talus skin that are usually caused by tightly
most bacterial and viral infections. above. In front are the navicular, fitting shoes. Verrucas (see plantar
Symptoms of food poisoning usually cuboid, and cuneiform bones, which warts) develop on the soles of the feet.
include diarrhoea, nausea and vomit- are attached to the metatarsals. The Athlete’s foot is a fungal infection that
ing, stomach pain, and, in severe cases, phalanges form the toes. affects the skin between the toes,
shock and collapse. Botulism affects the causing it to become very itchy, sore,
nervous system, causing visual distur- Calcaneus and cracked.
bances, difficulty with speech, para- Gout is a relatively common type of
Talus
lysis, and vomiting. arthritis that often affects the joint at
DIAGNOSIS the base of the big toe or one of the
Cuboid
The diagnosis of bacterial food poison- joints in the foot. An ingrowing toenail
ing can usually be confirmed from (see toenail, ingrowing) commonly oc-
Navicular
examination of a sample of faeces. curs on the big toe and may lead to
Chemical poisoning can often be diag- Cuneiforms inflammation and infection of the
nosed from a description of what the surrounding tissues (see paronychia).
person has eaten, and from analysis of a Metatarsals Foot-drop is the inability to raise the
sample of the suspect food. foot properly causing it to drag along
TREATMENT the ground when the person is walk-
Mild cases can be treated at home by Phalanges
ing. The condition may occur as a
replacement of lost fluids (see rehydra- result of damage to the muscles in the
tion therapy). In severe cases, or when leg that are responsible for performing
the very young or elderly are affected, this movement or, alternatively, to the
hospital treatment may be necessary. If nerves that supply these muscles.

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 FOOT-DROP

foot-drop forced vital capacity

A condition in which the foot cannot The largest volume of air that can be OBSTETRIC FORCEPS
be raised properly and hangs limp expired following a deep inhalation.
The two wide, blunt blades are
from the ankle, causing it to catch on Forced vital capacity (FVC) is one of designed to fit around the baby’s
the ground when the affected person the variables measured in a lung func- head. The handles are inserted
is walking along. tion test (see pulmonary function tests), separately and lock together so that
Neuritis (inflammation of a nerve) which is carried out to check for a the blades are held apart.
affecting the nerves that supply the variety of lung disorders. There are several different
foot muscles is a common cause. This sizes and shapes,
condition may be due to diabetes melli- forceps depending on the
tus, multiple sclerosis, or a neuropathy A tweezerlike instrument that is used position of
(nerve disease). Weakness in the foot for handling tissues or equipment dur- the baby.
muscles can also result from pressure ing surgical procedures. Various types
F on a nerve at the point where it leaves of forceps have been designed for spe-
the spinal cord, due to a disc prolapse cific purposes. For example, forceps FORCEPS
or a tumour. Damage to the muscles in that are used for holding and removing
the leg from an injury may also be a wound dressings have scissor handles
cause of foot-drop. to make manipulation easier; tissue
The underlying cause is treated, but forceps have fine teeth at the tip of
in many people the weakness persists. each blade so that body tissues can be
A lightweight plastic caliper splint may handled delicately during surgery. (See
be used to keep the foot in place when also forceps delivery.)
the person is walking.
forceps delivery
foramen The use of specially designed forceps
A natural opening in a bone or other (see forceps, obstetric) to ease out the
body structure, usually to allow the baby’s head during a difficult birth
passage of nerves or blood vessels. For (see childbirth). Positioning
The forceps blades lie along the sides of the
example, the foramen magnum is a WHY IT IS DONE baby’s head just in front of the ears.
hole in the base of the skull through Forceps delivery is used if the mother
which the spinal cord passes. is overtired or unable to push out her
baby unaided, or if the baby is show-
Forbes–Albright syndrome ing signs of fetal distress. Forceps are Obstetric forceps are of various types
A condition that is characterized by also used to control the baby’s head but basically consist of two blades that
amenorrhoea (the absence of menstrua- once the body has been delivered in cup around the baby’s head.
tion) and galactorrhoea (the production breech delivery to prevent an overly
of breast milk) that is not associated rapid birth. They may also be used if Fordyce’s disease
with pregnancy. Forbes–Albright syn- the baby’s head is stuck in the middle A fairly common condition consisting
drome is usually the result of a pituitary of the mother’s pelvis and needs to be of raised yellow patches on the lips
tumour that secretes excessive amounts rotated to make delivery possible. and gums and in the lining of the
of the hormone prolactin. Treatment HOW IT IS DONE mouth. The patches are composed of
with the drug bromocriptine may sup- The mother is given a painkiller and misplaced sebaceous glands. The disease
press prolactin production. However, either local or epidural anaesthesia. She is also known as Fordyce’s granules.
surgical removal of the tumour may be lies on her back, with her legs raised The condition is not serious and does
necessary. in stirrups. Forceps can be applied only not usually need treatment.
if the cervix (neck of the uterus) is
forced expiratory volume fully dilated and the baby’s head is forebrain
The maximum volume of air that can, engaged in the pelvis. An episiotomy The foremost, and largest, of the main
over a given period of time, be forcibly (making a cut in the perineum) is usu- divisions of the brain. The forebrain is
exhaled from the lungs, usually over ally needed for a forceps delivery. The responsible for controlling many of the
one second. Forced expiratory volume forceps blades are placed on either side brain’s higher functions, including
(FEV) tests are often carried out in of the baby’s head, just in front of the conscious thought.
conjunction with forced vital capacity ears, and gentle traction is applied to
(FVC) tests to check for a variety of bring about delivery of the baby. foreign body
lung disorders. (See also pulmonary Recovery and care for mother and An object that is present in an organ
function tests.) child is usually the same as after a or passage of the body but should not
A low result may indicate one of a vaginal delivery. be there. A foreign body may enter
variety of disorders, including chronic the body accidentally (for example, by
obstructive pulmonary disease (see forceps, obstetric inhalation or swallowing), or it may
pulmonary disease, chronic obstructive) Surgical instruments that are used in be introduced deliberately (for exam-
and diminished lung volume, such as forceps delivery to deliver the head of a ple, a child pushing a bead into a
that found in emphysema. baby in a difficult labour and birth. nostril). The most common sites for

320
 FOX–FORDYCE DISEASE

foreign bodies include the airways (see ballooning of the foreskin. There may formulary
choking), ears (see ear, foreign body in), also be recurrent balanitis (infection of A book of formulae. The term “formu-
eyes (see eye, foreign body in), rectum, the glans). Erection is frequently pain- lary” is commonly used to refer to a
and vagina. ful, which is why the condition is publication that lists drug preparations
often discovered only at puberty. In and their components and effects. The
foremilk paraphimosis, the foreskin becomes contents of a formulary may be decid-
The breast milk that is produced at the stuck in the retracted position, causing ed by a group of medical professionals
beginning of a feed (see breast-feed- painful swelling of the glans that who are working together to ensure
ing). Foremilk is bluish in appearance; requires emergency treatment. similar patterns of drug usage.
it contains lactose and proteins, but lit-
tle fat. (See also hindmilk.) forewaters fornix
A term that is commonly used to refer An archlike structure or the space
forensic medicine to the amniotic fluid (the “waters”) that encompassed by such a structure. The
The branch of medicine that is con- is discharged from the uterus when term is used to describe the fornix F
cerned with the law, especially criminal the part of the amniotic sac in front of cerebri, a triangular structure of white
law. A forensic pathologist is a doctor the presenting part of the fetus rup- matter in the brain, and also the recesses
who specializes in the examination of tures just before childbirth. This may of the vagina around the cervix.
bodies when it appears that death was happen before or after the onset of
the result of unnatural causes. Forensic labour. (See also hindwaters.) Fosamax
specialists may examine victims of A brand name for alendronate sodium
alleged sexual assault. forgetfulness (see alendronic acid), a drug for certain
Forensic scientists use laboratory The inability to remember (see mem- bone disorders (see bone, disorders of).
methods to study body fluids (such as ory). (See also amnesia.)
blood and semen) found on or near the fossa
victim and compare them with samples formaldehyde A depression or hollow area. Examples
obtained from suspects. Forensic scien- A colourless, pungent, irritant gas. In include the posterior fossa, which is an
tists are also trained in ballistics and in medicine, a solution of formaldehyde area at the back of the base of the brain
the identification of fibres from materi- and a small amount of alcohol in occupied by the cerebellum, and the
als such as clothing. In addition, water, a preparation known as forma- cubital fossa, which is the hollow at
forensic scientists may advise on blood lin, is used as a preserving medium for the front of the elbow joint.
groups and genetic fingerprinting in cer- tissue specimens or to harden them
tain legal investigations. before they are stained and examined. Fothergill’s disease
Formalin is also used as a disinfectant. An alternative name for trigeminal neu-
forensic psychiatry ralgia,a disorder of the trigeminal nerve
A branch of psychiatry specializing in forme fruste (the fifth cranial nerve, which supplies
the diagnosis of mental illness related The term that is used to describe any the facial muscles).
to criminal behaviour. disease that does not follow its usual
course. One example of forme fruste is fovea
foreplay when certain characteristic symptoms An area situated near the centre of the
A sexually stimulating activity that of the disease fail to appear; another retina that has the highest concen-
commonly precedes sexual intercourse example is when the progression of tration of light-sensitive cells. The
but may also occur independently. the disorder terminates at an earlier fovea allows detailed vision. (See also
Foreplay can involve any of a range of stage than expected. colour vision.)
activities, including kissing, caressing,
and oral sex. formication Foville’s syndrome
An unpleasant sensation, as though A neurological condition that results
foreskin ants were crawling over the skin. from damage to tissue (usually infarc-
The popular name for the prepuce, This feeling may occur following abuse tion or a tumour) in the centre of the
which is the loose fold of skin that of certain drugs, such as alcohol or brainstem. The damage causes numbness
covers the glans (head) of the penis morphine. Scratching of the skin in and paralysis on one side of the face,
when it is flaccid and which retracts an attempt to relieve the sensation can together with impaired eye movement.
during erection. sometimes cause a rash to develop, There is also damage to the motor
At birth, the foreskin is attached to which may result in an incorrect diag- nerve fibres to the opposite side of the
the glans and is not retractable. It sepa- nosis of skin disease. body, causing paralysis or weakness
rates from the glans during the first (see hemiplegia).
three to four years of life. The foreskin formula, chemical
may be removed (see circumcision) for A way of expressing the constituents Fox–Fordyce disease
religious or medical reasons. of a chemical in symbols and numbers. A chronic pruritic (itching) condition,
DISORDERS Water, for example, has the formula found most commonly in women, that
In phimosis, the foreskin remains per- H2O, indicating that each molecule is is characterized by small pimples in
sistently tight after the age of five, composed of two atoms of hydrogen areas where apocrine glands (see sweat
causing difficulty in passing urine and (H2) and one of oxygen (O). glands) are located.

321
 FRACTURE

The pimples of Fox–Fordyce disease are ness at the fracture site. The pain is to an unusual X-linked recessive pattern
caused by the obstruction and rupture often severe and is usually made worse of inheritance (see genetic disorders). Al-
of apocrine ducts in the epidermis (the by movement. though fragile X syndrome principally
outermost layer of the skin). Treatment DIAGNOSIS AND TREATMENT affects males, females can also inherit
with topical retinoids (derivatives of X-rays can confirm the presence of a the disorder. Both men and women can
vitamin A) and antibiotic drugs may help fracture. Bone begins to heal soon after be carriers without having any signs of
to relieve symptoms in patients who it has broken, so the first aim of treat- the disorder.
have suffered from the disease in ment is to ensure that the bone ends In addition to having learning diffi-
the long term. are aligned. Displaced bone ends are culties, affected people may have a
moved back into position, under gen- prominent nose and jaw, and increased
fracture eral anaesthesia, by manipulation either ear length; they are also prone to
A break in a bone. Fractures most often through the skin or through an inci- epileptic seizures and behavioural dif-
occur across the width of a bone, but sion. The bone is then immobilized. In ficulties. Males tend to have large
F can be lengthwise, oblique, or spiral. some cases, the ends of the bone may testes. Some carriers may also show
TYPES be fixed with metal pins or plates. intellectual impairment.
There are two main types of fracture: RECOVERY AND COMPLICATIONS The condition cannot be treated, but
closed (simple) or open (compound). Most fractures heal without any prob- affected children may benefit from
In a closed fracture, the broken bone lems. Healing is sometimes delayed speech therapy, specialist education,
ends remain beneath the skin and little because the blood supply to the affec- and help from a psychologist for any
of the surrounding tissue is damaged; ted bone is inadequate (as a result of accompanying behavioural problems.
in an open fracture, one or both of the damaged blood vessels) or because the Life expectancy is normal, but affected
bone ends project through the skin. If bone ends are not sufficiently close boys usually need lifelong care. Cou-
the ends of the bone have moved out together. If the fracture fails to unite, ples who have a family history of
of alignment, which can occur in internal fixation or a bone graft may be fragile X syndrome may wish to seek
either a closed or an open fracture, the needed. Osteomyelitis (infection of genetic counselling when planning to
fracture is termed “displaced”. bone tissue) is a possible complication have a child.
Fractures may be further divided of open fractures.
according to the pattern of the break: Physiotherapy plays an important part Fragmin
for example, transverse or spiral frac- in rehabilitation following a fracture A brand name for dalteparin, which is
tures of long bones. In a greenstick because complete immobility of a a low molecular weight heparin (an
fracture, the break is not through the bone for a prolonged period can result anticoagulant drug that is used in the
full width of the bone.This type of frac- in loss of muscle bulk in that area and prevention and treatment of abnormal
ture occurs only in children because stiffness in nearby joints. blood clotting).
their bones are more pliable. In an avul- (See also fracture, dental; humerus,
sion fracture, a small piece of bone is fracture of; jaw, fractured; march fracture; Fraley’s syndrome
pulled off by a tendon. Pott’s fracture; radius, fracture of; rib, frac- A rare condition in which the upper-
CAUSES ture of; skull, fracture of; Smith’s fracture; most renal calyces in the kidney (part
Most fractures are the result of a sud- stress fracture; ulna, fracture of.) of the central region where urine col-
den injury that exerts more force on lects before passing out of the kidney)
the bone than it can withstand. The fracture, dental are compressed; this is usually caused
force may be direct, for example when A break in a tooth (see teeth) most by some of the blood vessels that sup-
a finger is hit by a hammer, or indi- commonly caused by falling onto a ply the area. Abdominal pain, back
rect, for example when twisting the hard surface or by being hit in the pain in the area of the kidney, and
foot exerts severe stress on the shin. mouth with a hard object. Fractures blood in the urine are usually the main
In some diseases, such as osteopor- may involve the crown or the root of a symptoms. Possible complications of
osis and certain cancers, the bone is tooth, or both. this syndrome include recurrent uri-
weakened to such an extent that even a Fractures of the enamel can usually nary tract infections and kidney stones
minor injury, or occasionally no injury be repaired by bonding (see bonding, formation (see calculus, urinary tract).
at all, can cause the bone to break; this dental); in some cases, a replacement
is known as a pathological fracture. crown may be fitted (see crown, dental). Franceschetti’s syndrome
Compression fractures of the vertebrae Pulpotomy (removal of part of the pulp A rare genetic disorder, also known as
are common in people suffering from of the tooth) may be performed in Treacher–Collins syndrome, that causes
osteoporosis. Elderly people are most cases where the pulp is damaged. Root severe facial malformations. The con-
prone to fractures because they are fractures may be treated by splinting dition is congenital (present from
more likely to fall and their bones (see splinting, dental), root-canal treat- birth). The nose, cheek bones, lower
are very fragile. ment, or removal of the tooth (see jaw, and chin are deformed, and the
SYMPTOMS AND SIGNS extraction, dental). child may have a receding chin (see
Common sites of fracture include the micrognathia). There is a pronounced
hand, wrist (see Colles’ fracture), ankle fragile X syndrome droop to the outer corners of the eyes.
joint, clavicle (collarbone), and the neck An inherited defect of the X chromosome Surgery to reconstruct abnormal fea-
of the femur (see femur, fracture of). that causes learning difficulties. The dis- tures results in significant improvement
There is usually swelling and tender- order occurs within families according in appearance and function.

322
 FRANCESCHETTI’S SYNDROME

FRACTURES: TYPES AND TREATMENT

There are two main types of fracture: Compound fracture Simple fracture
simple (closed) and compound (open). A sharp piece of bone The broken bone does
Within these two categories are several punctures the skin and not break the skin.
is therefore exposed to Because organisms do
other types, three of which are organisms. There is a not come into contact
illustrated to the right. high risk of infection. with the fracture,
infection is rare.

Greenstick fracture
This type usually
occurs in children.
Sudden force causes
only the outer side of
the bent bone to break.
F
Transverse fracture
This may result from a
sharp, direct blow or
be a stress fracture Comminuted fracture
caused, for example, The bone shatters into
by prolonged running. more than two pieces.
This fracture is usually
caused by severe force,
such as in a car
accident.

REPAIR OF FRACTURES
There are various ways of repairing
fractures depending on the particular
bone, the severity of the fracture, and
the age of the patient.

Internal fixation
The photograph
(left) shows the
repair of a fracture
in the hip. A metal
pin has been
inserted through the External fixation
neck of the femur Immobilization may be achieved by means of
and is held in place a plaster cast (above) or, in cases such as an
by a plate screwed unstable fracture of the tibia (left and above
to the shaft. left), through the use of metal pins inserted into
bone on either side of the break and locked into
position on an external metal frame.

THE BONE HEALING PROCESS

After a fracture, the bone starts to

heal immediately. Any displacement 2cells)Macrophages
(immune system
invade the fracture
Remodelling
4denser,
takes place, with
stronger
of the bone ends must therefore be
corrected without delay to minimize site to remove wound bone being laid
debris. Fibroblasts then down. New blood
deformity. create a mesh to form a vessels have
base for new tissue. formed.

New bone (callus) is Over a period of

1the Aforms
blood clot
between
bone ends,
3the ends
laid down between
of the bones
5returns
weeks, the bone
to its former
sealing off the ends and over the fracture line. shape.
of the damaged
vessels.

323
 FRASER’S SYNDROME

Fraser’s syndrome that occurs with aging and to the dev- Friedreich’s ataxia
An inherited condition in which there elopment of cancers and possibly heart A rare inherited disease in which
is cryptophthalmos (absence of the disease. Free radicals and their effects degeneration of nerve fibres in the
opening between the upper and lower may be neutralized by antioxidants, spinal cord causes loss of coordinated
eyelids) together with malformations of such as vitamin C and vitamin E. movement and balance.
the ear; cleft palate (see cleft lip and SYMPTOMS
palate); narrowing of the larynx (the frenulum Symptoms tend to appear between the
voice-box); syndactyly (fusion of two or Any fold of tissue or mucous membrane ages of five and 15 years. Early signs of
more fingers or toes); imperforate anus that limits the movement of an organ or the condition include difficulty in
(see anus, imperforate); cardiac defects, part of the body. One example of a walking and deformities of the lower
kidney malformation; and genital masc- frenulum is the fold of mucous mem- legs and feet, such as claw-foot. The dif-
ulinization in females. Fraser’s syndrome brane on the inside of the upper lip that ficulty in movement then extends to
is inherited as an autosomal recessive connects the lip to the gum; another the arms and trunk. Once symptoms
F genetic trait (see genetic disorders). example is the attachment of the fore- have developed, the disease becomes
Many babies born with Fraser’s syn- skin to the glans (head) of the penis. progressively more severe; the muscles
drome die within the first year of life. then weaken and waste away. A gradual
For those who survive, surgery to the frequency loss of sensation occurs in the extremi-
eyelids and corneas may provide some See urination, frequent. ties, which may eventually spread to
degree of vision and eyelid movement. other parts of the body; speech
Freudian slip becomes slow and slurred; and nystag-
fraternal twins A slip of the tongue or a minor error mus (involuntary, jerky eye move-
An alternative term for dizygotic twins. of action that could betray what the ments) is common.
person really wanted to say or do. Other symptoms include chest pain,
freckle shortness of breath, and palpitations.
A tiny patch of pigmentation that occurs Freudian theory Many people with Friedreich’s ataxia
on sun-exposed skin. Freckles tend to A discipline that was developed by Sig- develop heart problems, such as cardio-
become more numerous with contin- mund Freud (1856–1939), a Viennese myopathy (disease of the heart muscle)
ued exposure to sunlight. A tendency neurologist. The theory developed out and abnormalities of the heart rhythm
to freckling is inherited and occurs of Freud’s treatment of neurotic patients (see arrhythmia, cardiac).
most often in fair and red-haired peo- using hypnosis and, later, the interpreta- TREATMENT AND OUTLOOK
ple. Freckles are harmless. tion of their dreams. The Freudian Treatment can help with the symptoms
theory formed the basis of the tech- but cannot alter the course of the
free-floating anxiety nique of psychoanalysis. disease. Braces or surgery may be used
An all-pervasive feeling of apprehen- Freud believed that an individual’s to correct deformities, physiotherapy
sion or tension with no apparent cause. feelings, thoughts, and behaviour were may help to maintain movement for as
Free-floating anxiety is often associated controlled by unconscious wishes and long as possible, and drugs can be given
with generalized anxiety disorder. conflicts originating in childhood. Prob- for heart conditions. However, most
lems are said to occur when the desires affected people die in early adulthood.
Freeman–Sheldon syndrome are not fulfilled or if conflicts remain
A rare congenital disorder with the fol- unresolved into adulthood. frigidity
lowing characteristics: sunken eyes; The essence of Freud’s theory con- A lack of desire for sexual contact
under-development of the cartilage of cerns early psychological development, or an inability to become aroused dur-
the nose; pursed lips; various skeletal particularly sexual development. Freud ing stimulation (see sexual desire,
malformations; and muscle weakness. defined three developmental stages: inhibited). (See also orgasm, lack of.)
Intelligence and life expectancy are oral, anal, and genital (representing the
normal. Freeman–Sheldon syndrome is areas of the body on which the infant’s frontal
usually inherited as an autosomal attention becomes fixed at different A term referring to the front part of an
dominant genetic trait (see genetic dis- ages). He also identified three compo- organ (for example, the frontal lobe of
orders). Affected children may need nents of personality: the id, the ego, the brain).
corrective surgery to improve deformi- and the superego (based respectively on
ties of the face, hands, or feet. pleasure, reality, and moral and social frostbite
constraints). (See also psychoanalytic Damage to body tissues caused by
free radicals theory; psychotherapy.) extremely cold temperatures. Frostbite
Highly active molecules that bind to can develop at any temperature below
and destroy body cells. Free radicals can friar’s balsam freezing; the lower the temperature,
be formed as a result of the effects of A brand name for the aromatic liquid the more rapidly the frostbite will dev-
external sources such as smoke, sun- tincture of benzoin. Friar’s balsam is elop. The risk of frostbite is increased
light, and food. They are produced in used with hot water as a steam inhala- by windy conditions.
the body principally as a result of the tion to help relieve nasal congestion, Frostbite can affect any part of the
chemical reactions involved in metabo- acute rhinitis, and sinusitis, as well as body, but the extremities (the nose,
lism. They are thought to contribute to to loosen coughs. Friar’s balsam is ears, fingers, and toes) are most sus-
the cumulative damage to body cells available over the counter. ceptible and tend to be affected first.

324
 FUGUE

People who have impaired circulation, results can be used to determine the dependent on insulin. For this reason,
such as those with diabetic vascular dis- appropriate surgical treatment. The sur- fructose can prove an important ele-
ease, are at increased risk. geon removes a sample of tissue and ment in the diet of people suffering
SYMPTOMS sends it to the pathology laboratory for from diabetes mellitus.
The first symptom of frostbite is a analysis. The sample is quickly frozen
pins-and-needles sensation, followed by in liquid nitrogen, cut into very thin frusemide
complete numbness in the affected sections, placed on a glass slide, and An alternative name for furosemide, a
region. The affected skin appears white, stained so that the cells can be exam- diuretic drug.
cold, and hard; it may then become ined under the microscope. The entire
red and swollen. process takes about 20 minutes. Infor- frustration
TREATMENT AND OUTLOOK mation about the sample is then A deep feeling of discontent and ten-
Treatment of frostbite involves rewarm- conveyed to the operating theatre. sion as a result of unresolved problems
ing the affected areas by immersion in or unfulfilled needs, or because the
warm water (ensuring that it is not too frozen shoulder individual’s path to a goal is blocked. F
hot to touch), then applying bandages. Stiffness and pain in the shoulder that In some people, frustration can lead
When warmed, mildly affected tissues limits normal movement of the joint. to regression (childlike behaviour),
become red, swollen, and sore. If frost- In severe cases of frozen shoulder, the aggression, or depression.
bite is more severe, blisters appear, and shoulder may be completely rigid, and
the area becomes very painful. pain may be intense. FSH
If the damage is restricted to the CAUSES An abbreviation for follicle-stimulating
skin and the tissues that immediately Frozen shoulder is caused by inflam- hormone, a gonadotrophin hormone pro-
underlie it, rewarming may result in mation and thickening of the lining of duced by the pituitary gland.
complete recovery of the tissues. the joint capsule. In some cases, it
Recovery from frostbite damage usually occurs following a minor injury to the FTT
occurs within about six months, but shoulder. Frozen shoulder can also The abbreviation for failure to thrive in
some lasting sensitivity to extreme occur if the shoulder is kept immobi- infants and children. A child who fails
temperatures is common. However, fol- lized for a long period of time, such as to grow at the appropriate rate needs
lowing severe frostbite, symptoms following a stroke. In many cases, how- tests to determine the cause.
including stiffness, pain, and numbness ever, the disorder develops for no
may persist indefinitely. apparent reason. Fuchs’ spots
If blood vessels are affected by frost- The condition is more common Pigmented spots that develop on the
bite, gangrene (tissue death) may follow. in people over the age of 40. People retina (the light-sensitive inner layer at
In such circumstances, amputation may with diabetes mellitus are also more sus- the back of the eye). The condition
be necessary. ceptible to developing frozen shoulder. sometimes occurs in people who suf-
TREATMENT fer from a severe degree of myopia
frottage Moderate symptoms of frozen shoul- (shortsightedness).
A sexual deviation in which an indi- der can be eased by exercise, by taking
vidual rubs his or her body against analgesic drugs (painkillers) and non- Fuchs’ syndrome
another person in order to achieve sex- steroidal anti-inflammatory drugs for the A slowly progressing disease that usu-
ual arousal. Typically, this activity is relief of pain and inflammation, and by ally affects both eyes and which may
carried out within a crowd of people applying ice-packs. However, in severe be hereditary. The condition is also
(such as on a crowded train) where a cases of frozen shoulder, corticosteroid known as Fuchs’ corneal dystrophy.
man rubs his (clothed) genitals against drugs may need to be injected into the Fuchs' syndrome occurs when cells in
a woman’s buttocks or thigh. affected joint. the innermost layer of the cornea (the
Manipulation of the joint under gen- transparent front part of the eyeball)
frozen section eral anaesthesia can restore mobility. gradually deteriorate. Fuchs’ syndrome
A method of preparing a biopsy speci- However, this treatment carries the risk may result in pain and severe visual
men (a sample of tissue removed for of increasing pain initially. impairment.
microscopic analysis) that can provide OUTLOOK There is no preventive treatment for
a rapid indication of whether or not a Recovery is often slow, and the shoul- the disease. In some cases, a corneal
tissue is cancerous. der may remain stiff for some months, transplant may eventually be necessary
WHY IT IS DONE but it is usually back to normal and to restore sight.
Frozen section may be used for the pur- pain-free within two years.
pose of determining whether breast Fucithalmic eye drops
lumps are cancerous. The technique fructose A brand of eye drops containing fusidic
can also be used to check whether thy- A simple sugar (monosaccharide) that acid, an antibiotic drug. The drops
roid or intestinal tumours are cancerous is naturally present in honey and certain are used for bacterial conjunctivitis.
and to diagnose lymphomas (cancerous fruits. Fructose and glucose are the two
tumours of lymphoid tissue). components of sucrose (table sugar). fugue
HOW IT IS DONE Fructose can be converted into en- An episode of altered consciousness
Frozen section may be undertaken dur- ergy as easily as glucose but, unlike in which a person purposefully wan-
ing an operation in order that the glucose, fructose metabolism is not ders away from home or work and,

325
 FULMINANT

in some cases, adopts a new identity. Usually, however, they are prevented on the infected area or given by mouth
Afterwards, the person has no recollec- from multiplying by competition from for generalized infections. (For further
tion of what has occurred. bacteria. Other fungi are kept from information, see Fungal diseases box,
Fugues may last for hours or days. multiplying to a harmful degree by the opposite.)
During a short fugue, the sufferer may body’s immune system.
be confused and agitated. During a Fungal infections are therefore more fungi
fugue lasting for days, behaviour may common in people who are taking Simple parasitic life-forms that include
appear normal but there may be antibiotic drugs (which destroy the bac- yeasts, moulds, mushrooms, and toad-
accompanying symptoms, such as hal- terial competition) and in those whose stools. The fungi that are responsible
lucinations, feelings of unreality, and immune systems are suppressed by for causing disease can be divided into
unstable mood. immunosuppressant drugs, corticosteroid two groups: filamentous fungi and
Fugues are rare. Possible causes in- drugs, by a disorder such as AIDS, or by yeasts. Filamentous fungi are made up
clude dissociative disorders, temporal lobe chemotherapy. Such serious fungal of branching threads known as
F epilepsy, depression, head injury, and infections are described as opportunistic hyphae, which form a network called
dementia. (See also amnesia.) infections because they take advantage a mycelium. Mushrooms and toad-
of the body’s lowered defences. Some stools are the reproductive structures
fulminant fungal infections are more common in (known as fruiting bodies) of a fila-
A term used to describe a disorder that people with diabetes mellitus. mentous fungus that has spread in
develops and progresses suddenly and Fungi that cause skin infections dead matter or soil. Yeasts are single-
with great severity. A virulent infec- thrive in warm, moist conditions, such celled organisms.
tion, a severe form of arthritis, or a as those that occur between the toes FUNGI AND DISEASE
cancer that has spread rapidly is often and in the genital area. The majority of fungi are either com-
described as being fulminant. TYPES pletely harmless or actually beneficial
Fungal infections can be broadly classi- to human health. However, there are a
fumes fied into three categories: superficial number of fungi that can cause illness
See pollution. (affecting the skin, hair, nails, inside of and disease.
the mouth, and genital organs); subcu- The fruiting bodies of some fungi
functional disorders taneous (beneath the skin); and deep contain toxins that may cause poison-
Illnesses in which there is no evidence (affecting internal organs). ing if they are eaten (see mushroom
of organic disturbance even though The main superficial infections are poisoning). Certain other fungi infect
physical performance is impaired. tinea (including ringworm and ath- food crops and also produce toxins
lete’s foot) and candidiasis (thrush), that may cause food poisoning. The
functional endoscopic sinus both of which are common. Tinea best known of these fungi is a species
surgery (FESS) affects external areas of the body. Can- that infects cereals and produces ergot,
Surgery that is carried out in order to didiasis is caused by the yeast CANDIDA a toxin that constricts blood vessels.
improve the drainage of the facial ALBICANS and usually affects the genitals Another fungus that sometimes grows
sinuses or to clear a blockage in them. or inside of the mouth. on peanuts and produces aflatoxin, a
The procedure, which involves the use Subcutaneous infections are rare. poison and carcinogen.
of an endoscope, enlarges the drainage The most common is sporotrichosis, The inhaled spores of some fungi
holes leading to the nose. which may follow contamination of a can cause allergic alveolitis, a persistent
scratch. Most other conditions of this allergic reaction in the lungs. Farmer’s
fundus type, the most important of which is lung, which is caused by spores from
The bottom or base of an organ, or the mycetoma, occur mainly in tropical mouldy hay, is an example of such a
part that is farthest away from the countries. reaction. Fungal spores are sometimes
organ’s opening. The optic fundus is Deep fungal infections are uncom- responsible for various other allergic
the back of the retina as viewed mon, but they can present a serious disorders, such as allergic rhinitis (hay-
through an ophthalmoscope. threat to people who have an immune fever) and asthma.
deficiency disorder or those who Some fungi are capable of invading
fungal infections are taking immunosuppressant drugs. the body and forming colonies in var-
A wide range of diseases that are Fungal infections of this sort include ious parts of the body such as the
caused by the multiplication and aspergillosis, histoplasmosis, cryptococco- lungs, the skin, or sometimes in a var-
spread of fungi. Fungal infections, also sis, and blastomycosis, all of which are iety of tissues throughout the body,
known as mycoses, range from mild caused by different species of fungi. leading to conditions that range from
and barely noticed to severe and some- The fungal spores enter the body mild irritation to severe, even fatal,
times even fatal. (In addition to through inhalation into the lungs. Can- widespread infection (see fungal infec-
infections, fungi are also responsible didiasis can also spread from its usual tions) and illness. For further
for some allergic disorders, such as sites of infection to affect the oesoph- information, see Fungal diseases box,
allergic alveolitis and asthma.) agus, the urinary tract, and other opposite. (See also candidiasis.)
CAUSES internal tissues.
Some fungi are harmlessly present all TREATMENT fungicidal
of the time in areas of the body such as Treatment of fungal infections is with A term used to describe the ability to
the mouth, skin, intestines, and vagina. antifungal drugs, either used topically kill fungi (see antifungal drugs).

326
 FYBOGEL

FUNGAL DISEASES

The skin, genitals, and nails are Scalp ringworm

common sites of fungal infection.
Examples include tinea (ringworm) and Candidiasis
(oral thrush)
candidiasis (thrush). Fungi may rarely
infect the lungs and other internal
Lung infection
organs, causing a more serious
disease. They may also cause allergic
lung disease, such as farmer’s lung.
Jock itch

Fungal nail infection

This condition can affect toenails or finger nails.
Onychomycosis
(nail infection) F
It is liable to last for years. Antifungal medications
are of benefit to some people.
Athlete’s foot

Common sites of
fungal infection
Fungi grow best in
Colony of fungal cells warm, moist areas
The microscope photograph (left) shows a colony of the body.
of yeast cells in a skin fragment.

FUNGAL GROWTH

Spores
Spore Hyphae

1haveMany fungal colonies

originate from spores that
been carried in the air
If nutrients are available and
2temperature)
other conditions (such as
are favourable, a
The cells of many fungi
3consisting
divide to form a network
of branched chains of
Eventually, a colony may
4spores.
start to form its own
These spores may be
and have settled at a suitable spore starts to divide. tubular filaments called hyphae. carried to new sites to set up
site for growth. new growths.

funny-bone Furosemide increases the rate at which FVC

A popular term for the small area at potassium is excreted from the body, The abbreviation for forced vital capacity.
the back of the elbow where the ulnar which may cause headaches, dizziness, (See also forced expiratory volume.)
nerve passes over a prominence of the and muscle cramps. In order to prevent
humerus (upper-arm bone). excessive potassium loss, doctors fre- Fybogel
A blow to the nerve causes acute quently give potassium supplements, or A brand name for a bulk-forming laxa-
pain, numbness, and a tingling sensa- alternatively potassium-sparing diur- tive drug.
tion in the forearm and hand. etics, in combination with the drug.
furosemide furuncle
A diuretic drug used in the treatment of An alternative term for a boil.
oedema (the accumulation of fluid in
body tissues) and heart failure. Furos- fusidic acid
emide belongs to a group of drugs A type of antibiotic drug that is used in
known as loop diuretics, which cause a the treatment of a variety of bacterial
rapid, temporary increase in the out- infections that are resistant to penicillin
put of urine. When given by injection, drugs. Fusidic acid is commonly used
furosemide has a very rapid effect; it in preparations applied to localized
may therefore be used in emergencies areas of skin in conditions such as
to relieve pulmonary oedema (a buildup impetigo. The drug is also used in eye
of fluid around the lungs). and ear preparations.

327
 G6PD DEFICIENCY

G6PD deficiency is diagnosed with a the throat.The reflex protects the airway

G
blood test. There is no specific treatment from becoming blocked by debris. If a
available, but symptoms provoked by a person becomes unconscious, however,
drug or food can, however, be prevented the gag reflex may be lost, and the per-
by avoiding that substance. son may be at risk of choking.
GABA gait
The abbreviation for gamma-amino- A term used to describe the manner or
butyric acid. This chemical is a neuro- style of walking. Gait varies from one
transmitter (a chemical released from person to another. An abnormal gait, or
nerve endings that relays messages an unusual change in the gait, may
G6PD deficiency within the nervous system). GABA con- indicate a neuromuscular or brain dis-
An X-linked disorder in which an abnor- trols the flow of nerve impulses by order (such as Parkinson’s disease). (See
mal gene causes a deficiency of G6PD blocking the release of other neuro- also festinating gait.)
(the enzyme glucose 6 phosphate de- transmitters, such as noradrenaline and
galactocele
G hydrogenase) in red blood cells. In a
healthy person, this enzyme contributes
dopamine, that stimulate electrical acti-
vity in the nerve cells; as a result, this A breast cyst that contains milk or a
to a chemical process that protects the activity is inhibited. milky substance. A galactocele can be
cells from damage. G6PD deficiency The action of GABA is enhanced by caused by obstruction of a milk duct in
makes the red cells prone to damage or benzodiazepine drugs, anticonvulsant drugs, the breast during breast-feeding. In most
destruction by infectious illness or by and possibly alcohol. In contrast, it has cases, it occurs at the end of breast-
certain drugs or foods. been suggested that people with Hunt- feeding when milk is allowed to
The disorder most commonly affects ington’s disease (an inherited disorder stagnate in the breast. The swelling may
southern European and black men. that causes a loss of brain function and occasionally become infected, leading
Women are unaffected but they can abnormal movements) suffer degen- to a breast abscess. Usually, no treatment
carry the abnormal gene and are at risk eration of GABA-secreting brain cells, is needed; the fluid is reabsorbed, or
of passing it on to their sons. leading to overstimulation of the basal can be expelled by massaging the breast
Some drugs, such as certain antimalar- ganglia (an area of the brain that helps towards the nipple.
ial drugs and antibiotics, may precipitate coordinate movement) and producing
haemolysis (destruction of red cells) in the typical symptoms. galactokinase deficiency
people with the abnormal gene; see the A rare, inherited condition in which
table below for drugs that may pose this gabapentin there is a deficiency of galactokinase, an
risk. In one form of G6PD deficiency, An anticonvulsant drug used either alone enzyme involved in the breakdown of
called favism, haemolysis may be trig- or with other anticonvulsants to treat galactose (a simple sugar that is derived
gered by a chemical in broad beans, and some types of epilepsy. Common side from the milk sugar lactose). Galactoki-
affected people must avoid eating them. effects include drowsiness, dizziness, nase deficiency is an autosomal recessive
After taking a precipitating drug or unsteadiness, and fatigue. genetic disorder. The condition leads to a
food, or during an infectious illness, an form of galactosaemia (the inability of
affected person develops symptoms of gag reflex the body to convert galactose into glu-
anaemia (see anaemia, haemolytic), such An automatic impulse to retch, brought cose, another simple sugar). The only
as jaundice, fatigue, headaches, and about by the autonomic nervous system in manifestation of galactokinase defi-
shortness of breath (which may occur response to a particular stimulus, such ciency galactosaemia is cataracts, which
even after mild exertion). as a foreign object touching the back of usually become apparent in affected
babies within the first few weeks of life.
DRUGS TO BE AVOIDED BY PEOPLE WITH G6PD DEFICIENCY galactorrhoea
Class Drugs to avoid
The spontaneous, persistent production
of breast milk by a woman who is
not pregnant or breast-feeding, or, very
Antimalarial drugs Primaquine, chloroquine*, quinine*, quinidine*,
dapsone rarely, by a man. Lactation (milk pro-
duction) is initiated by a rise in the
Antibacterial and antibiotic drugs Nitrofurantoin, sulphonamides level of prolactin, a hormone produced
(such as co-trimoxazole), quinolone drugs by the pituitary gland. Galactorrhoea is
(such as ciprofloxacin and nalidixic acid) caused by excessive secretion of pro-
lactin due either to a pituitary tumour or
Analgesics (painkillers) Aspirin* to another endocrine disorder, such as
hypothyroidism. It may also be caused by
Miscellaneous Vitamin K (water-soluble form), probenecid some antipsychotic drugs.
As well as triggering breast milk pro-
*These drugs do not usually cause problems in the type of G6PD deficiency that affects black people.
duction, excess prolactin may adversely
affect the ovaries, causing amenorrhoea
(absence of menstrual periods) or

328
 GALLBLADDER CANCER

infertility. If the underlying cause is a gallbladder

pituitary tumour, there may be symp- A small, muscular, pear-shaped sac, situ- ANATOMY OF THE
GALLBLADDER
toms associated with the tumour, such ated just beneath the liver, in which bile
as headaches and visual disturbances. is stored and concentrated. The gallbladder receives
Treatment with bromocriptine sup- Bile, which is produced by the liver, bile from the liver via the
presses prolactin production, but the enters the gallbladder via the hepatic common hepatic duct. It
underlying cause of the disorder may and cystic ducts. When food passes expels bile into the small
also require treatment. from the stomach into the duodenum intestine via the cystic duct
(the first part of the small intestine), and the common bile duct.
galactosaemia gastrointestinal hormones make the
Mucous
A rare, inherited condition in which the gallbladder contract. This causes it to membrane
body is unable to convert galactose (a release the bile, via the common bile
simple sugar that is derived from the duct, into the duodenum, where it aids Gallbladder
milk sugar lactose) into glucose (another the breakdown of fats contained in the
simple sugar) due to the absence of a food. (See also biliary system.)
particular enzyme (a protein that acts as
a catalyst to speed up a reaction) in the gallbladder cancer G
liver and in red blood cells. A rare cancer that occurs mainly in the
Galactosaemia causes no symptoms at elderly. It is usually associated with gall- Cystic
duct
birth, but jaundice, diarrhoea, and vom- stones, but affects only a tiny proportion
iting may develop after a few days, and of those people with gallstones.
the baby fails to gain weight. If untreat- Gallbladder cancer may cause jaundice
ed, the disorder may result in liver and tenderness in the abdomen, but it is Common
hepatic
disease, cataracts (opacities in the lenses sometimes symptomless. duct
of the eyes), and learning difficulties. The cancer is usually diagnosed by Serous coat
(covering membrane)
The diagnosis is confirmed by urine ultrasound scanning. Treatment is by sur-
and blood tests. An affected person must gical removal of the tumour, but if the Common bile duct
avoid milk products, and use lactose- cancer has spread to the liver by the
free milk, throughout life. time it is detected, the outlook is poor.

DISORDERS OF THE GALLBLADDER

The gallbladder rarely causes problems Only about 20 per cent of affected people oversized gallbladder, or two
in childhood or early adulthood but, experience symptoms or complications; gallbladders. These defects, however,
from middle age onwards, an increasing many carry “silent’’ gallstones, producing rarely cause problems.
occurrence of gallstones may sometimes no symptoms. Attempts by the gallbladder
give rise to symptoms. to expel the stone or stones, however, can Tumours
The digestive system can function cause severe biliary colic (abdominal pain). Gallbladder cancer usually occurs in a
normally without a gallbladder, and its gallbladder that contains gallstones.
removal has few known long-term Infection and inflammation This cancer is, however, extremely
adverse effects. If a gallstone lodges in the gallbladder uncommon compared to the high
outlet, trapped bile may irritate and inflame prevalence of gallstones.
Metabolic disorders the lining, and bile may become infected.
The principal disorder, with which This disorder is called acute cholecystitis. Other disorders
most other gallbladder problems are The first symptom may be biliary colic, In rare cases where the gallbladder is
associated, is the formation of gallstones. followed by fever and abdominal tenderness. empty and a stone obstructs its outlet,
Every year thousands of people develop Repeated attacks of biliary colic and the gallbladder may become distended
gallstones. Women are affected up to acute cholecystitis can lead to chronic and filled with mucus secreted by its
four times as often as men, depending cholecystitis, in which the gallbladder lining. A gallbladder with this problem
on their age and ethnicity. becomes shrunken and thick-walled and is known as a mucocele.
The formation of gallstones results ceases to function. Rarely, it may become
from a metabolic problem in which the inflamed when no gallstones are present:
chemical composition of bile (the a condition called acalculous cholecystitis. INVESTIGATION
digestive juice stored in the gallbladder) Cholecystitis can proceed to empyema, in
is altered. There are three main types of which the gallbladder fills with pus; a high Gallbladder problems are investigated
gallstone: stones formed from the fatty fever and severe abdominal pain may result. by physical examination and imaging
substance cholesterol; stones made from techniques such as ultrasound scanning,
bile pigments; and mixed gallstones, Congenital and genetic defects radionuclide scanning, or cholecystography,
which contain both cholesterol and Abnormalities that may be present from Blood tests may also be carried out.
pigments. The great majority are mixed. birth include absence of the gallbladder, an

329
 GALLIUM

gallium gamete premenstrual syndrome and eczema. Very

A metallic element whose radioactive A sex cell. Gametes are found in the large doses may cause abdominal pain
form is used in radionuclide scanning (a reproductive systems of adults: sperm and loose stools.
technique using a tiny amount of a are formed in the testes in males, and an
radioactive substance to obtain images ovum (egg cell) is released approximate- ganciclovir
of internal organs). Gallium is injected ly every month from the ovaries in An antiviral drug that is used to treat
into the bloodstream before a scan in females. Sperm and ova come together severe cytomegalovirus infection. Such a
order to reveal areas of inflammation, during fertilization to create offspring. condition occurs in those people whose
such as those that occur in cancers, (See also meiosis.) immune system is impaired or suppres-
abscesses, osteomyelitis, and sarcoidosis. sed because they have AIDS, they are
gamete intrafallopian taking immunosuppressant drugs, or have
gallstone ileus transfer (GIFT) had an organ transplantation.
See ileus, gallstone. A technique for assisting conception (see Ganciclovir is toxic and produces a
infertility) in women. It can only be used range of side effects, including nausea;
gallstones if a woman has functioning fallopian diarrhoea; abdominal pain; weakness;
G Lumps of solid matter found in the
gallbladder (the sac under the liver
tubes. In GIFT, ova (eggs) are removed
from the woman’s ovary during laparo-
and suppression of blood cell formation
in the bone marrow. For this reason, it
where bile is stored) or in the bile ducts scopy (viewing of the interior of the is used only when the benefits are likely
(which connect the gallbladder and liver abdomen) and mixed with sperm in the to outweigh the risks.
to the duodenum). Most gallstones are laboratory. The mixed eggs and sperm
made of cholesterol and bile pigments are introduced into one of the fallopian ganglia
from the breakdown of red blood cells. tubes, where fertilization takes place. A The plural form of ganglion.
CAUSES AND INCIDENCE fertilized egg may then become im-
Gallstones develop due to a disturbance planted in the uterus. ganglion
in the chemical composition of bile. A group of nerve cells that have a com-
They are rare in childhood and become Gamgee tissue mon function; for example, the basal
increasingly common with age. Women The brand name for a material consist- ganglia in the brain are concerned with
are affected more than men. Risk factors ing of a thick layer of highly absorbent the control of muscular movements.
for developing gallstones include a high- cotton wool enclosed in gauze. Gamgee The term is also used to describe a
fat diet and being overweight. tissue may be used for padding and fluid-filled swelling associated with the
SYMPTOMS compression of soft-tissue injuries, but sheath of a tendon. A ganglion may dis-
Most gallstones cause no symptoms. Any may also be used on open wounds, appear spontaneously; if necessary, it
symptoms often begin when a stone such as ulcers, to aid the healing process may be drained or removed surgically.
lodges in the gallbladder outlet. This by applying compression and soaking
problem causes biliary colic (intense pain up body fluids. gangrene
in the upper right area of the abdomen Death of tissue, usually caused by loss
or between the shoulderblades), nausea, gamma aminobutyric acid of the blood supply. Gangrene may
and sometimes indigestion and flatu- See GABA. affect a small area of skin or a large por-
lence. Possible complications include tion of a limb.
cholecystitis (inflammation of the gall- gamma camera SYMPTOMS AND TYPES
bladder) and bile duct obstruction. A piece of equipment used to generate Pain is felt as the tissues are dying, but
DIAGNOSIS AND TREATMENT diagnostic images in radionuclide scan- once dead they become numb. The
Gallstones are usually diagnosed by ning. A tiny amount of a radioactive affected tissue turns black. There are
ultrasound scanning, X-ray oral chole- substance is introduced into the body two types of gangrene: dry and wet.
cystography, or cholangiography. (usually by injection) and taken up by In dry gangrene, the tissue dies as it
Stones that are not causing symptoms the tissues to be examined. The gamma has no blood supply. The gangrene does
are usually left alone. In other cases, the camera detects radiation emitted by the not spread. Dry gangrene may be caused
gallbladder and stones may be surgically material and displays its pattern of by arteriosclerosis, diabetes mellitus,
removed by cholecystectomy. Ultrasonic distribution as an image on a monitor. thrombosis, frostbite, or an embolism.
shock waves (see lithotripsy) are some-
times used to shatter gallstones; the gamma-globulin
fragments pass into the intestines and A substance that contains antibodies
cause no further problems. Drugs such against a specific infection. Injections of
as ursodeoxycholic acid can dissolve some gamma-globulins provide temporary
gallstones if taken over several months, protection against diseases such as chick-
but further stones may form once the enpox and tetanus. (See immunization;
treatment is stopped. immunoglobulin injections.)

gambling, pathological gamolenic acid

A chronic inability to resist impulses to An essential fatty acid found in evening Gangrene of the foot
gamble, resulting in personal, social, primrose oil and starflower (borage) This shows a gangrenous foot, with areas of dead
and/or financial problems. oil. Gamolenic acid may be taken for tissue and blackening of the skin on the big toe.

330
 GASTRITIS

Wet gangrene develops when an area of causing a crackling sensation if the area They usually heal in a few days when
dry gangrene, or a wound, becomes is pressed. Other symptoms that develop treated with antacid drugs, H2-receptor
infected by bacteria. Redness, swelling, early in the infection include sweating, antagonists, or proton pump inhibitors
and oozing pus may occur around the fever, and anxiety. If left untreated, the (see ulcer-healing drugs). Drugs that
blackened tissues.The gangrene spreads, condition may lead to shock (failure of block the production of stomach acid
and the area gives off an unpleasant blood circulation), kidney failure, coma, are often given to people who are at
smell. A virulent type called gas gangrene and even death. high risk of developing erosions, such
is due to a bacterium that destroys mus- Penicillin drugs destroy the bacteria at as those receiving intensive care.
cles and produces a foul-smelling gas. the edges of the gangrene, but all of the
TREATMENT diseased tissue needs to be surgically gastric lavage
Treatment of dry gangrene involves at- removed. Amputation of an affected limb See lavage, gastric.
tempting to improve the circulation to may be required, in some cases, to con-
the affected area before the tissues die. trol the spread of infection. Hyperbaric gastric ulcer
Antibiotic drugs can prevent wet gan- oxygen treatment, in which the patient is A raw area in the stomach wall caused
grene from setting in. exposed to oxygen at high pressure, by a breach of the lining (see gastric ero-
To treat wet gangrene, amputation of
the affected part and the surrounding
may help to kill the bacteria. sion) that penetrates into the tissues. A
gastric ulcer is a type of peptic ulcer
G
tissue may be necessary. gastrectomy (ulcer of the stomach or duodenum).
Removal of the whole stomach (total
Ganser’s syndrome gastrectomy) or of part of the stomach gastrin
A rare factitious disorder in which an (partial gastrectomy). Total gastrectomy A hormone produced by cells in the
individual seeks, either consciously or is used to treat some stomach cancers. stomach lining. Gastrin causes the stom-
unconsciously, to mislead others about Partial gastrectomy used to be a treat- ach to produce more acid and helps to
his or her mental state and may simu- ment for peptic ulcers (ulcers of the propel food through the digestive tract.
late symptoms of psychosis. stomach or duodenum) but has largely (See also gastrointestinal hormones.)
been replaced by drug treatment.
Gardnerella vaginalis A person who has had a gastrectomy gastritis
A bacterium that is often found in may experience fullness and discomfort Inflammation of the stomach lining due
the vaginal discharge of women with after meals. Possible postoperative com- to irritation of the tissues.The condition
bacterial vaginosis. plications include the regurgitation or may be acute or chronic.
vomiting of bile, which may lead to Acute gastritis may be due to infection
gargle inflammation of the stomach or the with the HELICOBACTER PYLORI bacterium.
A liquid preparation to wash and freshen oesophagus; diarrhoea; and dumping It may also be caused by drugs, usually
the mouth and throat. Some gargles syndrome (sweating, nausea, dizziness, nonsteroidal anti-inflammatory drugs such
contain antiseptics or local anaesthetics and weakness after meals, due to food as aspirin; alcohol; or severe physical
to relieve sore throats. leaving the stomach too quickly). Other stress, such as burns or major surgery.
complications include malabsorption (a Chronic gastritis is most often due to
gargoylism reduced ability to absorb nutrients), H. PYLORI infection but may be due to
Another name for Hurler’s syndrome, in which may lead to anaemia or osteoporo- prolonged irritation by smoking, alco-
which the facial features are coarsened. sis (loss of bone density). After a total hol, or bile; by an autoimmune disorder
gastrectomy, patients cannot absorb vit- that damages the stomach lining (see
gas-and-air amin B12 and need injections of the anaemia, megaloblastic); or by degenera-
A mixture of nitrous oxide and oxygen vitamin for the rest of their lives. tion of the lining with age.
that is mainly used for temporary pain Symptoms include discomfort in the
relief in emergencies or during labour. gastric erosion upper abdomen, nausea, and vomiting.
A break in the surface layer of the mem- In acute gastritis, the faeces may be
gas gangrene brane that lines the stomach. Gastric blackened by blood lost from the stom-
A rare but life-threatening form of erosions occur in some cases of gastritis ach (see melaena); in chronic gastritis,
gangrene (tissue death), usually due to (inflammation of the stomach lining). slow blood loss may lead to anaemia
infection by the bacterium CLOSTRIDIUM Many result from ingestion of irritants (see anaemia, iron-deficiency), resulting
PERFRINGENS . This organism thrives in such as alcohol, iron tablets, or aspirin. in symptoms such as pallor, tiredness
anaerobic environments, where there is The physical stress of serious illness, and breathlessness.
little or no oxygen, such as dying tissue. injuries such as burns, or major surgery Diagnosis of gastritis is made through
Gas gangrene develops suddenly and may also cause erosions to develop. gastroscopy (examination of the stomach
normally occurs at the site of a recent, Often there are no symptoms, but lining with a flexible viewing instru-
serious wound. The bacteria multiply in erosions may bleed, causing vomiting of ment), during which a biopsy (removal
the damaged tissue, producing toxins blood or blood in the faeces. Persistent of a tissue sample for analysis) may be
that release a gas, and spread incredibly loss of blood may lead to anaemia. performed. Ulcer-healing drugs and anti-
rapidly to healthy tissue. Gastric erosions are diagnosed by biotics may be prescribed to treat H.
The affected area is swollen and pain- gastroscopy (inspection and examination PYLORI infection. Anaemia will be treated.
ful, and pale or reddish-brown in of the stomach via a flexible viewing There is no treatment for gastritis due
colour. Gas collects in the tissues, instrument; an endoscope). to an autoimmune disorder, however.

331
 GASTROENTERITIS

gastroenteritis
Inflammation of the stomach and intes- HORMONES IN THE DIGESTIVE TRACT
tines, usually causing sudden upsets Gastrin
Hormones released from endocrine
that last for two or three days. Dysentery, cells in the stomach, pancreas, and Secreted mainly by cells in the stomach in
typhoid fever, cholera, food poisoning, and response to eating food (especially protein),
intestine aid digestion by stimulating gastrin causes the stomach to produce more
travellers’ diarrhoea are all forms of the release of bile from the gallbladder acid and stimulates contraction of muscle in
gastroenteritis. Gastroenteritis may be the wall of part of the stomach, ileum, and
and enzymes from the pancreas into colon. This contraction propels food through
caused by a variety of bacteria, bacterial the duodenum. the digestive tract.
toxins, viruses, and other organisms in
Oesophagus
food or water. There are also a number Cholecystokinin
of non-infectious causes, such as food Released by the duodenum
in response to fats and acid, Gallbladder Food enters
intolerance and certain irritant drugs. cholecystokinin causes the the stomach
The usual symptoms are appetite loss, gallbladder to squeeze bile into
the duodenum and stimulates
nausea, vomiting, cramps, and diar- the production of pancreatic
rhoea. Their onset and severity depend enzymes, which pass into
the duodenum through the
G on the cause; symptoms may be mild,
or may be so severe that dehydration,
pancreatic duct.
Stomach
shock, and collapse occur.
Mild cases usually require rest and
rehydration therapy only. For severe ill-
ness, treatment in hospital may be
necessary, with fluids given by intra- Secretin
venous infusion. Antibiotic drugs may be Secreted by the lining of the
given for some bacterial infections, but duodenum in response to acid
entering from the stomach,
others need no specific treatment. secretin acts on the pancreas
to increase the output of
gastroenterology bicarbonate, which neutralizes
acid from the stomach. It also
The study of the digestive system and the increases the release of
enzymes from the pancreas. Duodenum Pancreas
diseases and disorders that affect it.
gastroenterostomy
Surgery that is performed to create a gastroscopy Gaucher’s disease
connection between the stomach and Examination of the stomach via a flexible A genetic disorder in which the lack of
the jejunum (the middle two thirds of endoscope (a viewing instrument) insert- the enzyme glucocerebrosidase leads to
the small intestine), sometimes com- ed through the mouth. The oesophagus accumulation of a fatty substance, glu-
bined with a partial gastrectomy (the and duodenum (the first part of the small cosylceramide, in the liver, spleen, bone
removal of the lower part of the stom- intestine) are also inspected; for this rea- marrow, and, sometimes, in the brain.
ach). The operation, formerly carried son, the procedure is more accurately The condition is treated by regular in-
out to treat duodenal ulcer (see peptic called an oesophagogastroduodenoscopy. jections of the missing enzyme.
ulcer), is now rarely performed. The patient is often sedated throughout.
Gastroscopy is used to investigate gauze
gastrointestinal hormones bleeding, or other disorders, of the An absorbent, open-weave fabric, usu-
A group of hormones released from spe- oesophagus, stomach, or duodenum. ally made of cotton. Sterilized gauze is
cialized cells in the stomach, pancreas, Attachments to the gastroscope enable a often used to clean wounds, or applied
and small intestine that control various biopsy (removal of a tissue sample for as a dressing to soak up fluids from
functions of the digestive organs. Gastrin, analysis) to be carried out, as well as wounds. It is not used on areas of dam-
secretin, cholecystokinin, and vasoactive treatments such as laser treatment. A gas- aged tissue such as burns or ulcers,
intestinal polypeptide are the best known troscope may also be used to ease the because it may stick to the surface and
of these hormones (see Hormones in the passage of a gastric feeding tube through dislodge new tissue when it is removed.
digestive tract), but new hormones are the skin (see gastrostomy).
still being discovered. gavage
gastrostomy Feeding of liquids through a nasogastric
gastrointestinal tract A surgically created opening in the tube, which is passed into the stomach
The part of the digestive system consist- stomach. It is usually made to connect through the nose (see feeding, artificial).
ing of the mouth, oesophagus, stomach, the stomach to the outside of the body, The term “gavage” can also refer to
and intestines. These structures together so that a feeding tube can be passed hyperalimentation (treating a patient by
form a long tube through which food into the stomach or small intestine. feeding beyond appetite requirements).
passes as it is digested. Gastrostomy may be performed on
people who cannot eat properly due gel
gastro-oesophageal reflux to oesophageal cancer (see oesopha- A jelly-like suspension consisting of
disease (GORD) gus, cancer of) or who are unable to small, insoluble particles that are dis-
The medical term for acid reflux. chew and swallow due to a stroke. persed through a liquid. Gels are often

332
 GENE MAPPING

used as bases for topical skin treatments, the nucleus of a cell. Each strand has genes also determine the specialization
particularly those that are used on the about 30,000 pairs of genes, arranged of cells. Within any cell, some genes are
face and scalp. on 23 pairs of chromosomes. All body active and others are idle, according to
cells (except egg and sperm cells) con- the cell’s particular function; for exam-
gemfibrozil tain identical sets of genes because they ple, nerve cells and liver cells will have
A drug that lowers the level of fats in are all derived, by a process of division, different sets of active and idle genes. If
the blood. Gemfibrozil is usually given from a single fertilized egg. the control genes are disrupted, however,
to people with hyperlipidaemia after During growth and cell repair, cells cells lose their specialist abilities and
dietary measures have failed to reduce divide to form two identical new cells, multiply out of control; this is the
blood fat levels. It may cause nausea and each containing a full set of genes (see probable mechanism by which cancers
diarrhoea, and should not be taken by mitosis). Gametes (cells involved in repro- develop (see carcinogenesis; oncogenes).
people with liver disease. duction), however, undergo a different GENE MUTATION
form of division, called meiosis; as a Occasionally, when new cells are formed,
gender identity result, they contain just one gene from a fault occurs in the copying process,
An individual’s inner feeling of male- each pair, so that each parent con- leading to a mutation (change). The mu-
ness or femaleness. Gender identity is
not necessarily the same as biological
tributes half of the genetic material
used to form an offspring.
tant gene is then passed on each time
the cell subsequently divides. Disorders
G
sex. It is fixed within the first two to GENE FUNCTION that result from such mutant genes are
three years of life and is reinforced dur- Each gene controls or influences a spe- known as genetic disorders.
ing puberty; once established, it cannot cific feature or process in the body. ALLELES
usually be changed. Genes act by directing the manufacture The gene at any particular location on a
A minority of people have persistent of specific proteins (see What genes are and chromosome can exist in any of various
feelings of discomfort about their sex- what they do, overleaf). Many proteins are forms, called alleles. If the effects of a
ual identity. This condition is called involved in forming body structures, or specific allele mask those of the allele
gender dysphoria; in the most severe in regulating particular chemical pro- at the same location on its partner
cases, a person may feel that he or she is cesses (see enzyme). Certain proteins, chromosome, that allele is described as
the wrong sex (see transsexualism). however, are made solely to influence dominant; the masked allele is recessive.
other genes by switching them “on” or (See also genetic code; inheritance.)
gene “off”. The genes that make these regula-
A particular area of DNA, the material tory proteins are called control genes. gene mapping
within cells that governs the physical The whole complex process of devel- A process by which the location of par-
characteristics, development, and func- opment and growth is regulated by the ticular genes on each chromosome is
tioning of an individual. DNA is a very sequential switching “on” and “off” of determined. In some cases, gene loca-
long, chain-like structure that exists in particular genes. The activities of control tion gene can be found by certain tests.

WHERE DO YOUR GENES COME FROM?

A person’s genes are inherited from Grandfather’s Grandmother’s Grandfather’s Grandmother’s

his or her parents. Half come from the genes genes genes genes
mother and half from the father via
the egg and sperm cells. Each parent
provides a different selection, or
“mix”, of his or her genes to each
child; this accounts for the marked
differences in appearance, health, and
personality among most brothers and
sisters. Everyone holds a copy of his
or her genes within each body cell. Sperm Egg Sperm Egg

Father’s genes Mother’s genes

Gene transmission
In this diagram, only eight genes are
shown – in reality, each cell in the
body contains about 30,000 genes. Child
Half of them come from the mother
and half from the father – thus a Sperm Egg
quarter of the genes originate from
each of the four grandparents.

333
 GENE MAPPING

WHAT GENES ARE AND WHAT THEY DO

Genes are units of DNA (the material

that controls the body’s growth,
structure, and functions) contained in
every cell. They exert their effects by 1 2 3 4 5
directing the manufacture of proteins.
All of a person’s genes come from
6 7 8 9 10 11 12
his or her parents. The physical
differences between people, such as
in eye, hair, and skin colour, arise from
13 14 15 16 17 18
slight differences in gene structure.

19 20 21 22 XY
DNA PRINTOUT Basic
Chromosomes body cell Nucleus Cytoplasm
G Through painstaking laboratory
Genes are contained in the chromosomes
within the nuclei of a person’s cells. Each
research, the exact structure of DNA
chromosome contains a long strand of DNA
many genes is now known. (deoxyribonucleic acid).

Genes

DNA and genes

DNA has a long, thread-like molecule made up
of two intertwined strands: the double helix.
Genes are segments of DNA contained within
chromosomes. Each individual gene directs the
manufacture of one particular type of protein;
the instructions for this function are encoded
within the structure of its segment of DNA.

DNA double helix

DNA base sequence A
T
This printout shows a small part of the A
sequence in the gene that codes for the C C G A
protein trypsin, a digestive enzyme.
C T T
T Sugar-phosphate
G side chain

T G Sequence of bases
A C Each strand of DNA is a string of nucleotide bases,
G A linked by sugar and phosphate side chains. There
A A are four types of base – adenine, cytosine, guanine,
and thymine (A, C, G, and T). The sequence of bases
C in a gene (segment of DNA) provides the code for
T protein manufacture.
G Guanine

G T
Thymine Structural proteins
Some proteins are
T used as structural
components of
A cells, tissues, and
C organs.
Adenine

C
Cytosine
C
Decoding process
G
To decode a gene, a negative
copy of it is made, using the
A gene as a template; this copy Enzymes
(called messenger RNA) then Other proteins are
G passes to the cytoplasm of enzymes, which
G
the cell for decoding regulate important
(see protein synthesis). Protein molecule chemical processes
T The information in a gene is vital to bodily growth
T decoded to make a protein and functioning.
molecule, which is folded and
consists of a string of amino acids.

334
 GENE THERAPY

DISORDERS DUE TO SINGLE GENE DEFECTS

Autosomal dominant Examples

Unaffected parent Affected parent
In these disorders, only one • Achondroplasia
copy of the defective gene • Familial polyposis
needs to be present in order • Hereditary spherocytosis
to cause an abnormality. Each • Huntington’s disease
child of an affected person • Marfan syndrome
usually has a 1 in 2 chance of • Neurofibromatosis
inheriting the defective gene • Polycystic kidney disease Unaffected Affected
and being affected, and a 1 in (adult type) child child
2 chance of being unaffected. • Tuberous sclerosis
1 in 2 chance 1 in 2 chance
Key Defective gene Normal gene

Autosomal recessive Examples

Unaffected parent (carrier) Unaffected parent (carrier)
In this group, the disorder occurs
when a pair of abnormal genes is
• Albinism (oculocutaneous)
• Cystic fibrosis
G
inherited. Usually, both parents • Friedreich’s ataxia
of an affected person are • Galactosaemia
unaffected carriers of the • Hurler’s syndrome
defective gene. Each of their • Phenylketonuria
children has a 1 in 4 chance of • Sickle cell anaemia Unaffected Unaffected Unaffected Affected
being affected and a 2 in 4 • Tay–Sachs disease child child (carrier) child (carrier) child
chance of being a carrier.

1 in 4 chance 1 in 4 chance 1 in 4 chance 1 in 4 chance

Key Defective gene Normal gene

X-linked recessive Examples

Carrier mother Unaffected father
These conditions are caused by • Christmas disease
defects on the X chromosome. They • Colour blindness (most types) X X Y X
usually cause abnormalities only in • Fragile X syndrome
males, in whom the defect cannot • G6PD deficiency
be masked by the equivalent gene • Haemophilia
on a second, normal X chromo- • Muscular dystrophy (Duchenne)
some. Women may be carriers of Unaffected Affected Unaffected Unaffected
the defect. There is a 1 in 2 chance boy boy girl girl (carrier)
of their sons having the disorder
X Y X Y X X X X
and a 1 in 2 chance that their
daughters will be carriers. 1 in 4 chance 1 in 4 chance 1 in 4 chance 1 in 4 chance

Key X Defective X chromosome X Normal X chromosome Y Y chromosome

Alternatively, the positions of genes that that relieve symptoms but do not treat patented name (its brand name). Most
are close to one another on one chromo- the underlying condition. (See anxiety; drugs are now prescribed under their
some (and so are usually passed on anxiety disorders.) generic names.
together) may be found by a process
called linkage analysis.The information is general paralysis of the insane gene therapy
shown as a diagram of a chromosome An outdated term describing the mental A treatment in which copies of a normal
with the gene locations marked on it. and physical deterioration of untreated gene are inserted into the DNA of a per-
or unsuccessfully treated syphilis. son’s cells to help fight cancer or to
general anaesthetic counter the effects of a faulty gene.
See anaesthesia, general. general practice Gene therapy is most likely to be suc-
The term used in the UK for the provi- cessful in the treatment of autosomal
generalized anxiety disorder sion of personal medical care outside a recessive diseases (see Disorders due to
A psychiatric illness characterized by hospital setting. Doctors who provide it single gene defects), such as cystic fibro-
chronic and persistent apprehension are called general practitioners (GPs). sis, which are caused by a pair of
and tension that has no particular focus. This form of health-care is now more defective genes. When a normal copy of
There may also be various physical commonly known as primary care. the gene is introduced into the body,
symptoms such as trembling, sweating, it overrides the abnormal ones and
lightheadedness, and irritability. generic drug corrects the condition. It is less success-
The condition can be treated with A medicinal drug that is marketed ful, however, in treating autosomal
psychotherapy, antidepressants, or with under its official medical name (its dominant disorders, such as Hunting-
drugs such as beta blockers or sedatives generic name) rather than under a ton’s disease, in which a faulty gene

335
 GENETICALLY MODIFIED FOODS

overrides a normal one. In these cases, along the DNA strands makes up the chromosome. In autosomal disorders,
the abnormal gene must be removed genetic code. During protein synthesis, the defective gene is carried on one of
and is then replaced by a normal copy. RNA (ribonucleic acid) is used to help the other 44 chromosomes. These disor-
The copies of the normal gene can be read this code and create the protein. ders are subdivided into autosomal
introduced into the body in various dominant and autosomal recessive dis-
ways. In one technique, a person’s white genetic counselling orders. See Disorders due to single gene
blood cells are grown in a culture with a Medical guidance offered to people who defects (previous page) for examples.
retrovirus containing the normal gene have a known risk of having a child with Another, rare group of single gene
and then reintroduced into the body, a genetic disorder, such as cystic fibrosis, defects involves the mitochondrial DNA,
where they multiply. An alternative or who are at increased risk of develop- which exists outside the nuclei.
method, currently being tried to treat ing a genetic disorder themselves. The X-linked recessive disorders The most
cystic fibrosis, involves packaging nor- counsellor will examine individual and common type of sex-linked disorder, X-
mal DNA in tiny liposomes, which are family medical histories and, in some linked recessive disorders are caused by
added to an aerosol spray. The spray is cases, arrange for tests such as chromo- a defective gene on an X chromosome.
inhaled and the liposomes bind to the some analysis and genetic probes. Haemophilia and colour blindness (see
G walls of cells in the lung tissue and the
normal gene is activated.
Genetic counselling enables people
to make informed decisions about their
colour vision deficiency) are this type.
Women have two X chromosomes;
Research is also being carried out to future, particularly parenthood. If there men have only one, inherited from their
assess the potential of gene therapy in is a significant risk of a couple having mothers. When a woman inherits one
treating cancer. In certain forms of can- an affected child, doctors may be able to defective gene, its effect is masked by
cer, a gene called p53 (which controls offer pre-implantation genetic testing the normal gene on her other X chro-
programmed cell death) is faulty, allow- with in vitro fertilization (see embryo diag- mosome and she has no abnormality.
ing cells to multiply uncontrollably to nosis), or antenatal diagnosis, to optim- She is, however, capable of passing the
form a tumour. The introduction of a ize the chances of their having a healthy gene on to her children, and is called a
normal p53 gene may prompt the death child. If parents already have an affected carrier. On average, carriers transmit the
of these abnormal cells. child, genetic counselling will provide defective gene to half their sons, who
information on the outlook for that child. are affected, and to half their daughters,
genetically modified foods who become carriers in turn. When a
Food or food constituents that are genetic disorders male inherits the defective gene from
derived from plants whose genetic Any disorder caused, wholly or partly, his mother, he has no normal gene on a
material has been deliberately altered in by one or more faults in a person’s DNA. second X chromosome to mask it, so he
order to modify certain characteristics. Genetic disorders may be congenital displays the abnormality. Affected males
In genetic modification, DNA is isolated (present at birth) or may become appar- therefore greatly outnumber affected
from one organism and inserted into ent later in life. Many of them are familial females. The males pass the defective
the DNA of another (the recipient). (shared by various people in the same gene to none of their sons but to all of
The procedure is intended to be ben- family). A child may, however, be born their daughters, who become carriers.
eficial; for example, transferred DNA with a genetic disorder when there is no autosomal dominant disorders In these
may enable recipient plants to be more previous family history. conditions, the defective gene is domi-
resistant to pests, which is likely to A genetic disorder can occur in two nant in relation to the equivalent normal
increase crop yields. There may also be different ways: one or both parents have gene, so only one copy needs to be pre-
disadvantages, however. Ecological and a defect in their own genetic material sent in order to cause an abnormality.
health concerns about GM foods are the that is then inherited by the child, or a People who have an autosomal dominant
subjects of ongoing debate. mutation occurs during the formation of disorder carry one normal copy and one
the ovum or sperm cell. defective copy of the affected gene, and
genetic code The disorders fall into three broad cat- are termed heterozygotes. Affected people
The inherited instructions, contained in egories: chromosomal abnormalities, single have a 50 per cent chance of passing the
genes, that specify the activities of cells gene defects, and multifactorial defects. defective gene on to their children.
and thereby the development and func- Chromosomal abnormalities involve a autosomal recessive disorders The defec-
tioning of the body. Each gene in a child having an abnormal number of tive gene that causes an autosomal
chromosome contains the coded instruc- whole chromosomes (as in Down’s syn- recessive disorder is recessive in relation
tions for a cell to make a protein that has drome), or extra or missing bits of to the normal gene, so two faulty copies
a specific function in the body. chromosomes. Single gene defects are of the gene are required to cause an
The DNA that makes up genes con- rare, and are caused by one abnormal abnormality. People who have the disor-
sists of two long, intertwined strands, gene or pair of genes. Multifactorial dis- der carry two identical defective copies
each comprising a sequence made up of orders are thought to be due to the of the gene, and are called homozy-
four chemicals called nucleotide bases effects of several genes combined with gotes. In most cases, both parents of an
(see nucleic acids). These four bases are environmental influences. affected individual are heterozygotes:
adenine, thymine, cytosine, and guanine SINGLE GENE DEFECTS they carry one copy of the defective
(often abbreviated to A, T, C, and G). There are two main forms of single gene gene and one copy of the normal gene.
They are joined in pairs (base-pairs), defect. In sex-linked disorders, the MITOCHONDRIAL DISORDERS
thus linking the two strands of the DNA defective gene is carried on one of the In rare cases, a defect in a specific area of
molecule. The sequence of these bases sex chromosomes – almost always the X mitochondrial DNA causes diseases.

336
 GENOTYPE

Such disorders include certain myo- analysed in comparison with that of a female, or in which the organs appear
pathies (muscle disorders), neuropathies sample from another person, or from to be those of the opposite chromo-
(nerve disorders), and some cases of the scene of a crime. somal sex. Cases of ambiguous genitalia
degeneration of the retina, and deafness. may result from an abnormality of the
These disorders are always passed on genetic probe sex chromosomes or a hormonal disorder
from the mother, because sperm cells A specific fragment of DNA used in labo- (see hermaphroditism; sex determination;
have very few or no mitochondria. ratory tests to determine whether a adrenal hyperplasia, congenital).
MULTIFACTORIAL DISORDERS particular genetic defect is present in a
A wide range of disorders, including person’s DNA. The probe contains the genital phase
asthma, diabetes mellitus, and most forms same structure as the abnormal gene A term used in psychoanalytic theory to
of hyperlipidaemia are thought to result and, when added to a sample of the refer to a stage of a person’s psycho-
from the cumulative effects of several person’s DNA, will bind to that gene if sexual development. The genital phase
faulty genes, together with environmen- it is present. A radioactive or fluorescent begins at around the ages of 3–5 years.
tal factors. The pattern of inheritance in marker may be added to the probe so (See also anal phase; oral phase.)
these disorders is less straightforward that it can easily be detected.
genital ulcer
than that in chromosomal abnormalities
or single gene defects.
Genetic probes are mainly used in
antenatal diagnosis of genetic disorders, An eroded area of skin on the genitalia.
G
and in determining whether people There are various possible causes. The
genetic drift with a family history of a genetic disor- most common cause of genital ulcers is
Chance fluctuation in gene frequency der carry the defective gene themselves a sexually transmitted infection, particu-
within a finite, isolated sample of a pop- (see familial screening). larly genital herpes (see herpes, genital)
ulation over a number of generations. or syphilis. Chancroid and granuloma
The chance of random variation increases genetics inguinale are tropical bacterial infections
as the population size decreases because, The study of inheritance (the trans- that cause genital ulcers. Lymphogran-
in a large population, the random nature mission of characteristics from one uloma venereum is a bacterial infection
of the transmission of alleles (various generation of an organism to the next). (CHLAMYDIA) producing genital blisters.
forms of a gene at a particular location) Genetics involves determination of the Behçet’s syndrome is a rare condition that
will tend to average out. chemical basis for inheritance of parti- causes tender, recurrent ulcers in the
cular characteristics, and investigating mouth and on the genitals. Cancer of
genetic engineering the causes of similarities and differences the penis or vulva may first appear as a
A branch of genetics concerned with the between individuals of a particular painless ulcer with raised edges.
alteration of genetic material in an species or between different species.
organism in order to produce a desired Branches of human genetics include genital warts
change in the organism’s characteristics. population genetics, which studies the See warts, genital.
Genetic engineering has mainly been relative frequency of various genes in dif-
used to mass-produce a variety of sub- ferent human races; molecular genetics, genito-urinary medicine
stances that are useful in medicine. which is concerned with the structure, The branch of medicine concerned
A gene responsible for making a useful function, and copying of DNA; and clini- with sexually transmitted infections and
protein is identified and isolated. It is cal genetics, which is concerned with the their effects on the body.
then inserted into “host” cells (most study and prevention of genetic disorders.
commonly bacteria or yeast); this altered genome, human
DNA is called recombinant DNA. The genetic screening The complete set of human genetic
host cells reproduce rapidly to form a See familial screening. material. The human genome consists
colony of cells containing the gene. This of 23 chromosomes, which, together,
colony produces the protein in large genital herpes contain about 30,000 genes. All cells
amounts. The human hormones insulin See herpes, genital. (except for egg and sperm cells) con-
and growth hormone and proteins, such as tain two sets of the 23 chromosomes,
factor VIII (used to treat haemophilia), are genitalia one inherited from the father and the
made in this way. Genetic engineering is The reproductive organs, especially those other from the mother.
also used in gene therapy. that are external. The male genitalia The Human Genome Project, an
include the penis, testes (situated within international research programme, was
genetic fingerprinting the scrotum), prostate gland, seminal vesi- launched in 1990 with the aim of
A technique that can be used to demon- cles, and associated ducts, such as the identifying all the genes in the human
strate relationships between people (for epididymis and vas deferens. The female body. The project was finally completed
example in paternity testing) or, in foren- genitalia include the ovaries, fallopian in the year 2003.
sic investigations, to identify a suspect. tubes, uterus, vagina, clitoris, vulva, and
DNA contains a genetic code (“genetic Bartholin’s glands. genotype
fingerprint”) that is unique to each The entire genetic makeup of an indi-
individual, except in the case of identi- genitalia, ambiguous vidual, or group of related individuals,
cal twins. DNA can be extracted from A group of conditions, also known as as opposed to the individual’s observ-
any material containing body cells, such intersex, in which an individual’s exter- able characteristics (see phenotype). The
as blood or semen. Its code can then be nal sex organs are not clearly male or term is also used to describe the set of

337
 GENTAMICIN

alleles(any of various forms of a gene) germ cell during which the infant develops in the
at a specific location within a chromo- An embryonic cell with the potential to uterus. (See also embryo; fertilization;
some; the genetic information carried develop into a spermatozoon or ovum. fetus; pregnancy.)
by alleles determines a particular char- The term also describes a gamete
acteristic of that organism. (mature sex cell) or any cell that is gestational diabetes
undergoing gametogenesis (the process Diabetes mellitus that develops during
gentamicin by which gametes are formed). pregnancy, usually clearing up after
An antibacterial drug given by injection delivery (see diabetic pregnancy).
to treat serious infections such as menin- germ cell tumour
gitis and septicaemia (blood poisoning). A growth comprised of immature sperm gestodene
Gentamicin can result in damage to the cells in the male testis or of immature A progestogen drug that is used with the
kidneys or the inner ear if the dosage is egg cells (see ovum) in the female ovary. oestrogen drug ethinylestradiol in low-
not carefully controlled. A seminoma is one type of germ cell strength combined oral contraceptives.
The drug is also used in various eye tumour (see testis, cancer of). Gestodene is reported to carry a slightly
and ear-drops but is unlikely to cause increased risk of venous thromboembol-
gerontology
G serious side effects when taken in these
types of preparation. The study of developmental, biological,
ism (the blockage of a blood vessel by a
fragment of a blood clot) in compari-
medical, psychological, and sociological son with older drugs.
gentian violet aging. (See also geriatric medicine.)
A purple dye used to make bacteria vis- Ghon’s tubercle
ible under a microscope. Gentian violet Gerstmann’s syndrome An abnormal area in the lung, also
was also formerly used as an antiseptic. A neurological disorder involving a known as a Ghon’s focus, that is pro-
writing disability such as agraphia, duced by infection with tuberculosis in a
genu valgum together with the inability to under- person who has not previously been
The medical term for knock-knee. stand mathematical calculations, to exposed to the disease. Often, a Ghon’s
distinguish right from left, and to iden- tubercle heals without causing symp-
genu varum tify the fingers (a type of agnosia). toms, but in some cases it may result in
The medical term for bowleg. Many sufferers also experience aphasia tuberculosis that spreads via the lym-
(complete loss of language skills). The phatic system, in the bloodstream, or in
geriatric medicine syndrome may occur after a stroke or the air sacs of the lungs. A healed tuber-
The medical speciality concerned with damage to the left parietal lobe of the cle may become calcified, and may be
the care of elderly people, also known brain, but the precise cause is unknown. discovered during a routine chest X-ray.
as “care for the elderly”. This group
require specialist medical care because Gerstmann–Straussler syndrome Gianotti–Crosti syndrome
they respond to illness and treatment in A rare, inherited type of human spongi- A characteristic, harmless response of
a different way from younger people. form encephalopathy, the group of de- the skin to certain viral infections,
Physical and mental decline due to generative brain disorders to which including hepatitis B infection, Epstein
aging can mean that illnesses are more Creutzfeldt–Jakob disease belongs. Gerst- Barr virus (see mononucleosis, infectious),
severe in older people, and people may mann–Straussler syndrome is believed and coxsackievirus. In this condition, a
have two or more diseases at once. In to be caused by infection with a prion papular (lumpy) rash develops on the
addition, the liver and kidneys become (slow virus). face, buttocks, and limbs and lasts for
less efficient at breaking down and The disease is characterized by ataxia several weeks. The condition mainly
excreting drugs, so drug dosages for (loss of balance) and dementia and is affects children between the ages of six
elderly people must be carefully con- not usually evident before early adult- months and twelve years.
trolled to avoid dangerous side effects. hood. It progresses more slowly than SYMPTOMS AND SIGNS
Geriatric medicine relies on an inte- Creutzfeldt–Jakob disease, but there is There may be no noticeable symptoms.
grated team of health-care workers, no cure, and death usually occurs with- Alternatively, there may be a mild tem-
including a doctor (or a specialist called in three to five years. perature, and swelling of the lymph
a geriatrician), nurse, physiotherapist, nodes in the armpits and groin that per-
and occupational therapist. This team Gestalt theory sists for some months. The liver may
helps older people to maintain inde- A school of psychology that emphasizes become enlarged.
pendence and health, and to cope after the viewing of personal experiences as a DIAGNOSIS AND TREATMENT
illness or injury. (See also rehabilitation.) whole rather than breaking them down Blood tests and liver function tests are car-
into collections of stimuli and respon- ried out to investigate liver function and
germ ses. Gestalt therapy aims to increase detect possible causative viruses. There
The popular term used to describe any self-awareness by looking at all aspects is no specific treatment, but a mild,
microorganism that causes disease, such of a person in his or her environment. topical corticosteroid cream may be pre-
as viruses and bacteria. scribed for itching. The rash usually
gestation fades in two to eight weeks.
German measles The period that lasts approximately nine
The common name for the viral infec- months between conception and the giant cell arteritis
tion rubella. birth of a human baby; it is the time An alternative name for temporal arteritis.

338
 GINGIVITIS

giardiasis
An infection of the small intestine HOW GIARDIASIS IS SPREAD
caused by the protozoan (single-celled)
Giardiasis is spread
parasite GIARDIA LAMBLIA. Giardiasis is m drinking untreate
by contaminated d fro
spread by eating or drinking contami- water or food, or by q
d
ui re sewage, or through han wate
ac y rson. d-to r o
nated food or water or through direct personal contact. a re ted b cted pe -ha r fo
a
s in inf e nd o
contact with an infected person. e
it am an
This parasitic o

d sex
t th

con en c ras

th ua
SYMPTOMS i

r
tac on
infection is most w

be pa

at l
t

ha
Most of those infected have no symp-

e
common in the

Th

s
toms. If, however, symptoms do occur, tropics, but it has
they begin between one and three weeks become a more
after infection. They include diarrhoea, frequent occurrence

sanitation may contam

in faeces, a nd in are inat e
The parasites pass as of wat
and wind, as well as faeces that are foul- in developed

he esti r and mu ipl y

y
countries, especially

al wall e the
smelling, greasy, and tend to float in the

lt
toilet. Abdominal discomfort, cramps, among groups of

s.
her
preschool children.
and swelling, loss of appetite, and nau-
G

inte nes, w
o t int ente
sea may also occur. In some cases,

stin
out poo er o
giardiasis may become chronic.

e t he es
er in t rasit
of
DIAGNOSIS AND TREATMENT

th

h pa
eb
The infection is diagnosed from micro- od e

r r
y Th it
scopic examination of a faecal sample fo
od Sym
w h
or by a jejunal biopsy (removal of a small . ptom ays ad
af s occur 1 to 3 d
dia ter infec d e
sample of tissue from the middle sec- rrho tion i nclu
ea and and cramps
tion of the small intestine for analysis). stomach
Acute giardiasis usually clears up
without treatment but the drug metro-
nidazole quickly relieves symptoms and
helps to prevent the spread of infection.
Infection can be prevented in the first Gilbert’s disease gingivectomy
place by avoiding food or water that A common inherited condition that The surgical removal of part of the gum
could possibly be contaminated. affects the way in which bilirubin is margin. Gingivectomy may be used to
processed by the liver. Usually there are treat severe cases of gingival hyperplasia
gibbous no symptoms, but jaundice may be (thickening of the gums) or to remove
A term meaning “humped”, as in a brought on by unrelated illnesses. Suf- pockets of infected gum in advanced
gibbous spine, which curves outwards ferers are otherwise healthy and no cases of periodontitis (gum disease).
(see kyphosis). A deformity called a gib- treatment is necessary. Gingivectomy is usually performed by a
bus (an extreme hunch in the back) dentist under local anaesthesia.
was once a common condition caused Gilles de la Tourette’s syndrome
by tuberculosis of the spine. A rare, inherited neurological disorder gingivitis
that is transmitted by an autosomal Inflammation of the gums. Gingivitis is
giddiness dominant gene (see genetic disorders). usually due to a build-up of plaque
See dizziness. Gilles de la Tourette’s syndrome is around the base of the teeth. Toxins pro-
more common in males and starts in duced by bacteria in the plaque irritate
GIFT childhood with repetitive grimaces and the gums, causing them to become
See gamete intrafallopian transfer. tics. Involuntary barks, grunts, or other infected, swollen, tender, and reddish-
noises may appear as the disease pro- purple in colour. Gingivitis may also
gigantism gresses. In some cases, the sufferer has result from injury to the gums, usually
Excessive growth (especially in height) episodes of compulsively using foul through rough toothbrushing or floss-
during childhood or adolescence that language (a condition called coprolalia). ing. Pregnant women and people with
results from overproduction of growth People with Tourette’s syndrome usu- diabetes mellitus are especially suscepti-
hormone by a tumour of the pituitary ally have it their whole lives; in some ble to the disorder.
gland (see pituitary tumours). If untreat- sufferers antipsychotic drugs may help to Gingivitis can be reversed; good oral
ed, the tumour may compress other relieve some of the symptoms. hygiene is the main method of prevent-
hormone-producing cells in the gland, ing and treating it. If left untreated,
causing symptoms of hormone defi- gingiva however, it may lead to damage of the
ciency (see hypopituitarism). The Latin name for the gums. gum tissue, which may in turn lead to
People with gigantism may be treated chronic periodontitis (an advanced stage
with a drug that blocks the release of gingival hyperplasia of gum disease). Acute ulcerative gingi-
growth hormone, such as bromocriptine, See hyperplasia, gingival. vitis (see gingivitis, acute ulcerative) may
or they may have to have surgery or develop in people who have chronic
radiotherapy to remove or destroy the gingival pocket gingivitis, particularly those with a
pituitary tumour. (See also acromegaly.) A feature of chronic periodontitis. lowered resistance to infection.

339
 GINGIVITIS, ACUTE ULCERATIVE

gingivitis, acute ulcerative There are two main types of gland: end-
Painful infection and ulceration of the ocrine and exocrine. Endocrine glands do
gums. Acute ulcerative gingivitis is not have ducts and release their secre-
uncommon, primarily affecting people tions directly into the bloodstream;
aged between 15 and 35. It is caused by examples include the pituitary, thyroid,
abnormal overgrowth of bacteria that and adrenal glands. Exocrine glands have
usually exist harmlessly in small num- ducts and release their secretions to the Neck
bers in gum crevices. Predisposing surface or interior of the body. Examples
factors include poor oral hygiene, smo- include the sebaceous glands, which
king, throat infections, and stress. In secrete sebum on to the surface of the
many cases, the disorder is preceded by skin, and the salivary glands, which
gingivitis or periodontitis. secrete saliva into the mouth. The pan-
The gums become sore and bleed creas releases endocrine and exocrine
easily. Crater-like ulcers, which bleed secretions (for example insulin and chole- Armpit
spontaneously, develop on the gum tips cystokinin, respectively).
G between teeth. There may be a foul taste
in the mouth, bad breath, and swollen
Lymph nodes are sometimes called
glands, particularly when they are
lymph nodes (see glands, swollen). The enlarged due to infection (see glands,
infection may spread to the lips and the swollen). Strictly speaking, this is incor-
insides of the cheeks (see noma). rect usage because lymph nodes do not
A hydrogen peroxide mouthwash can secrete chemicals. Groin
relieve the inflammation. Scaling is then
performed to remove plaque. In severe glanders Common sites of swollen glands
The three most common sites where swollen lymph
cases, the antibacterial drug metronida- An infection of horses caused by the bac- nodes (glands) can be felt are in the neck, armpit,
zole may be given to control infection. terium PSEUDOMONAS MALLEI. It rarely and groin.
affects humans. Symptoms include fever
and general aches and pains. Skin ulcers is more common in males. Inheritance
may develop and, if bacteria enter the is either autosomal recessive or X-
lungs, pneumonia may occur. In severe linked (see genetic disorders).
cases, septicaemia (blood poisoning) may In Glanzmann–Riniker syndrome, the
follow.Treatment is with antibiotics. blood contains virtually no B-lympho-
cytes (a type of white blood cell) and, as
glands, swollen a result, antibodies (proteins produced
Enlargement of the lymph nodes (which by B-lymphocytes to destroy invading
are commonly called “glands”), due to microorganisms) fail to form.
inflammation and/or proliferation of The condition is evident from early
white blood cells within them. Swollen infancy, when an affected child fails to
Example of gingivitis
The gums around the bases of the upper teeth are lymph nodes are a common symptom, thrive. It is characterized by absence of
puffy, shiny, and tender and overhang the teeth especially in children. They are usually the thymus (a gland that forms part of the
margins. Affected gums often bleed when brushed. caused by a minor infection or an aller- immune system) and susceptibility to
gic reaction (see allergy). bacterial, and viral infections. Symptoms
gingivostomatitis Rare causes include cancer affecting and signs include watery diarrhoea and
Inflammation of the gums and mouth. the lymph nodes (see Hodgkin’s disease; lung abscesses. Children do not normally
Gingivostomatitis is often due to a viral lymphoma) or cancer of the white blood survive beyond the first two years of life.
infection, particularly herpes simplex. cells (see leukaemia).
The condition can also be due to a bac- glare
terial infection or an adverse reaction to glandular fever The discomfort that results from bright
a prescribed drug. (See also cold sore.) See mononucleosis, infectious. light entering the field of vision (see
eye) either directly or by reflection from
ginkgo glans another surface, such as a computer
An extract from the maidenhair tree, The head of the penis. The glans is cov- screen or a stretch of water. The light
GINKGO BILOBA. Preparations containing ered by a loose fold of skin called the hits the retina and reduces central vision.
ginkgo are claimed to help treat circula- prepuce (foreskin), which retracts when
tory disorders, reduced circulation in the penis becomes erect; in some males, glasses
the brain, senility, depression, and pre- this skin is removed by circumcision. Devices, worn on the face, that contain
menstrual syndrome. Possible side effects The term “glans” may also be applied lenses to correct focusing errors in the
include muscle spasms and cramps. to the tip of the clitoris in females. eyes and thereby achieve clear vision.
Lenses are made of glass or plastic,
gland Glanzmann–Riniker syndrome and the shape and thickness of a lens are
A group of specialized cells that A severe, inherited immunodeficiency chosen during a vision test. Convex lenses
manufacture and release chemical sub- disorder (failure of the body’s immune (which curve outwards) are needed for
stances, such as hormones and enzymes. system to fight infection). The condition hypermetropia, or longsightedness, and

340
 GLAUCOMA

concave lenses (which curve inwards)

for myopia, or shortsightedness (see Why WHY GLASSES ARE USED
glasses are used box, right). Most lenses
Glasses compensate for certain visual defects in which the lens of the eye does not
are single-vision, but bifocal, trifocal, focus light correctly on to the retina, at the back of the eyeball. For hypermetropia
and varifocal lenses are becoming pop- (longsightedness) or presbyopia, convex (or plus) lenses are needed. Myopia
ular. Tinted lenses protect the eyes from (shortsightedness) requires concave (or minus) lenses.
sunlight. (See also bifocal; contact lenses.)
LONGSIGHTEDNESS Retina Before correction
glass eye Longsightedness occurs
when focusing power is
See eye, artificial. inadequate. Light from
distant objects is focused
glass test on to the retina, but light
A test for meningitis that involves press- from close objects is
Lens focused behind it.
ing a clear glass against a rash. If the
rash remains visible through the glass, it
may be a form of purpura (leaking of
blood beneath the skin), which some-
Convex lens After correction G
Convex magnifying (or plus)
times occurs in meningitis. lenses cause light rays to
converge (bend together). As
glaucoma a result, they focus the light
from close objects correctly
A condition in which the intraocular pres- Converging light on to the retina.
sure (fluid pressure inside the eyes) rays within lens
causes impaired vision. Aqueous humour
(watery fluid) is secreted into the front
of the eye by the ciliary body (a structure SHORTSIGHTEDNESS Before correction
behind the iris) to maintain the eye’s The focusing power of the eye
shape and nourish the tissues. Excess is too great. Light from close
objects is focused correctly;
fluid drains away at the edge of the iris. however, light from distant
In glaucoma, however, this excess fluid objects is focused in front of
may not be able to escape. It causes com- the retina, and the objects
pression and obstruction of the blood appear blurred.
vessels that supply the retina and the optic
nerve. This, in turn, may destroy nerve Concave lens After correction
fibres and cause gradual loss of vision. Concave weakening (or
TYPES, CAUSES, AND SYMPTOMS minus) lenses cause light
The most common form of glaucoma is rays to diverge (bend apart).
chronic simple (open-angle) glaucoma. As a result, they focus the
light from distant objects
It rarely occurs before the age of 40, correctly on to the retina.
and tends to run in families. In this Diverging light
rays within lens
condition, the outflow of aqueous
humour is gradually blocked over a
period of years, causing a slow rise in ASTIGMATISM
pressure. There are often no symptoms
In astigmatism, the surfaces of Vertical plane Lens
until visual loss is advanced. in focus
In acute (closed-angle) glaucoma, the the cornea, rather than being a
outflow of aqueous humour is rapidly hemisphere as normal, are
blocked, and the pressure rises sudden- steeper in one direction than in
the others; as a result, the light
ly. This may cause a severe, dull pain in
rays in one meridian (plane) are
and above the eye, fogginess of vision, out of focus. Lenses to correct
and the perception of haloes around astigmatism are designed with Horizontal plane
lights at night. Nausea and vomiting additional curvature in one out of focus
Retina
may occur, and the eye may become red meridian, then set accurately in
with a dilated pupil. the frame of the glasses so that
Congenital glaucoma is due to an ab- the steepest curves correspond
normality in the drainage angles of the to the flattest meridian of the
eyes that develops before birth. Glaucoma cornea. As a result, they cancel
can also be caused by injury or an eye out the effects of the distortion
disease such as uveitis or lens dislocation. in the cornea. Both concave and
A less common form, called normal- convex lenses can be designed
to correct astigmatism.
pressure or low-tension glaucoma, occurs
in people whose intraocular pressure is
normal or only slightly raised but causes

341
 GLEASON’S SCORE

usual procedure is iridectomy, in which a pancreas to increase insulin secretion.

small opening is made at the edge of Side effects are infrequent but may
the iris so that aqueous humour can include mild nausea and diarrhoea. Low
drain more easily, blood sugar (see hypoglycaemia) may
Treatment for normal-pressure glau- occur if the drug is not taken with suffi-
coma is the same as for open-angle cient food.
glaucoma, but is aimed at reducing the
intraocular pressure to an even lower glioblastoma multiforme
level than normal. A fast-growing and highly cancerous
type of primary brain tumour. Glioblas-
Gleason’s score toma multiforme is a type of glioma that
A system of grading prostate cancer often develops in the cerebrum (the
Ciliary body cells (see prostate, cancer of) to deter- main mass of the brain). The cause is
Blocked mine the most appropriate treatment unknown. Treatment of glioblastoma
drainage and the patient’s outlook. multiforme may include surgery, radio-
channel
G Several tissue samples are taken and
are assigned a score between 1 and 5.
therapy, and/or chemotherapy.

Cornea The lowest and highest scores are added glioma

Iris together to give the Gleason’s score, A type of brain tumour arising from con-
which is a number between 1 and 10. A nective tissue (glial cells) in the brain.
Aqueous humour low Gleason’s score indicates that the Types of glioma include astrocytoma,
Lens cancer cells are very similar to normal glioblastoma multiforme, ependymoma,
prostate cells; a high score means that medulloblastoma, and oligodendroglioma.
Acute closed-angle glaucoma the cancer cells are very different. In Symptoms, diagnosis, and treatment are
This type of glaucoma is caused by an unduly general, the more the cancerous cells as for other types of brain tumour.
narrow angle between the iris and the back diverge from the normal prostate cells,
of the peripheral cornea. Dilation of the pupil Glioma
Ventricle
may therefore lead to a sudden complete blockage the more serious the cancer.
of the outflow, which, in turn, causes a rapid The Gleason’s score is often used in
increase in pressure in the eyeball. conjunction with a measure called the
TNM classification, which defines the
the same damage to the retina and optic extent to which a cancer has spread.
nerve as excessively high fluid pressure.
This condition is not well understood; glenoid
and it seems that the pressure, although A term meaning “resembling a pit or
not considered to be excessive, is too socket”. For example, the glenoid fossa
high for the tissues to withstand, and (depression) is the cavity at the top of
thus causes damage. the scapula (shoulderblade) into which
DIAGNOSIS AND TREATMENT the head of the humerus (the bone of
Tonometry is used to check for glaucoma the upper arm) fits.
by measuring the pressure within the
eye. Ophthalmoscopy may show depres- glibenclamide
sion of the head of the optic nerve due An oral hypoglycaemic drug (see hypo-
to the increase in pressure. Tests of the glycaemics, oral) used to treat type 2
visual field will be needed to assess (non-insulin dependent) diabetes melli-
whether vision has already been dam- tus. In this form of diabetes, body cells
Brain scan of a glioma
aged, because longstanding or severe are resistant to the action of the hor- In this scan, taken from below, a glioma (a type of
glaucoma can result in loss of peripher- mone insulin, and absorb insufficient brain tumour) is visible as a dark area in the right
al vision (see tunnel vision). Prompt glucose.The drug causes the pancreas to hemisphere (on the left of the image).
treatment is essential to prevent perma- increase insulin secretion thereby com-
nent loss of vision. pensating for the resistance. glipizide
Chronic simple glaucoma can usually An oral hypoglycaemic drug (see hypo-
be controlled with eye-drops, such as gliclazide glycaemics, oral) used to treat type 2
timolol, or tablets that reduce pressure in An oral hypoglycaemic drug (see hypo- diabetes mellitus. Glipizide acts by stim-
the eye. Treatment needs to be contin- glycaemics, oral) used to treat type 2 ulating the pancreas into increasing its
ued for life. If drugs are ineffective, diabetes mellitus along with dieting. The production of insulin. Side effects are
surgery or laser treatment can unblock drug causes the pancreas to increase usually mild and infrequent, but dizzi-
the drainage channel at the edge of the insulin secretion. Side effects are mild. ness and drowsiness may occur. Rarely,
iris or create an artificial channel. glipizide can cause an abnormal reac-
Acute glaucoma requires emergency glimepiride tion of the skin to sunlight and can
drug treatment, often in hospital. Sur- An oral hypoglycaemic drug (see hypo- reduce blood sodium levels. Low blood
gery or laser treatment may be needed glycaemics, oral) used to treat type 2 sugar (see hypoglycaemia) may occur if
in order to prevent a further attack. The diabetes mellitus. The drug causes the the drug is not taken with sufficient food.

342
 GLOMERULONEPHRITIS

global Glomerulonephritis also occurs in cer- analysis of urine), and, in most cases,
A term used of a disorder affecting an tain autoimmune disorders, such as kidney biopsy (removal of a small tissue
entire body function or system. For systemic lupus erythematosus. Infectious sample for microscopic analysis).
example, global aphasia (see aphasia) is diseases such as malaria and schistosomi- Treatment for glomerulonephritis is
the loss of all ability to speak, write, or asis are causes in tropical countries. usually given in hospital, and depends
understand language; global paralysis is SYMPTOMS on the cause and the severity of the dis-
extreme weakness of the muscles in Mild glomerulonephritis may cause no ease. Children with nephrotic syndrome
every part of the body, which may result symptoms, and it may only be dis- usually respond to corticosteroid drugs.
in a complete inability to move. covered during routine urine testing; Glomerulonephritis caused by a strepto-
alternatively, the condition may remain coccal infection usually clears up after
globin undetected until the kidney damage has the infection is successfully treated with
The protein that combines with certain reached an advanced stage and accumu- antibiotic drugs.
iron-containing compounds to form the lated waste products have started to Adults tend to respond less well to
oxygen-carrying pigments haemoglobin, produce symptoms. treatment, but kidney failure may some-
which is found in red blood cells, and Some people develop symptoms sud- times be prevented or delayed. Drugs
myoglobin, which is present in muscle. denly. They may experience a dull ache
over the kidneys.The urine may become
may be prescribed to control hyper-
tension, and a special diet may be given
G
globulin bloodstained because when damaged to reduce the workload on the kidneys.
Any of a group of proteins that are in- the glomeruli allow red blood cells to Temporary dialysis may be necessary to
soluble in water but soluble in dilute salt escape into the urine. Protein may also help remove waste products from the
solutions. There are many globulins in be lost into the urine, causing oedema blood, and diuretic drugs may be given
the blood, including immunoglobulins (see nephrotic syndrome); this is a com- to help treat any oedema.
(also called antibodies). mon condition in affected children. A few people with severe glomerulo-
Hypertension (high blood pressure) is a nephritis respond to treatment with
globus hystericus potentially serious complication. Long- immunosuppressant drugs (which reduce
A condition in which there is an term glomerulonephritis is a common the activity of the immune system);
uncomfortable feeling of a “lump in the cause of chronic kidney failure. others may undergo plasmapheresis (a
throat”. This lump is felt to interfere DIAGNOSIS AND TREATMENT procedure that removes immune com-
with swallowing and breathing; how- Diagnosis involves kidney function tests, plexes and other harmful substances
ever, there is no physical basis for the urinalysis (the microscopic and chemical from the bloodstream).
condition. In severe cases, hyperventila-
tion (rapid breathing) and symptoms of
a panic attack ensue. THE EFFECTS OF GLOMERULONEPHRITIS
Globus hystericus occurs most com-
monly in people who are anxious or Normally, the glomeruli retain red cells and protein molecules in the blood while
depressed. Treatment is by reassurance, filtering out salts and waste. If they are damaged, however, they allow blood cells
and protein to leak into the urine, causing characteristic symptoms.
breath-control training, or psychotherapy.
glomerulonephritis Renal
Damaged
glomerulus
Inflammation of the filtering units (see vein
Red blood cells
glomerulus) in both kidneys. Damage to
Protein
the glomeruli hampers the removal of
Urine travelling
waste products, salt, and water from the towards the
bloodstream, which may cause serious Renal bladder
complications. This condition occurs artery
Cross-section of a damaged glomerulus
worldwide; in the US and Europe, it is Kidney Ureter Damage to the tiny blood vessels of the
one of the most common causes of glomerulus causes red blood cells and protein
chronic kidney failure. Kidney tubule to pass into the urine. As a result, the urine
may be bloodstained.
CAUSES
Some types of glomerulonephritis are
caused by the immune system making Normal Swollen
antibodies to eliminate microorganisms tissue tissue
(usually infectious bacteria, such as Water Water
those that cause streptococcal infections of
the throat). The antibodies combine Blood Blood
with bacterial antigens to form particles
Protein Protein
called immune complexes. These par-
ticles circulate in the bloodstream and Healthy tissue Oedema
become trapped in the glomeruli, trig- Through osmosis, protein molecules in the If protein is lost into the urine, there is a fall
gering an inflammatory process that blood draw back water that has been lost to in osmotic pressure and more water escapes
may damage the glomeruli and prevent surrounding tissues. into surrounding tissues, causing swelling.
them from working normally.

343
 GLOMERULOSCLEROSIS

glomerulosclerosis glossolalia
Scarring caused by damage to the Speaking in an imaginary language that LOCATION OF THE
glomeruli (see glomerulus), the filtering has no actual meaning or syntax. (See GLOSSOPHARYNGEAL NERVE
units of the kidney. also neologism.)
The nerve arises from the medulla
Mild glomerulosclerosis occurs as a
glossopharyngeal nerve oblongata and branches to the lower
normal part of the aging process. The jaw and the throat.
condition may also occur in some severe The ninth cranial nerve. This nerve sup-
types of glomerulonephritis. In addition, it plies the tongue and the throat, and
may be associated with diabetes mellitus, performs both sensory and motor func-
hypertension (high blood pressure), AIDS, tions. It conveys sensations, especially Midbrain
or intravenous drug abuse. taste, from the back of the tongue, regu-
lates the secretion of saliva by the
glomerulus parotid gland, and controls movement of
A filtering unit in the kidney. Each the throat muscles. Cerebellum
glomerulus consists of a cluster of capil-
glottis
G laries (tiny blood vessels) enclosed in a
capsule and supplied with blood from The part of the larynx (voice-box) that
the renal artery; it forms part of a larger consists of the vocal cords and the slit- Pons
filtering unit called a nephron. Filtered like opening between them.
blood eventually leaves the kidney via the
renal vein. (See also glomerulonephritis; glucagon
glomerulosclerosis.) A hormone that stimulates the break-
Glossopharyngeal
down of stored glycogen into glucose (a nerve
glomus tumour simple sugar). Glucagon is released by Medulla
A small, bluish swelling in the skin, the pancreas when the blood level of oblongata
usually on a finger or toe near or under glucose is low (see feedback). Spinal cord
the nail. The swelling feels tender and is Glucagon is used as an injected drug
more painful if the limb is hot or cold. in the emergency treatment of people
Glomus tumours are caused by an over- with diabetes mellitus who are uncon-
growth of the nerve structures that scious as a result of hypoglycaemia (low occurs mainly in the liver and muscles,
normally control blood flow and tem- blood glucose). Nausea and vomiting is an important source of energy when
perature in the skin. They are harmless are occasional adverse effects. insufficient amounts of carbohydrate
but can be surgically removed. are available (for example, between
glucagonoma meals or when a person is fasting).
glossectomy A tumour of the pancreas that secretes
Removal of all or part of the tongue. glucagon (the hormone responsible for glucosamine
Glossectomy may be performed to treat raising blood sugar levels). Glucagon- A molecule that occurs naturally as a
tongue cancer. If a large part of the omas, which can be cancerous or component of various substances in the
tongue is removed, speech is impaired noncancerous, may lead to attacks of body, including cartilage and collagen.
and eating is difficult. hyperglycaemia (high blood glucose) Glucosamine is also sold as a food sup-
due to excess glucagon production. plement and is recommended to relieve
glossitis symptoms of arthritis.
Inflammation of the tongue. The tongue glucocorticoids
feels sore and swollen and looks red and A group of corticosteroid hormones, pro- glucose
smooth; adjacent parts of the mouth duced by the cortex (outer layer) of the A simple sugar (monosaccharide) that
may also be inflamed. adrenal glands, that affect the chemical is naturally present in fruits and is also a
Glossitis occurs in various forms of breakdown of carbohydrates by increas- product of the digestion of starch and
anaemia and in vitamin B deficiency. ing both the blood sugar level and the sucrose. Glucose is the chief source of
Other causes include infection of the amount of glycogen stored in the liver. energy for the body and is carried to all
mouth (especially by herpes simplex), Glucocorticoids also enable the body to tissues in the circulation. (The term
irritation by dentures, and excessive use respond effectively to physical stress. “blood sugar” refers to levels of glucose
of alcohol, tobacco, or spices. Both natural and synthetic glucocorti- in the bloodstream.)
Treatment is for the underlying cause. coids are used to treat inflammatory The level of glucose in the blood is
Rinsing of the mouth with a salt solu- conditions (see corticosteroid drugs). The normally kept fairly constant by the
tion and good oral hygiene may help to main glucocorticoid is hydrocortisone, actions of various hormones, notably
relieve the soreness. also called cortisol. insulin, glucagon, adrenaline, corticosteroid
hormones, and growth hormone. An ab-
glossodynia gluconeogenesis normally high level of glucose in the
A painful, burning sensation in the A process in which glucose (a simple blood (known as hyperglycaemia) may
tongue, often with no known cause. sugar) is synthesized from sources cause glucose to be lost into the urine.
Glossodynia tends to disappear of its other than carbohydrates, such as amino An abnormally low blood glucose level
own accord over time. acids and glycerol. The process, which is called hypoglycaemia.

344
 GLYCOGEN STORAGE DISEASES

glue ear glue-sniffing

LOCATION OF THE
Accumulation of fluid in the cavity of See solvent abuse. GLUTEUS MAXIMUS
the middle ear, causing impaired hear-
ing. Persistent glue ear is most common glutaraldehyde
The top of the muscle is
in children. It is often accompanied by A topical (applied to the skin) prepara- attached to the sacrum,
enlarged adenoids and frequently occurs tion for the treatment of warts, especially coccyx, and pelvis. The
with viral respiratory tract infections, plantar warts (verrucas). Glutaraldehyde lower part is attached to
such as the common cold. It is usual for may cause a rash or irritation and may the femur (thigh bone).
both ears to be affected. stain the skin brown.
In glue ear, the lining of the middle
ear becomes overactive, producing large gluteal
amounts of a sticky fluid, and the eusta- A term meaning “relating to the but- Iliac crest
of pelvis
chian tube (which links the middle ear tocks”, as in the gluteal muscles.
to the back of the nose and throat) Gluteus
becomes blocked so that the fluid gluten maximus

cannot drain away. The accumulated

fluid interferes with the movement of
A combination of gliadins and gluten-
ins (types of proteins) present in wheat,
Sacrum
G
the delicate bones of the middle ear. rye, and barley. Mixed with water, flours
Glue ear is sometimes first detected containing gluten become sticky and Coccyx
by hearing tests. Examination with an trap air, thus forming dough. Sensitivity
otoscope (viewing instrument) can to gluten causes coeliac disease.
confirm the diagnosis. Hamstring
Mild cases of the condition often gluten enteropathy muscles
clear up without specific treatment. If See coeliac disease.
symptoms persist, the insertion of grom-
mets (small tubes) may be necessary, gluten intolerance
which allows air into the middle ear See coeliac disease.
and encourages fluid to drain away.
Adenoidectomy (removal of the aden- gluteus maximus
oids) may also be required. The large, powerful muscle in each of
the buttocks that gives them their
rounded shape. The gluteus maximus is
responsible for moving the thigh side-
ways and backwards.
glycogen
glycerol The main form of carbohydrate stored in
A colourless, syrupy liquid that has a the body. Glycogen is a polysaccharide,
sweet taste. Glycerol is an essential con- consisting of chains of glucose mol-
stituent of triglycerides (simple fats) in ecules, and is found mainly in the liver
the body. It may also be prepared com- and in muscles.
mercially from fats and oils. Glycerol is When there is excess glucose in the
added to moisturizing creams to help blood, it is converted to glycogen by
prevent dryness and cracking of the the action of insulin and glucocorticoids
skin. It is also used in eardrops to help (a class of corticosteroid hormones).
Eardrum soften earwax, and in cough remedies to When the blood glucose level is low,
Labyrinth
Ossicles help soothe a dry, irritating cough. Fur- glycogen is converted back to glucose
Vestibulocochlear thermore, glycerol is added to rectal (regulated by adrenaline and glucagon)
nerve suppositories; it relieves constipation by and released into the bloodstream.
softening hard faeces.
glycogen storage diseases
glyceryl trinitrate A group of rare genetic disorders charac-
A vasodilator drug used for the treatment terized by an absence or deficiency of
Cochlea
and prevention of symptoms of angina certain enzymes (proteins that act as
Middle ear
pectoris (chest pain due to inadequate catalysts) responsible for the metabo-
(filled with blood supply to the heart). Sublingual or lism of glycogen. These enzyme defects
excess fluid) buccal sprays and tablets are available for may lead to abnormal concentrations of
rapid pain relief and slow-release tablets glycogen in the tissues, insufficient glu-
Eustachian tube or skin patches for sustained pain relief. cose (a simple sugar) in the blood, or
The drug is sometimes prescribed to the inability of the body to use glucose
Effects of glue ear
In this condition, sticky fluid in the middle ear treat anal fissures but is not licenced as energy. Also known as glycogenoses
prevents free movement of the eardrum and for this use. High doses may cause or GSDs, these diseases may affect the
ossicles, causing deafness. headaches, flushing, and dizziness. liver, the muscles, or both.

345
 GLYCOSURIA

TYPES AND CAUSES GM foods DIAGNOSIS AND TREATMENT

There are several types of GSD. One is See genetically modified foods. Diagnosis may involve various thyroid-
glycogen storage disease type I. This function tests, including blood tests and
condition is caused by a defect in glu- gnathic radionuclide scanning, to determine the
cose-6-phosphatase, an enzyme that Pertaining to the jaw, as in gnathitis activity of the thyroid gland.
aids gluconeogenesis in the liver. The (inflammation of the jaw). A goitre that is not due to disease
majority of GSDs have an autosomal may eventually disappear of its own
recessive pattern of inheritance: they goitre accord. Goitre due to iodine deficiency
occur when a child inherits the affected Enlargement of the thyroid gland, visible can be treated by iodine-rich foods.
gene from parents who are carriers. as a swelling at the base of the neck. When a goitre is the result of disease,
SYMPTOMS AND SIGNS CAUSES treatment is for the underlying disorder.
These features vary according to the The thyroid gland may enlarge (with- Large goitres can be surgically removed
particular type of GSD. Symptoms and out any disturbance of its function) at (see thyroidectomy).
signs may include failure to grow nor- puberty, during pregnancy, or in women
mally during childhood; muscle cramps taking oral contraceptives. In many parts gold
G and wasting; an enlarged liver; and low
blood glucose levels.
of the world the main cause of a goitre
is a dietary deficiency of iodine, an ele-
A precious metal. Certain compounds
containing gold are used to treat severe
DIAGNOSIS, TREATMENT, AND OUTLOOK ment that the thyroid needs in order to rheumatoid arthritis and, occasionally,
Diagnosis may involve biochemical tests produce thyroid hormone. This form of arthritis arising as a complication of
(see biochemistry) on tissue samples from the condition is called endemic goitre. psoriasis (see disease-modifying antirheu-
a muscle or a liver biopsy. A condition called toxic goitre devel- matic drugs).
Some types of GSD can be controlled ops as a result of thyrotoxicosis in Graves’ Gold is used in a form called sodium
by management of symptoms, includ- disease and in certain other forms of aurothiomalate, given as intramuscular
ing by diet control. In certain cases a hyperthyroidism (overactivity of the thy- injections, or is taken orally (see auran-
liver transplant is an option, but in other roid gland). A goitre is also a feature of ofin). A common adverse effect of gold
cases no treatment is possible and death different types of thyroiditis (inflamma- treatment is dermatitis (skin inflamma-
occurs in the first few years of life. tion of the thyroid gland), including tion). Gold may result in damage to the
Hashimoto’s thyroiditis and De Quervain’s kidneys, liver, and bone marrow and
glycosuria thyroiditis. Other causes include a tumour may also cause loss of appetite, nausea,
The presence of glucose in the urine. or nodule in the gland and, in rare and diarrhoea.
Glycosuria results from failure of the cases, thyroid cancer.
kidneys to reabsorb glucose back into There are also various types of fam- Goldberg–Maxwell syndrome
the bloodstream after the blood has ilial goitre. This kind of goitre is caused A common form of male pseudo-
been filtered to remove waste products. by an inherited thyroid disorder; it hermaphroditism (a biological intersex
Failure to reabsorb sufficient glucose appears during childhood and is often condition in which the external geni-
may be due to hyperglycaemia (an ab- associated with signs of hypothyroidism, talia of a genetic male resemble those of
normally high blood glucose level), as such as learning difficulties. a female). Affected individuals have
in diabetes mellitus. It may also occur if SYMPTOMS testes but have a small penis and a
the kidney tubules have been damaged A goitre can range in size from a barely divided scrotum that resembles labia.
(for example, through drug poisoning) noticeable lump to a large swelling, de- (See also sex determination.)
and thus cannot reabsorb even normal pending on the cause. Large goitres may
amounts. In addition, glycosuria may press on the oesophagus or the trachea Goldenhar’s syndrome
occur during pregnancy, but is usually and therefore make swallowing or A rare, congenital type of dysplasia
not serious provided that the blood glu- breathing difficult. (growth abnormality) in which the
cose level is normal and there are no head and face fail to develop normally
other symptoms. before birth. Common features include
Glycosuria is diagnosed by testing the missing or abnormally developed ears
urine (see urinalysis). The treatment and malformations of the jaw, mouth,
depends on the cause. palate, eyes, and vertebrae.
glycosylated haemoglobin golfer’s elbow
A form of haemoglobin that is bound to A condition caused by overuse of the
the sugar glucose. In most people, forearm muscles that bend the wrist
between three and eight per cent of and fingers, usually due to activities
haemoglobin is glycosylated. In people such as using a screwdriver or playing
with diabetes mellitus, the level of glyco- golf with a faulty grip. The injury leads
sylated haemoglobin may be raised if to inflammation of the epicondyle (bony
treatment has not kept the blood glu- prominence) on the inner part of the
cose level within the normal range. Appearance of goitre elbow, where the affected muscles are
The thyroid gland can become enlarged for a
Glycosylated haemoglobin levels in- variety of reasons, including dietary deficiency of
attached. Symptoms include pain and
dicate blood glucose levels over the iodine, inflammation, or an autoimmune disorder tenderness of the elbow and sometimes
preceding three months. affecting the gland. also the forearm.

346
 GOUT

Treatment consists of resting the elbow, the basis of pregnancy tests. HCG ex- DIAGNOSIS AND TREATMENT
applying ice-packs, and taking analgesic tracted from the urine of pregnant Tests are performed on a sample of dis-
drugs (painkillers). Severe or persistent women is given by injection to treat charge or on swabs taken from the
pain may be relieved by local injections certain types of infertility. It may help to urethra, cervix, or rectum in order to
of a corticosteroid drug. induce ovulation in women who have confirm the diagnosis.
not been ovulating, and, in men, it may Gonorrhoea is treated with antibiotic
gonadal dysgenesis increase sperm production. HCG is occa- drugs. Treatment is effective but does
Defective development of the gonads sionally given to prevent miscarriage in not protect against reinfection; in addi-
(the testes and ovaries). Gonadal dysge- women whose production of proges- tion, bacterial resistance to antibiotics is
nesis is a feature of Turner’s syndrome. terone is deficient. an increasing problem. The patient’s
recent sexual contacts will need to be
gonadorelin gonads tested to establish whether or not they
A medicinal version of gonadotrophin- The sex glands: the testes (see testis) in are also infected (see contact tracing).
releasing hormone (GnRH), which is men and the ovaries (see ovary) in
naturally released by the hypothalamus. women. The activities of the gonads, Goodpasture’s syndrome
GnRH stimulates the nearby pituitary
gland to secrete the two gonadotrophin
both male and female, are regulated by
gonadotrophin hormones, which are
A rare autoimmune disorder (in which
the body’s immune system attacks its
G
hormones follicle-stimulating hormone released by the pituitary gland. own tissues) causing inflammation of the
(FSH) and luteinizing hormone (LH). glomeruli (see glomerulus) in the kid-
Gonadorelin can be given by injec- gonorrhoea neys and the alveoli (tiny air sacs) in the
tion. It is used to investigate suspected One of the most common sexually lungs, as well as anaemia. Goodpasture’s
disease of the hypothalamus. transmitted infections. Gonorrhoea is syndrome is a serious disease; unless
Gonadorelin analogues are synthe- widespread throughout the world. treated early it may lead to life-threaten-
sized forms of, and closely resemble, CAUSES AND INCIDENCE ing bleeding into the lungs and
gonadorelin. They cause the hypotha- Gonorrhoea, which is caused by the progressive kidney failure. It is most
lamus to release less GnRH, and this bacterium NEISSERIA GONORRHOEAE, is most common in young men, but can devel-
effect leads to a reduction in the levels often transmitted during sexual activity, op at any age and in women.
of FSH and LH. Gonadorelin analogues including oral and anal sex. An infected Goodpasture’s syndrome may respond
are used to counter the effects of natural woman may also transmit the disease to to treatment with immunosuppressant
hormones during gonadorelin treat- her baby during childbirth. drugs and plasmapheresis (a procedure
ment of infertility. The drugs are also used SYMPTOMS AND SIGNS for removing unwanted antibodies from
to treat endometriosis and hormone- Gonorrhoea has an incubation period blood plasma). People who have severe
dependent cancers including breast of between two and ten days. In men, or repeated attacks of the disorder re-
cancer and prostate cancer. symptoms include a discharge from the quire dialysis (a technique for removing
urethra and pain on passing urine. Many waste products from the blood) and,
gonadotrophin hormones infected women have no symptoms; if ultimately, a kidney transplant.
Hormones that stimulate cell activity in symptoms are present, they usually con-
the ovaries and testes. Gonadotrophins sist of a vaginal discharge or a burning GORD
are essential for fertility. The most sensation on passing urine. The abbreviation for gastro-oesophageal
important are follicle-stimulating hor- Infection acquired through anal sex reflux disease (see acid reflux).
mone (FSH) and luteinizing hormone can cause gonococcal proctitis (inflam-
(LH), secreted by the pituitary gland. mation of the rectum and anus). Oral goserelin
Another gonadotrophin, HCG (see gon- sex with an infected person may lead to A synthetic drug chemically related to
adotrophin, human chorionic), is produced gonococcal pharyngitis, which some- the hypothalamic hormone gonadorelin.
by the placenta in pregnancy. times causes a sore throat. A baby Goserelin is used to treat breast cancer,
Certain gonadotrophins are used as exposed to the infection during birth prostate cancer, fibroids, infertility, and
drugs in the treatment of infertility. may acquire the eye infection gonoc- endometriosis. Adverse effects of gosere-
occal ophthalmia. lin include loss of bone density after
gonadotrophin, human COMPLICATIONS prolonged application.
chorionic Untreated gonorrhoea may spread to
A hormone produced by the placenta in other parts of the body. In men, it may gout
early pregnancy. Human chorionic gon- cause prostatitis (inflammation of the A common metabolic disorder that causes
adotrophin (HCG) stimulates the ovaries prostate) or epididymo-orchitis (inflam- attacks of arthritis, usually in a single
to produce oestrogen and progesterone, mation of a testis and the chamber joint (often the base of the big toe).
which are necessary for a healthy preg- where sperm mature), affecting fertility. Gout is due to high levels of uric acid
nancy. HCG may also be produced in In women, it causes pelvic inflammatory in the blood (see hyperuricaemia); the
nonpregnant women by a choriocarcino- disease, which may damage the fallopian arthritis is due to the deposition of uric
ma (a cancerous tumour of the uterus), tubes. This problem increases the risk of acid crystals in joint tissue.
and by some testicular tumours (see later ectopic pregnancy and may lead to The affected joint is red, swollen, and
testis, cancer of) in men. infertility. Gonococcal bacteria in the extremely tender. Attacks last for a few
HCG is excreted in the urine; the bloodstream may result in septicaemia days and often recur. They are sometimes
detection of HCG levels in urine forms or septic arthritis. accompanied by fever. With recurrent

347
 GRAEFE’S SIGN

attacks, more joints may be involved, and

there may be constant pain due to joint GOUT
damage from chronic inflammation. In Gout is a common joint disease, affecting 10 times more men than women. In men
addition, gout may be associated with it may occur at any time after puberty; in women it usually occurs only after the
kidney stones (see calculus, urinary tract) menopause. There is often a family history of the disorder. Hyperuricaemia (excess
or, rarely, with kidney damage due to the uric acid in the blood) leads to the formation of uric acid crystals inside joints.
deposition of crystals in the kidney tissue. Crystals may also be deposited in the soft tissues in the ears and around tendons.
The diagnosis is confirmed by tests
on blood or fluid from the affected
joint to measure uric acid levels. DIAGNOSIS
The pain and inflammation of acute Femur Gout is suspected if an attack
(of sudden onset) attacks can be con- of arthritis affects a single joint.
trolled by nonsteroidal anti-inflammatory A blood test is usually performed;
drugs (NSAIDs) or by colchicine. If these a high level of uric acid will suggest
Patella
drugs are ineffective, a corticosteroid drug gout. Examination of fluid from the
G may be injected into the joint. Many
people require no further treatment.
joint may confirm the diagnosis.

Long-term treatment with drugs that

help to lower urate levels, such as allo- Crystals in
joint space
purinol or sulfinpyrazone, can stop or
reduce the frequency of recurrent
attacks. These drugs, however, may trig- Tibia
ger an attack at the start of treatment, so
are initially prescribed with NSAIDs.
Crystal precipitation
Graefe’s sign Crystals of uric acid precipitate (solidify) into
the joint space and surrounding tissues of the
Lagging of the upper eyelid (see lid lag) knee, causing intense inflammation and
as it follows the downward rotation of extreme pain. Aspiration
the eyeball in Graves’ disease. Fluid is aspirated (removed through a
needle into a syringe) from the swollen
grafting joint and examined under a microscope to
detect any uric acid crystals.
The process of transplanting healthy tis-
sue from one part of the body to
another (autografting) or from one
person to another (allografting). Tissue
transplantation from an animal to a per-
son (xenografting) is also carried out.
Grafting is used to repair or replace
diseased, damaged, or defective tissues
or organs. Common operations of this
type are skin graft, bone graft, bone marrow
transplant, corneal graft, kidney transplant,
heart transplant, liver transplant, heart–lung Appearance of gout Microscopic evidence
transplant, heart-valve surgery, and micro- Deposition of uric acid crystals in the joint The presence of uric acid crystals in the
space has caused inflammation and swelling of fluid confirms the diagnosis of gout.
surgery on blood vessels and nerves.
the patient’s affected left knee.
COMPLICATIONS
With autografting, the grafted tissue is
usually assimilated well into the sur-
rounding tissue at the new site. given immunosuppressant drugs to sup- followed by diarrhoea, abdominal pain,
There is a risk of tissue rejection fol- press the body’s natural defences. (See jaundice, inflammation of the eyes and
lowing other forms of grafting.The only also transplant surgery.) mouth, and breathlessness. Most people
exceptions are grafts between identical with GVH recover within a year, but
twins, because their tissue matches graft-versus-host disease about one in five may eventually devel-
exactly, and corneal grafting, because A complication of a bone marrow trans- op fatal complications.
the cornea has no blood supply and plant in which certain immune system GVH disease can usually be prevented
therefore no white blood cells and anti- cells, called killer T-lymphocytes, in the by giving immunosuppressant drugs to all
bodies to act as a defence system against transplanted marrow attack the tissues transplant patients. If, despite prophy-
the foreign cells. of the recipient. lactic treatment, the disease develops, it
To overcome rejection, as close a Graft-versus-host (GVH) disease may can be treated with corticosteroid drugs
match as possible between the tissues of occur soon after transplantation or may and immunosuppressant drugs such as
recipient and the tissues of donor is take some months to appear. The first ciclosporin. In some cases, however, it
sought (see tissue-typing).The recipient is sign is usually a skin rash. This may be can be difficult to control.

348
 GREY BABY SYNDROME

Gram’s stain to certain infections, such as tubercu- Other conditions result from an immune
An iodine-based stain used to differen- losis,or to a foreign body, such as a system response to a foreign substance
tiate between types of bacterium. suture (stitch), but they may also devel- or infectious organism. Causes include
A specimen of bacteria is stained op for unknown reasons in conditions tuberculosis, fungal infections, and
with gentian violet and a solution of such as sarcoidosis. inhaled rock or mineral dusts. In some
Gram’s stain. It is then treated with a A pyogenic granuloma is an excess of diseases, however, such as sarcoidosis,
decolorizing agent, such as acetone, granulation tissue developing at the site the cause is unknown.
before being counterstained with a red of an injury to the skin or mucous
dye. Bacteria that retain the dark violet membrane. (See also granuloma annulare; grasp reflex
stain are known as Gram-positive; those granuloma inguinale.) A primitive reflex (see reflex, primitive)
that lose the violet stain after decolori- in which the fingers or toes curl when
zation and take up the counterstain (so granuloma annulare the palm or sole is touched or stroked.
that they appear pink) are known as A harmless skin condition characterized The grasp reflex is normal in babies,
Gram-negative. by circular, raised areas of skin that but if it continues into later life or
Examples of Gram-positive bacteria spread outwards, forming rings. It appears in an adult, it may indicate a
include STREPTOCOCCUS and CLOSTRIDIUM.
Gram-negative bacteria include VIBRIO
occurs mostly in children and young
adults, usually on the backs of the
disorder of the frontal lobe of the brain. G
CHOLERAE , which causes cholera, and vari- hands and feet. The cause is unknown. Graves’ disease
ous species of SALMONELLA. The diagnosis of granuloma annulare An autoimmune disorder (in which the
is often made simply from its appear- immune system attacks the body’s own
grand mal ance, but may be confirmed by a skin tissues) that affects the thyroid gland.
The former name for tonic–clonic biopsy (removal of a tissue sample for Graves’ disease is characterized by toxic
seizures, which occur in epilepsy. The analysis). No treatment is necessary. In goitre (an overactive and enlarged thy-
episode may start with warning sensa- most cases, the skin heals fully over sev- roid gland); excessive production of
tions, such as unease or fear. This eral months or years. thyroid hormones (hyperthyroidism),
so-called aura lasts for a few seconds. leading to thyrotoxicosis; and exophthal-
The person then loses consciousness granuloma inguinale mos (bulging eyeballs).
and collapses, and may briefly stop A sexually transmitted infection that causes
breathing. During the seizure there are ulceration of the genitals.The infection is gravida
generalized, jerky muscle contractions. caused by CALYMMATOBACTERIUM GRANULO- The medical term for a pregnant
As it finishes, the muscles relax and MATIS , also known as Donovan’s bodies. woman. The term “gravida” is often
bowel and bladder control may briefly It is common in parts of the tropics but combined with a prefix to indicate the
be lost. This type of seizure usually lasts rare in temperate countries. number of pregnancies that a woman
for only a few minutes; the person may The first symptoms are painless, has had (including the current one); for
have no recall of it on awakening. raised nodules on the penis or labia example, a primigravida is a woman
(external female genitals) or around the who is pregnant for the first time.
grand multipara anal area.The nodules gradually ulcerate
A term relating to a pregnant woman forming red, raised areas, which may gravitational ulcer
who has had five or more previous contain pus. Left untreated, the affected A form of skin ulcer that occurs in the
pregnancies that have resulted in deli- areas may eventually heal but there will lowermost parts of the body. The usual
very. During any subsequent pregnancy, be extensive scarring. site is the lower leg (see leg ulcer), and a
a grand multipara woman is considered A biopsy (removal of a tissue sample common cause is varicose veins.
to be at increased risk of a variety of for microscopic analysis) is performed
conditions including anaemia, hyper- on a sore in order to confirm diagnosis. gray
tension (high blood pressure), diabetes The antibiotics tetracycline or erythro- An SI unit (part of the International Sys-
mellitus, placenta praevia, malpresentation, mycin are effective treatments. tem of Units) of radiation dosage (see
prolonged labour, delivery by caesarean radiation unit).
section, ruptured uterus, and postpartum granulomatosis
haemorrhage. Any condition marked by the formation graze
of multiple granulomas (collections of See abrasion.
granulation tissue inflamed tissue), such as Hodgkin’s dis-
Red, moist, granular tissue that develops ease and Wegener’s granulomatosis. greenstick fracture
on the surface of an ulcer or an open A type of fracture that occurs when a
wound during the process of healing. granulomatous lung disease long bone in the arm or leg bends and
A condition in which one or more cracks on one side only. This type of
granulocyte granulomas (collections of inflamed fracture occurs only in children, whose
A type of white blood cell. tissue) develop within the lungs. In bones are still growing and flexible.
certain diseases, such as Churg–Strauss
granuloma syndrome and Wegener’s granulomatosis, grey baby syndrome
A growth comprising cells of a type granulomas and vasculitis (an inflam- A rare but potentially fatal condition in
associated with chronic inflammation. mation of the blood vessels) develop at newborn, and particularly premature,
Granulomas usually occur as a reaction the same time. babies. Grey baby syndrome is caused

349
 GREY MATTER

by the antibiotic drug chloramphenicol, griseofulvin equalizes the pressure on both sides of
which is not usually prescribed for An oral antifungal drug. Griseofulvin is the eardrum, permitting mucus to drain
newborns, but may be passed to a baby particularly useful for infections affect- down the eustachian tube into the back
via the mother’s bloodstream. Newborn ing the scalp, beard, palms, soles of the of the throat.
babies’ bodies cannot process or excrete feet, and nails. Common side effects are Grommets are usually allowed to fall
the drug effectively, so very high levels headache, dry mouth, abdominal pain, out as the hole in the eardrum closes;
build up. An affected infant is cold and and photosensitivity (increased sensitivity this generally occurs six to 12 months
has grey skin (see cyanosis) due to cir- of the skin to sunlight). Long-term after insertion.
culatory collapse (see shock). treatment with the drug may cause liver
If the condition is detected early, and or bone marrow damage group therapy
the drug is discontinued, the infant may Any treatment of psychological prob-
recover fully. Treatment with chloram- Groenouw’s corneal dystrophy lems in which a group of patients is
phenicol should be avoided in late An inherited disorder of the eye. There given therapy together.The group meets
pregnancy and during breast-feeding. are two forms of the condition: type I regularly, under the guidance of a thera-
(granular) and type II (macular). pist, in order to discuss their problems.
grey matter
G Regions of the central nervous system
Granular corneal dystrophy is an auto-
somal dominant disorder (see genetic
Interaction between the members of the
group is thought to be beneficial.
consisting mainly of closely packed and disorders) characterized by small granu- Group therapy may be useful for
interconnected nerve cell bodies and lar opacities in the top layers of the people with personality problems and
their branching dendrites. (In contrast, cornea. It develops in the first ten years for those who are suffering from alcohol
the nerve cells’ axons, which conduct of life. Macular corneal dystrophy is an dependence, drug dependence, anxiety dis-
nerve impulses, make up the white matter autosomal recessive disorder typified orders, and eating disorders.
of the central nervous system.) by a diffuse haze with areas of dense
Grey matter is found mostly in the corneal opacity. It develops in young growing pains
outer layers of the cerebrum (the main people up to the age of 20. Vague aches and pains that occur in the
mass of the brain that is responsible for Treatment for discomfort associated limbs of children aged between six and
advanced mental functions) and in with the disorder may include antibiotic 12 years old. Pains are usually felt at
deeper regions of the brain, such as the eye-drops. Severe cases may require night, often in the calves. The cause is
basal ganglia. Grey matter also makes up laser surgery or a corneal transplant. unknown, but the pains seem to be
the core of the spinal cord. unrelated to the growing process itself.
groin Growing pains are of no medical sig-
grief The hollow between the lower abdo- nificance and need no treatment. In
A painful emotion, usually caused by men and the top of the thigh. contrast, pains that occur in the morn-
loss of a loved one. (See bereavement.) ing, cause a limp, or prevent normal use
groin, lump in the of a limb are not growing pains and
grip A swelling in the groin. The most com- should be assessed by a doctor.
The ability of the hand to hold objects mon cause is enlargement of a lymph
firmly. The hand has an opposable node due to an infection (see glands, growth
thumb (which can touch each of the swollen). Another common cause is a An abnormal proliferation of cells in a
fingers), specialized skin on the palm hernia, in which the abdominal contents localized area (see tumour). Growth is
and fingers to give adhesion, and a protrude through a weak area in the also increase in size, usually as a result
complex system of muscles, tendons, abdominal wall. Rarely, in males, an of increasing age (see growth, childhood).
joints, and nerves that enables precise undescended testis may lead to a lump
movements of the digits. The hand is in the groin (see testis, undescended). growth, childhood
capable of performing two types of Treatment depends on the cause. The increase in size that occurs as a
grip: grasping, in which the whole child develops. Growth is usually moni-
hand is used, and pinching, a precise groin strain tored by measuring height, weight,
hold using the thumb and one finger. Pain and tenderness in the groin as a and, in babies, head circumference.
Gripping ability is greatly reduced by result of overstretching a muscle, typi- The period of fastest growth occurs
conditions that cause muscular weak- cally while running or playing sport. before birth. Growth is still rapid in the
ness or impairment of sensation in the The muscles commonly affected are the first few years of life, especially in the
hands. Such conditions include stroke or adductors (on the inside of the thigh) first year, but the rate decreases during
nerve injury, and disorders that affect the and the rectus femoris (at the front of childhood. Puberty marks another major
bones or joints of the hand or wrist, the thigh). Groin strain is most often period of growth, which continues until
such as arthritis or a fracture. treated with physiotherapy, but recovery adult height and weight are reached,
may be slow. usually at age 16 to 17 in girls and bet-
gripe ween 19 and 21 in boys. See growth
Severe abdominal pain (see colic). grommet charts (p.352).
A small tube that may be inserted The body shape changes during
grippe through an incision in the eardrum dur- childhood because different areas grow
An outdated term of French origin for ing surgery to treat glue ear, usually in at different rates. For example, at birth,
any illness resembling influenza. children (see myringotomy).The grommet the head is already about three quarters

350
 GUILLAIN–BARRÉ SYNDROME

CHANGES IN BODY PROPORTIONS BETWEEN BIRTH AND ADOLESCENCE

As a child grows, the

body proportions 1
change radically in
relation to the body’s 2
overall length (see
right). For example, a 3
newborn baby’s legs
account for only three 4
eighths of the body
length, while before
5
adolescence legs
account for one half.
A newborn’s head 6
accounts for as much
as a quarter of the 7 G
total body length,
while an adolescent’s 8
head accounts for
only one eighth. Eighths Newborn 2 years 5 years 8 years Adolescence

of its adult size; it grows to almost full growth hormone guar gum
size in the first year. Thereafter, it be- A substance produced by the pituitary A gum extracted from the cluster bean
comes proportionately smaller because gland that stimulates normal body (CYAMOPSIS TETRAGONOLABA). Guar gum is
the body grows at a much faster rate growth. Growth hormone increases the not digested in the body. It is used to
than that of the head. production of protein in muscle cells help control the blood glucose level in
Growth can be influenced by heredity and the release of energy from the people with diabetes mellitus because it
and by environmental factors, such as breakdown of fats. Oversecretion of the slows the absorption of glucose from
nutrition and general health. Hormones hormone leads to gigantism if it occurs the small intestine. The gum is taken as
also play an important role, particularly before puberty or acromegaly if it occurs granules sprinkled on food or dissolved
growth hormone, thyroid hormones, and, at afterwards. A deficiency of the hormone in water. It may cause flatulence, nausea,
puberty, the sex hormones. may result in short stature. Synthetic and abdominal discomfort.
A chronic illness, such as cystic fibro- growth hormone may be given by
sis, may retard growth. Even a minor injection to treat short stature caused by Guillain–Barré syndrome
illness can slow the growth rate briefly, pituitary or genetic disorders. A rare condition affecting the peripheral
although the rate usually catches up nervous system that causes weakness,
when the child recovers. In some cases, growth rate usually in the limbs.
slow growth is the only sign that a child The increase in size of an individual CAUSES
is ill, malnourished, or emotionally dis- over a given period of time. Growth The cause of Guillain–Barré syndrome
tressed, when it is known as failure to rate may be expressed in absolute terms is believed to be an allergic reaction to
thrive. However, short stature does not or relatively, as a percentage of the aver- an infection, usually viral; the nerves
always indicate poor health. age growth rate. (See also growth, are damaged by antibodies produced
Abnormally rapid growth is rare. childhood; height velocity.) against the virus. Most cases develop
Usually, it is a familial trait, but it may two or three weeks after the infection.
occasionally indicate an underlying dis- growth, restricted SYMPTOMS
order, such as a pituitary gland tumour See short stature. Weakness, often accompanied by
causing gigantism. (See also age; child numbness and tingling, usually starts in
development.) G syndrome the legs and spreads to the arms. It may
See Opitz syndrome. worsen, resulting in paralysis. The mus-
growth, excessive cles of the face and those controlling
See gigantism. GTN speech, swallowing, and breathing may
The abbreviation for glyceryl trinitrate. also be affected.
growth factor DIAGNOSIS AND TREATMENT
Any of various chemicals that are invol- guaiac Diagnosis is confirmed by electrical tests
ved in stimulating new cell growth A chemical used to detect haemoglobin to measure how fast nerve impulses are
and maintenance. Some growth factors, (the oxygen-carrying pigment in red conducted, and by a lumbar puncture, in
such as vascular endothelial growth fac- blood cells) in faeces. Tests using guaiac, which a sample of cerebrospinal fluid is
tor, which stimulates the formation of known as faecal occult blood tests, are per- taken from the spinal canal for analysis.
new blood vessels, are significant in the formed to detect hidden bleeding in the Most people recover fully with only
growth and spread of cancers. digestive tract (see occult blood, faecal). supportive treatment. Severe cases may

351
 GUILLAIN–BARRÉ SYNDROME

GROWTH CHARTS

Growth charts are used to record the growth of children from The vertical axis on the charts show the weight, in kilograms
the age of two to 18 years. Recording of a child’s weight and and pounds, and the height in centimetres and inches; the
height are carried out as part of a routine health check. The horizontal axis shows the age range from two to 18 years.
doctor or health visitor measures the child’s weight and height About 98 per cent of children fall below the line of the 98th
and plots them against age on a chart. The growth curve is percentile; the 50th percentile is the average, and 50 per cent
compared with the typical range, represented by the shaded fall below this line; only 2 per cent of children fall below the
area on the chart, for all children of the same age and gender. line of the 2nd percentile.

BOYS’ WEIGHT (2–18 YEARS) GIRLS’ WEIGHT (2–18 YEARS)

Weight Weight
lb kg lb kg

G 98th percentile 98th percentile

50th percentile
50th percentile 2nd percentile
2nd percentile

Age (years) Age (years)

BOYS’ HEIGHT (2–18 YEARS) GIRLS’ HEIGHT (2–18 YEARS)

Height Height
in cm in cm

98th percentile 98th percentile

50th percentile 50th percentile

2nd percentile 2nd percentile

Age (years) Age (years)

Growth in boys Growth in girls

Normally, there is a steady increase in height and weight until the onset of Normally, there is a steady increase in height and weight until the onset of
puberty. A sudden spurt in growth occurs during puberty (between the ages puberty. A sudden spurt in growth occurs during puberty (between the ages
of 13 and 16). This chart was constructed using the height and weight of of 11 and 14). These charts were constructed using the height and weight of
thousands of children; it is used by doctors to check whether growth of a thousands of children; it is used by doctors to check whether growth of a
particular boy is significantly above or below average. particular girl is significantly above or below average.

352
 GYNAECOMASTIA

need treatment with plasmapheresis (in gullet at a higher risk of developing plaque
which blood is treated to remove anti- The common name for the oesophagus. psoriasis (the more common form of
bodies) or immunoglobulin. Mechanical psoriasis) in later life.
ventilation may be used to aid breathing gum
if the chest muscles and diaphragm are The soft tissue surrounding the teeth gynaecology
severely affected. Some people are left that protects underlying structures and The medical speciality concerned with
with a permanent weakness, others may keeps the teeth in position in the jaw. the female reproductive tract. Gynaecology
have further attacks of the disease, and a Healthy gums are pink or brown and deals with contraception; the investigation
number may suffer both weakness and firm. Careful oral hygiene helps to keep and treatment of menstrual problems
further attacks. the gums clean and prevent disease. Gin- (see menstruation, disorders of); sexual
givitis (an early, reversible stage of gum problems; infertility; problems relating to
guilt disease characterized by inflammation the menopause; and disorders such as
A painful emotion that arises from the of the gums) may occur if plaque is uterine fibroids and ovarian cysts. Gynae-
awareness of having broken a moral allowed to collect around the base of cologists also deal with disorders in the
code. Guilt (unlike shame, which dep- the teeth. If untreated, it may lead to early stages of pregnancy, such as recur-
ends on how other people view the
transgression) is self-inflicted. Some psy-
chronic periodontitis, advanced gum dis-
ease in which infected pockets form
rent miscarriage. G
choanalysts view it as a result of the between the gums and the teeth. gynaecomastia
prohibitions of the superego (con- Bleeding gums are nearly always a Enlargement of one or both breasts in
science) that are instilled in early life, symptom of gingivitis; rarely, they are men or boys. The condition is some-
while others see guilt as a conditioned due to leukaemia or scurvy (vitamin C times due to an excess of the female sex
response to actions that on previous deficiency). Gingival hyperplasia (fleshy hormone oestrogen.
occasions have led to punishment. thickening of the gums) occurs most CAUSES AND INCIDENCE
Feeling guilty for no reason, or for an commonly as a side effect of treatment Mild, temporary gynaecomastia can
imagined crime, is one of the main with phenytoin (an anticonvulsant drug). occur in boys at birth due to maternal
symptoms of depression. (See also receding gums.) hormones, and the condition is also
common at puberty.
Guinea worm disease gumboil Gynaecomastia that develops in later
A tropical disease caused by a parasitic See abscess, dental. life may be due to a chronic liver dis-
worm about 1 m long. The disease ease, such as cirrhosis, in which the liver
occurs in Africa, South America, the gumma is unable to break down oestrogen.
Middle East, and India. A soft tumour that may develop in the Hormone-secreting tumours, such as
Infection results from drinking water late stages of untreated syphilis. Gummas pituitary or testicular tumours, may also
containing the water flea CYCLOPS, which are rare in developed countries. be responsible for the condition.
harbours the worm larvae. Once con- Adult gynaecomastia, which some-
sumed in a drink, the larvae pass gustatory times occurs in only one breast, can also
through the intestine and mature in Related to the organs or sense of taste. occur when synthetic hormones and
body tissues. After about a year, the adult some drugs, such as digoxin, spirono-
female worm, now pregnant, reaches gut lactone, and cimetidine, cause a change to
the skin surface and creates an inflamed A common name for the intestine. the balance of sex hormones. Very
blister that bursts, exposing the end of rarely, a discrete lump that develops on
the worm. Urticaria (nettle rash), nausea, Guthrie test one breast may be caused by a male
vomiting, and diarrhoea often develop A blood test performed routinely on breast cancer.
during the formation of the blister. blood samples taken from the heels of DIAGNOSIS AND TREATMENT
The traditional remedy for the disease babies between the eighth and the four- Investigation may involve blood tests. If
is to wind the worm from the skin on teenth days after birth. The test is used cancer is suspected, a biopsy (removal of
to a small stick. The drugs tiabendazole to check for the inherited disorder the lump or a piece of tissue for analy-
and niridazole are given to reduce phenylketonuria, which can lead to severe sis) will be performed.
inflammation, antibiotic drugs are given brain damage if left untreated Treatment depends on the cause. If a
to control secondary infection, and the drug is responsible, an alternative will
patient is immunized against tetanus. guttate psoriasis be given if possible. If there is no
A form of psoriasis (a skin disease underlying disease, the swelling usually
Gulf War syndrome characterized by patches of inflamed subsides over a period of time. In severe
A group of symptoms affecting armed skin) that is found mainly in children cases, however, cosmetic surgery (see
forces personnel of various nationalities and young adults, especially following mammoplasty) may be considered.
involved in the war in the Persian Gulf in streptococcal infections. A particular
1991. A wide range of symptoms has feature of guttate psoriasis is the for-
been associated with the illness, includ- mation of multiple small, teardrop-
ing severe fatigue, fever, headaches, shaped skin blemishes. When it occurs
rashes, chronic bronchitis, visual distur- in children following a streptococcal
bances, impaired short-term memory, infection, it usually clears up com-
and depression.The cause is unknown. pletely. However, affected children are

353
 H 1 -RECEPTOR ANTAGONISTS

haem-

H
causes abnormal bleeding). Any joint
A prefix that is placed before a variety may be affected and bleeding into the
of words (for example, haemoglobin) to joint may occur spontaneously or be
indicate blood. caused by even a minor knock. Overuse
of anticoagulant drugs can also cause
haemangioblastoma haemarthrosis.
A rare type of brain tumour consisting of Repeated haemarthrosis may damage
blood-vessel cells. Haemangioblastomas joint surfaces, causing osteoarthritis.
develop slowly as cysts, often in the cere- SYMPTOMS AND SIGNS
bellum, and are mostly noncancerous. Haemarthrosis causes a joint to swell
Symptoms include headache, vomiting, immediately after injury. The joint may
H1-receptor antagonists nystagmus (abnormal jerky eye move- gradually stiffen into a fixed position as a
A common abbreviation for histamine1- ments) and, if the tumour is in the result of spasm in surrounding muscles.
receptor antagonists, a type of antihista- cerebellum, ataxia (lack of muscle coordi- TREATMENT
mine drug, that are used in the treatment nation). Most haemangioblastomas can Ice-packs may reduce swelling and pain.
of allergic reactions. be removed surgically. Fluid may be withdrawn from the joint
in order to relieve pain and for diagno-
H2-receptor antagonists haemangioma sis. Haemophiliacs are given factor VIII to
H A common abbreviation for histamine2- A birthmark caused by an abnormal dis- promote blood clotting. Resting the
receptor antagonist, a type of ulcer-heal- tribution of blood vessels. Haemangiomas joint in an elevated position can prevent
ing drug. (See also cimetidine; ranitidine; may be flat or raised. further bleeding.
famotidine.) TYPES
Port-wine stains are large, flat, purple- haematemesis
habit tic red marks, which are permanent and The medical term for vomiting blood.
A type of tic (repetitive, involuntary can be unsightly. In rare cases, port-
movement of a muscle) that has a wine stains are associated with abnor- haematocolpos
psychological cause and does not result malities in the blood vessels of the The accumulation of menstrual blood
from damage to or disease of the ner- brain (see Sturge-Weber syndrome). in the vagina due to blockage of the
vous system. Small, flat marks, often known as vaginal opening. This rare condition
stork marks or stork bites, are common occurs either when the hymen (the
habitual abortion in newborn babies, particularly on the membrane around the vaginal opening)
An outdated term for the spontaneous back of the neck. Most begin to fade lacks the perforation that would nor-
abortion (see miscarriage) of a fetus in about three weeks after birth. mally allow the blood to leave the body
three or more consecutive pregnancies, Raised bright red haemangiomas, or as a result of developmental abnor-
after less than 24 weeks’ gestation. often called strawberry marks, usually malities of the vagina. Haematocolpos
Habitual abortion is now more com- enlarge rapidly during the first few requires surgical treatment to drain the
monly known as recurrent pregnancy weeks after birth. They generally disap- blood and, if necessary, to reconstruct
loss or recurrent miscarriage. Habitual pear without leaving a scar by the time the vagina.
abortions may be caused by defects or a child is five to seven years old.
disorders of the uterus, such as fibroids, COMPLICATIONS AND TREATMENT haematology
or of the cervix (see cervical incompe- Haemangiomas do not usually require The study of blood and its formation, as
tence). Certain conditions affecting the treatment. However, a haemangioma well as the investigation and treatment
mother, such as systemic lupus erythe- that bleeds persistently or that looks un- of disorders that affect the blood and
matosus or Hughes’ syndrome, may also sightly may need to be removed by laser the bone marrow.
cause habitual abortion. treatment, cryosurgery (destruction of Microscopic examination and count-
tissue by extreme cold), radiotherapy, ing of blood and bone marrow cells are
habituation embolization (obstruction of blood flow essential procedures in diagnosing types
The process of becoming accustomed to to tissue), or plastic surgery. of blood disorder, such as anaemia or
an experience. In general, the more a leukaemia. Analysis of blood is used in
person is exposed to a stimulus, the less haemarthrosis the diagnosis of a range of disorders as
he or she is affected by it. People can Bleeding into a joint, causing the cap- well as specific blood disorders.
become habituated to certain drugs and sule that encloses the joint to swell, and
develop a reduced response to their resulting in pain and stiffness. haematoma
effects (see tolerance). CAUSES A localized collection of blood (usually
Haemarthrosis is usually the result of clotted) that is caused by bleeding from
haem severe injury to a joint, such as a torn a ruptured blood vessel. Haematomas
An iron-bearing pigment that combines capsule, torn ligaments, or fracture of a can occur almost anywhere in the body
with globin (a protein) to form haemo- bone forming part of the joint. Often and vary from a minor to a potentially
globin, the main component of red blood the cause is a sports injury to the knee. fatal condition.
cells. The haem binds with oxygen in Less common causes are bleeding dis- Less serious types of haematoma in-
order to transport it from the lungs to orders, such as haemophilia (in which clude those that develop under the nails
the tissues. failure of the blood-clotting mechanism or in the tissues of the outer ear (cauli-

354
 HAEMOLYTIC DISEASE OF THE NEWBORN

flower ear). Most haematomas disappear section (withdrawal of blood from a haemoglobinopathy
without treatment in a few days, but if vein). Initially, the procedure is performed A term used to describe the genetic dis-
they are painful they may need to be every week. After iron levels have returned orders in which there is a fault in the
drained. More serious types include to normal, however, the process of vene- production of the globin chains of
extradural and subdural haematomas, section is required less often. (See also haemoglobin (the oxygen-carrying sub-
which press on the brain (see extradural haemosiderosis.) stance in the blood). Examples of
haemorrhage; subdural haemorrhage). haemoglobinopathies include sickle cell
haemodialysis anaemia and the thalassaemias.
haematoma auris One of the two means of dialysis (artifi-
The medical term for cauliflower ear. cial filtration of the blood) used to treat haemoglobinuria
kidney failure. The presence of haemoglobin in urine.
haematospermia Haemoglobin is an oxygen-carrying
An alternative term for haemospermia, haemoglobin substance mainly contained in red blood
the medical term for blood in the The oxygen-carrying pigment that is cells, but a small amount is free in the
semen (see semen, blood in the). present in red blood cells. Haemoglobin blood plasma. Excessive breakdown of
molecules, which are produced by bone red blood cells, due to heavy exercise,
haematuria marrow, are made up of four protein cold weather, falciparum malaria, or
Blood in the urine, which may or may chains (two alpha- and two beta-glo- haemolytic anaemia, increases the con-
not be visible to the naked eye. In small bin) and four haem (a red pigment that centration of free haemoglobin in the H
amounts, it may give the urine a smoky contains iron). plasma. The body excretes the excess
appearance. haemoglobin in the urine.
Almost any urinary tract disorder can
cause haematuria. Urinary tract infection is Alpha haemolysis
a common cause; prostatitis may be a chains The destruction of red blood cells.
cause in men. Cysts, kidney tumours, blad- Haemolysis is the normal process by
der tumours, stones (see calculus, urinary Haem which old red blood cells are destroyed,
tract), and glomerulonephritis (inflamma- mainly in the spleen. Bilirubin, a waste
tion of the filtering units of the kidney) product of haemolysis, is excreted into
may cause haematuria. Bleeding disorders the bile by the liver. Abnormal haemoly-
Iron
may also cause the condition. sis, in which red blood cells are destroyed
Blood that is not visible to the naked prematurely, may cause anaemia and
eye may be detected by a dipstick urine jaundice (see anaemia, haemolytic).
test or microscopic examination. CT Beta
scanning, ultrasound scanning, or intra-
chains
haemolytic anaemia
venous urography can help to determine See anaemia, haemolytic.
the cause. If bladder disease is suspec-
ted, cystoscopy is performed. Structure of haemoglobin
Each molecule contains four globin chains –
haemolytic disease of the
two alpha and two beta. Each chain carries newborn
haemochromatosis a haem component capable of binding oxygen. Excessive haemolysis (destruction of red
An inherited disease in which too much blood cells) in the fetus and newborn
dietary iron is absorbed. Excess iron Oxygen from the lungs enters red blood by antibodies produced by the mother.
gradually accumulates in the liver, pan- cells in the bloodstream. The oxygen Haemolytic disease of the newborn is
creas, heart, testes, and other organs. then combines chemically with the most often caused by Rhesus incompati-
Men are more frequently affected than haem in the haemoglobin to form oxy- bility. This occurs when a mother with
women because women regularly lose haemoglobin, which gives blood in the Rh-negative type blood, who has previ-
iron in menstrual blood. arteries its bright red colour. In this ously been exposed to Rh-positive
SYMPTOMS AND COMPLICATIONS medium, oxygen is carried around the blood through birth, miscarriage, abor-
Haemochromatosis rarely causes prob- body and delivered to the areas that tion, or amniocentesis, is pregnant with
lems until middle age. Loss of sex drive need it. When the oxyhaemoglobin has a baby that has Rh-positive blood. Haem-
and a reduction in the size of the testes released its oxygen it reverts to haemo- olytic disease has become uncommon
are often the first signs. Excess iron over globin, giving the blood in the veins its since the introduction of routine preven-
a period of time causes enlargement of distinctive darker colour. tive treatment for Rh-negative women
the liver and cirrhosis (chronic liver DISORDERS during pregnancy (see anti-D (Rh0)
damage) and can lead to diabetes melli- Some defects in haemoglobin produc- immunoglobulin).
tus, bronzed skin coloration (due to tion are the result of a genetic disorder; SYMPTOMS AND SIGNS
iron pigment deposition in the skin), defects such as these are subdivided In mild cases of the disease, the new-
cardiac arrhythmia, and, eventually, liver into two types, namely errors of haem born baby becomes slightly jaundiced
failure and liver cancer. production, known as porphyrias, and during the first 24 hours of life (due to
DIAGNOSIS AND TREATMENT those of globin production, known as an excess of the bile pigment bilirubin in
Diagnosis is based on blood tests and a haemoglobinopathies. Other defects, such the blood) and slightly anaemic. In more
liver biopsy (removal of a small sample of as some types of anaemia, have a non- severe cases, the level of bilirubin in the
tissue for analysis). Treatment is by vene- genetic cause. blood may increase to a dangerous level,

355
 HAEMOLYTIC–URAEMIC SYNDROME

causing a risk of kernicterus (a type of sex-linked inheritance. Affected males haemorrhoidectomy

brain damage). Severely affected babies pass on the gene not to their sons but Surgical removal of haemorrhoids. The
have marked anaemia while still in the to their daughters, who are carriers of procedure is used to treat large, prolaps-
uterus. They become swollen (hydrops the condition. Some of the sons of car- ing, or bleeding haemorrhoids, if other
fetalis) and are often stillborn. rier females may be affected, and some simpler methods such as banding have
TREATMENT of the daughters of carriers may them- not been successful.
In mild cases, no treatment is necessary. selves be carriers. Many haemophiliacs Complete healing after a haemor-
In other cases, the aim is to deliver the have an uncle, brother, or grandfather rhoidectomy takes three to six weeks.
baby before the anaemia becomes too also affected. However, in about one Laxative drugs are usually given during
severe, usually by induction of labour at third of cases there is no family history this period to soften faeces and make
35–39 weeks’ gestation. If the baby is of haemophilia. them easier to pass.
too young to be delivered safely, fetal SYMPTOMS
blood transfusions may be necessary. The severity of the disorder differs haemorrhoids
After birth, phototherapy (light treat- markedly among individuals. However, Swollen veins in the lining of the anus.
ment that converts bilirubin in the skin episodes of bleeding are painful and, Haemorrhoids may occur close to the anal
into a water-soluble form that is more unless treated promptly, can lead to opening, when they are called external
easily excreted from the body) can help deformity of the knees, ankles, and haemorrhoids, or higher in the anal canal,
to reduce jaundice. An exchange blood other joints. Injury, and even minor in which case they are called internal
H transfusion may be needed. operations such as tooth extraction, haemorrhoids. Sometimes these veins pro-
may lead to profuse bleeding. Internal trude outside the anal canal, in which case
haemolytic–uraemic syndrome bleeding can lead to blood in the urine they are called prolapsing haemorrhoids.
A rare disease in which red blood cells or extensive bruises. CAUSES
are destroyed prematurely and the kid- DIAGNOSIS AND TREATMENT Haemorrhoids are caused by increased
neys are damaged, causing acute kidney Haemophilia is diagnosed by blood-clot- pressure in the veins of the anus, most
failure. Thrombocytopenia (reduction of ting tests and by amniocentesis or chorionic commonly through straining repeatedly
platelets in the blood) can also occur. villus sampling in a fetus. Bleeding can to pass hard faeces. Such faeces may
haemolytic–uraemic syndrome most be controlled by infusions of factor VIII result from a diet that is too high in
commonly affects young children. concentrates. People with a severe form refined foods and too low in fibre (see
CAUSES of the disorder may need regular intra- constipation). Haemorrhoids are also
The precise cause of haemolytic–urae- venous injections of factor VIII as a common during pregnancy, when the
mic syndrome is uncertain, but the preventive measure. weight of the fetus exerts pressure on
disorder may be triggered by a serious OUTLOOK blood vessels.
bacterial or viral infection. It is thought Most people with haemophilia can SYMPTOMS
that the lining of small blood vessels in lead an active life but should avoid Rectal bleeding and discomfort on defae-
the kidneys becomes damaged, causing the risk of injury. Contact sports, such cation are the most common features.
small clots to form. These clots cause as football, are not advisable but other Prolapsing haemorrhoids often produce a
haemolysis (breakdown of red cells) as forms of exercise, such as swimming mucous discharge and itching around the
blood flows past them. and walking, can be beneficial. The anus. A complication of prolapse is throm-
SYMPTOMS female relatives of anyone with haemo- bosis and strangulation. This occurs when
The onset of the disease is sudden; philia should obtain genetic coun- a blood clot forms in the vein, preventing
symptoms include weakness, lethargy, selling before planning a pregnancy. it from returning to its position in the
and a reduction in the volume of urine. anus and restricting its blood supply. The
Severe hypertension (high blood pres- Haemophilus influenzae condition can cause extreme pain.
sure) is common and may cause seizures. A bacterium (see bacteria) responsible DIAGNOSIS AND TREATMENT
DIAGNOSIS AND TREATMENT for numerous cases of the infectious Diagnosis is usually by proctoscopy (in-
Blood and urine tests can determine the diseases epiglottitis and meningitis. spection of the rectum with a viewing
degree of kidney damage. Dialysis (artifi- instrument). Mild cases are controlled
cial filtration of the blood) may be needed haemoptysis by drinking plenty of fluids, eating a
until the kidneys have recovered. Most The medical term for coughing up blood. high-fibre diet, and establishing regular
patients recover normal renal function. bowel movements. Rectal suppositories
haemorrhage and creams that contain corticosteroid
haemophilia The medical term for bleeding. (See also drugs and local anaesthetics reduce pain
An inherited bleeding disorder caused by haematoma.) and swelling. More troublesome haem-
deficiency of a blood protein, factor VIII, orrhoids may be treated by sclerotherapy
which is essential for blood clotting. haemorrhagic fever (injection of an irritant liquid), cryosur-
Haemophiliacs (who are almost always See viral haemorrhagic fever. gery (application of extreme cold), or
male) suffer recurrent bleeding, usually by banding, in which a band is tied
into their joints, which may occur haemorrhagic shock around the haemorrhoid, causing it to
spontaneously or after injury. Physiological shock (a dangerous reduc- wither and drop off. A haemorrhoidec-
INCIDENCE AND CAUSES tion of blood flow throughout the body tomy (the surgical removal of haemor-
The lack of factor VIII is due to a defec- tissues), which is caused by severe rhoids) is generally required for pro-
tive gene, which shows a pattern of blood loss. (See also hypovolaemia.) lapsing haemorrhoids.

356
 HAIR

haemothorax
TREATING HAEMORRHOIDS A collection of blood in the pleural cav-
ity (the space between the chest wall
In the procedures shown below, the patient will usually have been given a laxative
so that the lower bowel is clear of faeces. Banding requires no anaesthesia; either
and the lung). Haemothorax is most
general or epidural anaesthesia is given before a haemorrhoidectomy is performed. commonly caused by chest injury, but it
may arise spontaneously in people with
BANDING HAEMORRHOIDS defects of blood coagulation or as a
result of cancer.
Symptoms of haemothorax include
pain in the affected side of the chest
and upper abdomen, and breathless-
ness. If extensive, there may be partial
lung collapse. Blood in the pleural cav-
ity is withdrawn through a needle.
Hailey–Hailey disease
Also known as benign familial pemph-
igus, a form of pemphigus (a blistering
This common, simple, skin disease) that mainly affects the H
1is usually
and effective procedure
painless (causing
3is firedThe trigger mechanism of
the banding instrument
and the bands are
neck, armpits, and groin. Hailey–Hailey
disease tends to run in families.
no more than a mild ache squeezed on to the neck of
afterwards) and no
anaesthesia is required.
the mass. The proctoscope
is withdrawn, leaving the
hair
The patient lies on one haemorrhoid with its base A threadlike structure composed of dead
side, the proctoscope The banding instrument is tightly constricted by the cells containing keratin, a fibrous protein.
(instrument for examining
the rectum) is positioned,
2 inserted and pressed into the
anal wall. Gentle traction is applied
bands. The haemorrhoid
then withers and drops off
STRUCTURE AND FUNCTION
and the haemorrhoid is to draw the mass into the drum of painlessly within a few days
The root of each hair is embedded in a
grasped with forceps. the instrument. of the operation. tiny pit in the dermis (inner) layer of
the skin called a hair follicle. Each shaft
HAEMORRHOIDECTOMY of hair consists of a spongy semihollow
Skin of anal margin Haemorrhoid Retractor
core (the medulla), a surrounding layer
of long, thin fibres (the cortex), and, on
the outside, several layers of overlapping
cells (the cuticle).
While a hair is growing, the root is
enclosed by tissue called a bulb, which
supplies the hair with keratin. The bulb
is the pale swelling that sometimes can
be seen when a hair is pulled out. The
upgrowth of dead cells and keratin
Stages of the procedure of tumour. The patient is then placed in the from the root forms the hair. Once the
Under general or epidural anaesthesia, lithotomy position. The haemorrhoid is clamped, hair has stopped growing, the bulb
the patient’s rectum is examined with a placed under traction (as shown above), secured retracts from the root and the hair even-
proctosigmoidoscope to exclude a diagnosis with a suture, and then removed with a knife. tually falls out.
Hair is involved in the regulation of
body temperature (known as thermo-
haemosiderosis and plug the bleeding points. Third, the regulation). If the body is too cold,
A general increase in iron stores in the blood plasma coagulates, forming fila- erector pili muscles in the skin contract,
body. Haemosiderosis may occur after ments of a substance called fibrin, which pulling the hairs upright to form goose
repeated blood transfusions or, more help to seal the damaged blood vessel pimples. Erect hairs trap an insulating
rarely, as a result of excessive iron intake. (see blood clotting). Defects in any of these layer of air next to the skin.
mechanisms can cause a bleeding disorder. TYPES
haemospermia There are three types of human hair.
The medical term for blood in the haemostatic drugs From the fourth month of gestation, the
semen (see semen, blood in the). A group of drugs to treat bleeding disor- fetus is covered with downy hair called
ders and to control bleeding. Haemostatic lanugo, which is shed during the ninth
haemostasis preparations that help blood clotting are month. After birth and until puberty,
The arrest of bleeding. There are three given to people with clotting factor defi- vellus hair, which is fine, short, and
main natural mechanisms by which ciencies. For example, factor VIII is used for colourless, covers most of the body. The
bleeding is stopped after injury. First, haemophilia. Drugs that prevent the break- third type, terminal hair, is thicker, long-
small blood vessels constrict. Second, down of fibrin in clots, such as tranexamic er, and often pigmented; it grows on the
small blood cells called platelets aggregate acid, can also help stop bleeding. scalp, the eyebrows, and the eyelashes. At

357
 HAIRBALL

the hair appears white. The degree of made in a bald area, known as the recipi-
THE STRUCTURE OF A HAIR curliness of a hair depends on the cross- ent site. The procedure usually takes
section shape of its follicle. 60–90 minutes. The patient is given a
The hair shaft consists of dead cells
and keratin. It has three layers: the DISORDERS mild sedative and the donor and recipi-
medulla (core), the cortex, and the Brittle hair may be due to excessive ent sites are anaesthetized.The donor site
cuticle (covering). styling, hypothyroidism (underactivity of heals in about five days. Although trans-
the thyroid gland), or severe vitamin or planted hairs fall out shortly afterwards,
Cuticle mineral deficiency. Very dry hair can be new hair growth appears from the folli-
Medulla caused by malnutrition. Ingrown hairs cles between three weeks and three
Cortex occur when the free-growing end of months later.
Hair shaft the hair penetrates the skin near the fol- Other transplant techniques include
Sebaceous gland licle, which may cause inflammation. punch grafting, in which a punch is
(See also hirsutism; hypertrichosis.) used to remove small areas of bald
scalp, which are replaced with areas of
hairball hairy scalp; flap grafting, in which flaps
A ball of hair in the stomach, found in of hairy skin are lifted, rotated, and
people who nervously suck or chew stitched to replace bald areas; and male
their hair (see bezoar). pattern baldness reduction, which in-
H volves cutting out areas of bald skin and
hair cycle stretching surrounding areas of hair-
The alternating phases of activity in a bearing scalp to replace them.
hair follicle. There are two main phases:
an active phase, when new hair forms in
the follicle, and a resting phase, when SCALP HAIR GROWTH
cell activity slows down and stops. The
active phase lasts for several years, until There are about 100,000 hairs on the
scalp, though there is considerable
a hair has reached its maximum length.
individual variation. The exact number
During the resting phase, that hair dies. depends on the number of hair
During the next growth phase, a new follicles, which is established before
hair is formed and pushes the dead one birth. Scalp hair grows about one
out of the follicle. centimetre per month. Each hair goes
Follicle Root Bulb Blood vessel Erector pili
The growth cycles of hairs may be through alternating periods of growth
disrupted by various factors, including and rest. On average, a person sheds
hormonal or immune system disorders; about 100 scalp hairs a day.
pregnancy; adverse reactions to drugs;
Growth phase Hair shaft
and radiotherapy. At the start of a
growth phase
hairiness, excessive (which, on the
See hirsutism; hypertrichosis. scalp, lasts about
three years for
hair removal each hair),
the hair root
Hair is usually removed from the body stimulates the
Cross-section through a hair purely for cosmetic reasons. It may also growth of a bulb
In this light micrograph, the medulla, the be shaved from around an incision site and then a shaft.
cortex, and the outer cuticle of the hair can before surgery. Temporary methods of
all be clearly differentiated.
hair removal include shaving, waxing, Bulb
depilatory creams, and waxing; electro- Root
lysis, however, is the only permanent
puberty, terminal hair replaces vellus in method of removal. Old hair
Rest phase falls out
the pubic area and the armpits. In most During the rest
men and some women the process con- hair transplant phase (which
tinues on the face, limbs, and trunk. A cosmetic operation in which hairy lasts about three
COLOUR AND TEXTURE sections of scalp are removed and trans- months on the
scalp), the bulb
Hair colour is determined by the planted to hairless areas to treat alopecia retracts from the
amount of pigment called melanin that (baldness). There are several different root and
is present in the hair shaft. Melanin is techniques available. eventually the
produced by cells called melanocytes at HOW IT IS DONE hair falls out. A
the base of the hair follicle. Red mela- In strip grafting, a strip of skin and hair new hair begins
to grow in the
nin is responsible for red and auburn is taken from a donor site, usually at the same follicle.
hair, black melanin for all other colours. back of the scalp or behind the ears. The
If cells receive no pigment, the cortex removed hairs and their follicles are New hair forms
of each hair becomes transparent and then inserted into numerous incisions

358
 HAMSTRING MUSCLES

hairy cell visual hallucinations. Hallucinations of of halothane may result in damage to

A large, abnormal white blood cell with smell are associated with temporal lobe the liver and, for this reason, it is now
numerous hairlike projections. Hairy epilepsy. Those of touch and taste are less widely used.
cells occur with a rare form of leuk- rare, however, and occur mainly in peo-
aemia, known as hairy cell leukaemia, ple with schizophrenia. People subjected hamartoma
when they proliferate in the blood, to sensory deprivation or overwhelming A noncancerous mass, resembling a tu-
bone marrow, liver, and spleen. physical stress sometimes suffer from mour, which consists of an overgrowth
temporary hallucinations. of tissues that are normally found in the
Haldol affected part of the body. Hamartomas
A brand name for the antipsychotic hallucinogenic drug are common in the skin (the most com-
drug haloperidol. A drug that causes hallucination. Hallu- mon is a haemangioma), but they also
cinogens include certain drugs of abuse, occur in the lungs, heart, or kidneys.
half-life such as LSD, marijuana, mescaline, and
The time taken for the activity of a sub- psilocybin. Some prescription drugs, such hammer-toe
stance to reduce to half its original level. as anticholinergic drugs and levodopa, oc- A deformity of the toe (usually the sec-
The term is usually used to refer to the casionally cause hallucinations. ond toe) in which one of the joints
time taken for the level of radiation emit- remains in a bent position due to a ten-
ted by a radioactive substance to decay hallux don abnormality. A painful corn often
to half its original level. The concept is The medical name for the big toe. develops on this joint. A protective pad H
useful in radiotherapy for assessing how can ease pressure on the joint and
long material will stay radioactive in the hallux rigidus relieve pain, but surgery may be needed
body. Half-life is also used to refer to the Loss of movement in the large joint at if the pain is persistent.
length of time taken by the body to the base of the big toe as a result of Hammer toe
eliminate half the quantity of a drug. osteoarthritis. The joint is usually tender
and swollen. Treatment comprises rest-
halitosis ing the toe and wearing a support insert
The medical term for bad breath. Hali- in the shoe. Surgery may be required.
tosis is usually the result of smoking,
drinking alcohol, eating onions or gar- hallux valgus
lic, or poor oral hygiene. Persistent bad A deformity of the big toe in which the
breath not caused by any of these may joint at the base projects out from the
be a symptom of mouth infection, foot, and the top of the toe turns
sinusitis, or certain lung disorders, such inwards. The condition is more com-
as bronchiectasis. mon in women, because it is usually
associated with wearing narrow, point-
Hallervorden–Spatz syndrome ed, high-heeled shoes, but it may be Appearance of hammer-toe
This photograph shows the typical appearance of
A very rare disorder thought to be caused by an inherited weakness in the a hammer-toe, in which one of the joints of the
caused by a build-up of iron in certain joint. A hallux valgus often leads to second toe is fixed in a bent position.
areas of the brain.The symptoms, which formation of a bunion or to osteoarthritis
are progressive, usually appear in early in the joint, causing pain and limiting hamstring muscles
childhood and include abnormal muscle foot movement. Severe deformity may be A group of muscles at the back of the
rigidity and spasms (see dystonia). corrected by osteotomy (removal of part thigh. The upper ends of the hamstring
of a bone) or arthrodesis (fusion of muscles are attached by tendons to the
Hallgren’s syndrome bones in a joint). pelvis; the lower ends are attached by
A congenital disorder (present at birth) tendons called hamstrings to the tibia
that is characterized by deafness; con- haloperidol and fibula. The hamstring muscles bend
genital cataract (opacity of the lens of An antipsychotic drug used to treat mental the knee and swing the leg backwards
the eye); and ataxia (clumsiness and illnesses such as schizophrenia and mania. from the thigh.
incoordination) due to brain damage. Haloperidol is also given to control the Tearing of the hamstring muscles is
symptoms of Gilles de la Tourette’s syn- common in sports. The injury happens
hallucination drome (a rare neurological disorder) and, suddenly and is very painful. Bruising
A perception that occurs when there is in small doses, to sedate people who are over the area develops several days later.
no external stimulus. Auditory halluci- aggressive due to dementia. Side effects Repeated strenuous exercise may sprain
nations (the hearing of voices) are a include drowsiness, lethargy, weight the muscles (see overuse injury). Both
major symptom of schizophrenia but may gain, dizziness, and parkinsonism (symp- types of injury can often be prevented
also be caused by manic–depressive illness toms such as abnormal movements and by warming-up exercises.
and certain brain disorders. Visual hallu- stiffness of the face and limbs). Painful spasms of the hamstring mus-
cinations most often occur in states of cles can also sometimes occur as a
delirium brought on by a physical illness halothane protective response to a knee injury; by
(such as pneumonia) or alcohol with- A colourless liquid inhaled as a vapour to restricting movement of the damaged
drawal (delirium tremens). Hallucinogenic induce and maintain general anaesthesia knee joint, the muscle spasms help to
drugs are another common cause of (see anaesthesia, general). Repeated use limit further injury.

359
 HAND

hand contracture, inwhich damage to muscles handedness if, for example, the domi-
The hand, which is the most versatile in the forearm causes wrist and finger nant hemisphere of a person’s brain has
part of the body, allows humans (and deformities. Degeneration of a tendon been damaged.
other primates) to hold and manipulate sheath on the upper side of the wrist Handedness is related to the division
objects. This ability is primarily due to may cause a harmless swelling called a of the brain into two hemispheres,
the fact that the fingers and thumb can ganglion. Osteoarthritis commonly affects each of which controls movement and
move independently and can grip. the joint at the base of the thumb. sensation on the opposite side of the
STRUCTURE Rheumatoid arthritis may cause deformity body. In most right-handed people
The hand is made up of the wrist, palm, by attacking the joints at the base of the the speech centre is in the left brain
and fingers. Movement of the hand is fingers and rupturing tendons. hemisphere. Inheritance is probably the
achieved mainly by tendons that attach most important factor in determining
the muscles of the forearm to the bones hand–arm vibration syndrome an individual’s handedness.
of the hand (the carpals, metacarpals, and Pain and numbness in the hand and arm
phalanges). These tendons are sur- due to prolonged use of vibrating tools. hand-foot-and-mouth disease
rounded by synovial sheaths containing Symptoms often also include blue or An infectious disease, mainly affecting
a lubricating fluid that prevents friction. white coloration of the fingers and a young children, that is caused by the
Other movements are controlled by tingling sensation in affected areas. coxsackievirus. Hand-foot-and-mouth dis-
short muscles in the palm of the hand; Hand–arm vibration syndrome tends to ease may occur in small epidemics,
H some of these muscles make up the develop slowly over years and is the usually in the summer.
prominent areas along the sides of the result of repeated damage to blood ves- The illness is usually mild and lasts
hand from the bases of the thumb and sels and nerves. Exposure to cold tends for only a few days. Symptoms include
little fingers to the wrist. to aggravate the condition. blistering of the palms, soles of the feet,
Blood is supplied to the hand by two There is no specific treatment, but and inside of the mouth, and a slight
arteries (the radial on the thumb side of avoiding vibrating tools is essential to fever. There is no treatment other than
the wrist and the ulnar on the little fin- prevent the disease progressing. In some mild analgesic drugs. This infectious dis-
ger side). Prominent veins on the back of cases, calcium channel blockers may help ease is not related to foot-and-mouth
the hand drain blood away. Sensation and to relieve some symptoms. disease, which occurs in cattle.
movement in the hand are controlled by
the radial, ulnar, and median nerves. handedness handicap
DISORDERS Preference for using the right or left The extent to which a physical or men-
The hands are highly susceptible to hand. Some 90 per cent of adults use the tal disability interferes with a person’s
injury, including cuts, burns, bites, frac- right hand for writing; two thirds prefer normal functioning and causes him or
tures, and tendon injuries. Dermatitis is the right hand for most activities requir- her to be disadvantaged.
also common, since the hands are ing coordination and skill. The others
exposed to a considerable variety of are either left-handed or ambidextrous Hand–Schuller–Christian
irritating substances. (able to use both hands equally well). disease
Other hand disorders include Dupuy- It is uncertain why all humans are A form of histiocytosis X that affects
tren’s contracture, which causes shrinkage not simply ambidextrous. Up to the age children. Problems include patchy bone
of tissues in the palm, and Volkmann’s of about 12, it is possible to switch loss, loose teeth, exophthalmos (pro-
truding eyeballs), and swollen lymph
nodes. Involvement of the pituitary
THE SKELETAL STRUCTURE OF THE HAND AND WRIST gland can result in diabetes insipidus and
growth hormone deficiencies.
Four of the eight wrist bones (carpals) articulate with the radius and ulna. The rest
are connected to the five bones of the palm (metacarpals). Each metacarpal, in hangnail
turn, articulates with a phalanx (a finger bone).
A strip of skin torn away from the side
Trapezium bone or base of a fingernail, exposing a raw,
Trapezoid bone painful area. Hangnails usually occur
Capitate bone when frequent immersion in water has
Hamate bone dried the skin on the fingers. Biting the
Scaphoid bone Carpals nails is another common cause. Unless
Triquetral bone trimmed away and covered until it
Lunate bone heals, a hangnail may develop into
Pisiform bone paronychia (infection of the skin fold
(beneath triquetral around the nail).
bone)

Radius hangover
The unpleasant effects that are commonly
experienced after over-indulgence in
Ulna
alcohol, characterized by headache, nau-
Phalanges Metacarpals sea, vertigo, and depression. Alcohol
increases production of urine, and some

360
 HAY FEVER

of the symptoms of a hangover are a toms range from a minor flu-like illness similar to those of pellagra: a red,
result of mild dehydration. (See also with headache and a sore throat to high scaly rash on skin exposed to the sun;
alcohol intoxication.) fever, nausea and vomiting, and abnor- depression; and thought disorders.
mal bleeding. Some strains of hantavirus There may also be headaches and diar-
Hanhart’s syndrome can cause severe infections that may rhoea. Symptoms can be triggered by
A birth defect in which there are severe lead to kidney failure, serious lung dam- infections, stress, or exposure to sun-
physical deformities, including under- age, and death. light and last for up to four weeks.
development of the lower jaw (see Flare-ups are often followed by long
micrognathia) and tongue, misshapen Harada’s syndrome periods of remission.
and missing teeth, and malformations A combination of certain eye and brain The diagnosis can be confirmed by
of the limbs. disorders that occurs in the Far East, testing the urine for abnormally high
particularly in Japan. The condition usu- levels of amino acids. Treatment with
Hansen’s disease ally affects young adults. nicotinic acid and a high-protein diet
A chronic bacterial infection, also called The eye problems, which affect both often offers a good prognosis. The
leprosy, that damages nerves, mainly in eyes, include severe inflammation of the frequency of attacks usually decreases
the limbs and facial area, and may cause iris, the ciliary body, or the choroid; oede- with increasing age.
skin damage. ma (a build-up of fluid) in the retina;
CAUSE and retinal detachment. These problems Hashimoto’s thyroiditis
The disease is caused by a bacterium, are associated with meningoencephalitis An autoimmune disorder in which the H
MYCOBACTERIUM LEPRAE, which is spread in (inflammation of the brain tissue and body’s immune system develops anti-
droplets of nasal mucus. Hansen’s dis- the membranes surrounding it). Other bodies against its own thyroid gland
ease is not highly contagious; a person conditions that occur with Harada’s syn- cells. As a result, the thyroid gland can-
is infectious only in the early stages. Pro- drome include deafness, alopecia (hair not produce enough thyroid hormones, a
longed close contact puts people at risk. loss), and patchy loss of pigmentation in condition known as hypothyroidism.
The disease is most prevalent in Asia, the skin, eyes, and ends of the hair. Hashimoto’s thyroiditis is eight times
Central and South America, and Africa. more common in women than men.
SYMPTOMS AND SIGNS hardening of the arteries The principal symptoms of Hashimoto’s
Hansen’s disease has a long incubation The popular term for atherosclerosis. thyroiditis are tiredness, muscle weak-
period – about three to five years. There ness, and weight gain, and the thyroid
are two main types: the lepromatous harelip gland becomes enlarged (see goitre).
type, in which damage is widespread, A common term for the birth defect in A positive diagnosis is confirmed by
progressive, and severe; and the tuber- which there is a split in the upper lip blood tests indicating the presence of
culoid type, which is milder. Damage is due to failure of the two sides to fuse antithyroid antibodies and low levels of
initially confined to the skin or to peri- during fetal development. A harelip is thyroid hormones. Treatment is by life-
pheral nerves supplying the skin and often associated with a similar failure of long thyroid hormone replacement
muscles. Skin areas supplied by affected the two halves of the palate to join. (See therapy. In some cases, other autoim-
nerves become lighter or darker and also cleft lip and palate.) mune disorders may also develop.
sensation and sweating are reduced. As
the disease progresses, the peripheral Harrison’s sulcus hashish
nerves swell and become tender. Hands, A depression seen at the lower part of Sometimes shortened to “hash”, this is
feet, and facial skin eventually become the ribcage of a child that is usually another name for marijuana.
numb and muscles become paralysed, caused by exaggerated suction of the
leading to deformity. Other possible diaphragm muscle in respiratory condi- Haverhill fever
features include blindness, destruction tions such as severe asthma. Harrison’s A form of rat-bite fever (see rats, dis-
of bone, and sterility. sulcus may also be the result of the nor- eases from) caused by infection with
DIAGNOSIS AND TREATMENT mal pull of the diaphragm on ribs that the bacterium STREPTOBACILLUS MONILIFOR-
The presence of the causative bacteria is have been weakened – for example, in MIS . Unlike other forms of the disease,
confirmed by a skin biopsy. Drug treat- conditions such as rickets. Haverhill fever can not only be trans-
ment may be with a combination mitted through the bite of a rodent but
of dapsone, rifampicin, and clofazimine, Hartnup disease can also be passed on indirectly, in con-
which kills most of the bacteria in a few A rare disorder, inherited in an auto- taminated water or milk products.
days. Any damage that has occurred somal recessive manner (see genetic
before treatment, however, is irrevers- disorders), in which the body does not Havrix
ible. Plastic surgery may be necessary to absorb and process sufficient amounts The brand name for one form of a vac-
correct deformities; and nerve and of certain amino acids (chemical com- cine given to provide protection against
tendon transplants may improve the pounds that make up proteins), par- hepatitis A.
function of damaged limbs. ticularly tryptophan (see metabolism,
inborn errors of). hay fever
hantavirus A deficiency in tryptophan may result The popular name for the seasonal form
A viral infection that is transmitted to in episodes of various symptoms, in of allergic rhinitis (see rhinitis, allergic)
humans through the urine or faeces of particular cerebellar ataxia (a poorly that is often combined with another
infected rodents, such as rats. Symp- coordinated, unsteady gait); symptoms condition, allergic conjunctivitis.

361
 HB

Hb (high blood pressure), temporal arteritis longer than a few minutes, or coma (a
The abbreviation for haemoglobin, an (inflammation of arteries in the face, state of unconsciousness and unrespon-
oxygen-carrying component of red neck, and scalp), an aneurysm (balloon- siveness to stimuli), which may be fatal.
blood cells. ing of a blood vessel), and increased Post-concussive amnesia (loss of
pressure within the skull. memory of events that occurred after an
HCG TREATMENT accident) may occur, especially if the
The abbreviation for the hormone Most headaches can be relieved by skull has been fractured. This amnesia
human chorionic gonadotrophin (see painkillers and rest. If a neurological cause usually lasts more than an hour after
gonadotrophin, human chorionic). is suspected, CT scanning or MRI (magnetic consciousness is regained. There may
resonance imaging) may be performed. also be pretraumatic amnesia (loss of
HDL memory of events that occurred before
The abbreviation for the lipoprotein head-banging the accident). The more serious the
known as high density lipoprotein. The persistent, rhythmic banging of the injury to the brain, the longer uncon-
head against a wall or hard object. sciousness and amnesia are likely to last.
head Head-banging is seen in some people After a severe brain injury, a person
The part of the body that contains the with severe learning difficulties, particu- may suffer some muscular weakness or
skull, the brain, and the organs of sight, larly those who lack stimulation. It also paralysis and loss of sensation.
hearing, smell, and taste. The term head occurs in some normal toddlers, often Symptoms such as persistent vomiting,
H is also used to refer to the uppermost when they are frustrated or angry; most pupils of unequal size, double vision, or a
part of any structure and to the rounded children grow out of the behaviour. deteriorating level of consciousness sug-
portion of a bone that slots into an area gest progressive brain damage.
of another bone to form a joint. head injury TREATMENT
Injury to the head may occur as a result Investigations may include skull X-rays and
headache of traffic accidents, sports injuries, falls, MRI or CT scanning (techniques that pro-
One of the most common types of pain. assault, accidents at work and at home, duce cross-sectional or three-dimensional
A headache is only rarely a symptom of a or bullet wounds. Most people suffer a images of body structures). A blood clot
serious underlying disorder. The pain minor head injury at least once in their inside the skull may be life-threatening
arises from tension in the meninges (the lives, but very few of the injuries are and requires surgical removal. Severe
membranes around the brain), and in the severe enough to require treatment. skull fractures may also require surgery.
blood vessels and muscles of the scalp. A head injury can damage the scalp, OUTLOOK
Headache may be felt all over the skull, or brain. Minor injuries usually Recovery from concussion may take
head or may occur on only one side, cause no damage to the underlying several days. There may be permanent
or in the forehead or the back of the brain. Even when there is a skull frac- physical or mental disability if the brain
neck. Sometimes the pain shifts from ture, or the scalp is split, the brain may has been damaged. Recovery from a
one area to another. The pain of not be damaged. However, a blow to major head injury can be a very slow
headache may be superficial, throbbing, the head may severely shake the brain, process and there may be signs of pro-
or sharp and may be accompanied by and this can sometimes cause brain gressive improvement for several years
nausea, vomiting, and visual or other damage even when there are no exter- after the injury.
sensory disturbances. nal signs of injury.
TYPES A blow often bruises the brain tissue, head lag
Many headaches are simply a response causing death of some of the brain cells The backward flopping of the head that
to some adverse stimulus, such as hun- in the injured area. When an object actu- occurs when an infant is placed in a sit-
ger. Headaches such as these usually ally penetrates the skull, foreign material ting position. Head lag is obvious in a
clear up quickly. Tension headaches, due and dirt may be implanted into the brain newborn because the neck muscles are
to tightening in the face, neck, and scalp and lead to infection. A blow or a pene- still weak, but by four months the baby
muscles as a result of stress or poor pos- trating injury may also tear blood vessels can hold his or her head upright (see
ture, are also common, and may last for causing brain haemorrhage (bleeding in or child development).
days or weeks. Migraine can be a severe, around the brain). Head injury may cause
incapacitating headache that is preceded swelling of the brain; this is particularly head lice
or accompanied by visual and/or stom- evident after bullet wounds because their Tiny, wingless insects (PEDICULUS HUMANUS
ach disturbances. Cluster headaches cause high velocity causes extensive damage. If CAPITIS ) that live on the human scalp
intense pain behind one eye. the skull is fractured, bone may be driven and feed by sucking blood. Infestation
CAUSES into the underlying brain. with head lice is extremely common,
Common causes of headache include SYMPTOMS AND SIGNS especially among young school chil-
hangover and noisy or stuffy environ- If the head injury is mild, there may be dren, and is not caused by low
ments. Some headaches are caused by no symptoms other than a slight head- standards of hygiene. An affected child
the overuse of painkillers (see analgesic ache. In some cases there is concussion, may often pass head lice on to other
drugs). Other possible causes include which may cause confusion, dizziness, family members.
sinusitis, toothache, cervical osteoarthritis, and blurred vision (sometimes persist- The insects do not fly or jump but are
and head injury. Food additives may also ing for several days). More severe head spread through head-to-head-contact or
be a cause. Among the rare causes of injuries, particularly blows to the head, shared combs, hairbrushes, and hats.
headache are a brain tumour, hypertension may result in unconsciousness that lasts Female lice stick their eggs (which are

362
 HEARING TESTS

known as nits) to hair shafts, close to health appropriate recommendations for him
the scalp. The nits may be seen as small, At its simplest, a term that is used to or her, for example regarding diet and
white specks; often, however, the first describe the absence of physical and exercise. Healthy living advice may also
sign of infestation is intense itching due mental disease. A wider concept pro- be given opportunistically; for example,
to an allergy to lice bites. moted by the World Health Organization individuals may be advised to give up
TREATMENT is that all people should have the oppor- smoking when they see their doctor for
Infestations can be treated with med- tunity to fulfil their genetic potential. blood pressure checks.
icated lotions containing insecticides, This includes their ability to develop
which kill the lice. Because head lice without the impediments of poor nutri- hearing
can develop resistance to particular tion, environmental contamination, or The sense that enables sound to be per-
chemicals, a pharmacist should be con- infectious diseases. (See diet and disease; ceived. The ear transforms the sound
sulted about local patterns of resistance. health hazards.) waves it receives into nerve impulses
For children under two years of age or that pass to the brain.
those with eczema or asthma, treatment health centre Each ear has three distinct regions:
should be discussed with a doctor or Premises in which healthcare profession- the outer, middle, and inner ear. Sound
pharmacist. It is important to treat all als, such as health visitors, district nurses, waves are channelled through the ear
family members at the same time. and general practitioners, work together. canal to the middle ear, from where a
Some people are reluctant to use complex system of membranes and tiny
insecticides repeatedly. An alternative health food bones conveys the vibrations to the H
method of ridding the scalp of head lice A term applied to any food products inner ear. The vibrations are converted
is to apply liberal amounts of hair con- thought to promote health. into nerve impulses in the cochlea.These
ditioner and comb through the hair impulses travel along the auditory nerve
carefully with a fine tooth comb to health hazards to the medulla of the brain. From there,
remove the insects and nits. This proce- Environmental factors that are known to they pass via the thalamus to the superi-
dure needs to be repeated every few cause, or are suspected of causing, dis- or temporal gyrus, part of the cerebral
days in order to be effective and to pre- ease. The major types of health hazard cortex involved in perceiving sound.
vent recurrences. Whichever method is are the numerous infectious diseases For further details, see Hearing box,
used, frequent inspection of a child’s that are transmitted by contact or by overleaf. (See also deafness.)
head is the key to controlling head lice. insects or other animals (see bacteria;
fungal infections; insects and disease; hearing aids
Heaf test viruses; zoonosis); an insufficient supply, Electronic devices that improve hearing
A type of tuberculin test. or the contamination, of food and water in people with certain types of deafness.
(see food additives; food-borne infection; A hearing aid consists of a tiny micro-
healing food poisoning); work-related hazards phone (to pick up sounds), an amplifier
The process by which the body repairs (see occupational disease and injury); haz- (to increase their volume), and a speak-
bone, tissue, or organ damage caused ards associated with domestic and social er (to transmit sounds). Newer devices
by injury, infection, or disease. life; smoking and alcohol consumption; are now small enough to be hidden
The initial stages of healing are the and global environmental hazards (see completely within the ear canal. The
same in all parts of the body. After injury, pollution; radiation hazards; sunlight, particular device required depends on
blood clots form in damaged tissues. adverse effects of). the type and cause of the hearing loss.
White blood cells, enzymes, histamine, (See also cochlear implant.)
other chemicals, and proteins from which health promotion
new cells can be made accumulate at the The work of healthcare professionals in hearing loss
site of damage. Fibrous tissue is laid encouraging people to adopt a healthier A deterioration in the ability to perceive
down within the blood clot to form a lifestyle and so reduce their risk of sound. (See also deafness.)
supportive structure, and any dead cells developing various diseases. The print
are broken down and absorbed by the and broadcast media, as well as patient hearing tests
white blood cells. Some tissues, such as self-help or campaigning groups, also Tests carried out to assess hearing. In
bone and skin, are then able to regenerate have a role to play in health promotion newborns and young babies, otoacoustic
by the proliferation of new cells around at a national or community level. emission tests can be used to check for a
the damaged area. In skin injuries, the Health promotion involves the recom- normal response of the inner ear to
fibrous tissue shrinks as new skin forms mendation of specific tests as appropriate. sound. Hearing tests are also performed
underneath. The tissue hardens to form a Examples include encouraging women as part of a routine assessment of child
scab, which falls off when new skin to undergo regular cervical smear tests development and whenever hearing im-
growth is complete. A scar may remain. and mammograms (see mammography) pairment is suspected. They are some-
An inadequate blood supply or persis- to detect early signs of cervical or breast times included in a general medical
tent infection prevents regeneration, and cancer, and advising people at increased examination. The tests may also be used
some tissues, such as nerve tissue, may risk of coronary heart disease to have in people with tinnitus or dizziness.
be unable to regenerate. In these cases, their blood cholesterol levels checked. An audiometer (an electrical instru-
the fibrous tissue may develop into tough In addition, health promotion may ment) is used to test the ability of an
scar tissue, which keeps the tissue struc- involve a formal individual consultation individual to hear sounds at different
ture intact but may impair its function. to review a person’s health and make frequencies and volumes. The lowest

363
 HEARING TESTS

HEARING

The ears are the organs of hearing. Each ear has three of the throat to the middle ear. Inside the middle ear,
regions: the outer ear, middle ear, and inner ear. The outer a complex system of membranes and tiny bones conveys
ear channels sound vibrations through the eardrum to the vibrations to the inner ear via a membrane called the
the middle ear. The eardrum has to have equal air pressure oval window. In the inner ear, the vibrations are converted
on each side so that it can vibrate freely; the pressure is to nerve impulses and sent to the brain via the
equalized via the eustachian tube, which runs from the back vestibulocochlear nerve.
Structure and function of cochlea Malleus (hammer) Stapes (stirrup) Vestibulocochlear nerve
Running the length of the cochlea is a fluid-filled tube called the and incus (anvil) and oval window Tiny nerve fibres from the
The malleus, attached to The stapes transmits cochlea join up to form
cochlear duct. It contains several membranes and a structure vibrations from the incus the vestibulocochlear
the eardrum, transmits
called the organ of Corti. Tiny hairs on the organ of Corti brush vibration to the incus. to the oval window, the nerve, which carries
against a membrane called the tectorial membrane, producing membrane between the impulses from the
electrical signals. These signals are detected by nerve fibres. middle and inner ear. cochlea to the brain.

ROUTE TO THE BRAIN Outer ear

The pinna (the visible
part of the ear) channels
Electrical signals are picked up by
H nerve fibres in the cochlea and
sound waves into the
ear canal towards the
pass along the vestibulocochlear eardrum.
nerve to the medulla. From there,
they pass via the thalamus to the
Eardrum
superior temporal gyrus – the part The eardrum separates
of the cerebral cortex (see brain) the outer and middle ear.
involved in receiving and Sound waves of different
frequencies cause the
perceiving sound. eardrum to vibrate at
Thalamus different speeds.

Cochlea
The cochlea consists of a
hollow spiral passage. It Eustachian tube
Oval window
picks up sound vibrations This tube allows
transmitted through the air to pass into
oval window and converts and out of the
them into nerve impulses middle ear.

Normal coiled
shape of
cochlea

Superior
temporal
Vestibulocochlear gyrus
Medulla nerve Cochlear duct Cochlea
Nerve fibres (shown uncoiled)

COMPARISON OF FREQUENCY RANGES

The frequency of a sound

(how high or low it is) is Human
measured in Hertz (Hz).
Different animals can Bat
hear different ranges of
sound frequencies. The Dolphin
diagram shows the
normal ranges that can Dog
be heard by a human, a
bat, a dolphin, and a dog. Electron micrograph of inner ear
Humans can hear a range 10 Hz 100 Hz 1,000 Hz 10,000 Hz 100,000 Hz This image shows four rows of hair cells (centre)
between about 20 and Bottom of Frequency Top of in the organ of Corti. On their surfaces are
20,000 Hz. humans’ range humans’ range sensory hairs (top right), which convert sound
waves into electrical impulses; these are picked
up by the vestibulocochlear nerve (bottom right).

364
 HEART, ARTIFICIAL

level at which a person can hear and

repeat words (the speech reception HEARING TESTS
threshold) is tested in each ear, as is the Tests Function
ability to hear words clearly (speech
discrimination). Tuning fork tests (see Tuning These basic tests are used to conduction is greater than bone
Rinne’s test) can be used to determine fork tests determine whether hearing loss is conduction. In conductive hearing
whether hearing loss is conductive or conductive or sensorineural. In loss, bone conduction is greater
sensorineural (see deafness). Rinne’s test, the patient is asked than or equal to air conduction.
whether the sound is louder with the Weber’s test, in which the base of
vibrating tines held near the opening the fork is placed on the forehead,
heart of the ear canal (air conduction) or is useful for diagnosing unilateral
The muscular pump in the centre of the with the base of the fork held hearing loss. If the hearing loss is
chest that beats continuously and rhyth- against the mastoid bone (bone conductive, the patient hears the
mically to send blood to the lungs and conduction). In a normal ear or one tuning fork better in the ear with the
with sensorineural loss, air poorer hearing.
the rest of the body. During an average
lifetime, the heart contracts more than Pure-tone This is a test in which an audiometer frequency, the sound is increased in
2,500 million times. audiometry is used to generate sounds of intensity until it can be heard. The
STRUCTURE different frequencies and intensities patient gives a signal at the moment
Much of the heart consists of myo- and a person’s ability to hear these when he or she detects each sound
cardium, a type of muscle, which, when sounds is measured. Hearing is first
assessed by transmitting the sounds
and the results are recorded on a
graph called an audiogram. Bone
H
given oxygen and nutrients, contracts through one earphone while the conduction is then assessed in the
rhythmically and automatically without other ear is prevented from hearing same way but the signal is
any other stimulus. The internal surface them. The sound frequencies range transmitted through a rubber pad
of the heart is lined with a smooth from 250 to 8,000 Hertz; for each held against the bone behind the ear.
membrane called endocardium, and the
entire heart is enclosed in a tough, Auditory This test may be used to evaluate the analysed by means of electrodes
membranous bag, the pericardium. evoked presence of hearing in someone who placed on the scalp. Auditory evoked
response cannot cooperate with other tests response can also help to rule out
Inside the heart there are four cham- (such as a very young baby). The acoustic neuroma (a benign tumour
bers. A thick central muscular wall, the brain’s response to sound stimulation affecting the auditory nerve, part of
septum, divides the heart cavity into produced by an audiometer is the vestibulocochlear nerve).
right and left halves. Each half consists
of an upper chamber, called an atrium Impedance Also known as tympanometry, this through the probe at varying
(plural: atria), and a larger lower cham- audiometry test is used to assess middle-ear pressures and, at the same time, a
ber, called a ventricle. (See Structure of the damage occurring in cases of microphone in the probe registers the
conductive deafness or to detect the differing reflections of sounds from
heart box, overleaf.) effects of fluid within the middle ear. the eardrum as pressure changes in
The body’s principal blood vessels A probe is fitted tightly into the the ear canal. The reflections are
emerge from the top and sides of the entrance of the ear canal, thereby recorded on a graph known as a
heart. The superior and inferior venae sealing off the outside air pressure tympanogram. The pattern of differing
cavae (see vena cava), the largest veins, and sound. The probe emits a reflections relates to the type of
continuous sound. Air is pumped disease that is causing the deafness.
deliver deoxygenated blood from the
body to the heart. The aorta, which is
the main artery, carries oxygen-rich
blood to be circulated around the body. THE CARDIAC CYCLE carried to the atria and ventricles partly
The pulmonary vessels carry blood to The pumping action of the heart con- by the heart muscle itself and partly
and from the lungs, where the blood sists of three phases, which together by nerve fibres.
absorbs oxygen and releases the waste make up a cycle corresponding to one In order to prevent bottlenecks from
product carbon dioxide. heartbeat (see Heart cycle box, overleaf). developing in the blood circulation, the
FUNCTION These phases are called diastole, atrial volume that is pumped at each beat
The two sides of the heart have distinct, systole, and ventricular systole. In dias- by the two sides of the heart must be
though interdependent, functions. The tole, the heart muscle relaxes and the balanced exactly. Resistance to blood
right atrium receives deoxygenated heart fills with blood. In atrial systole, flow through the general circulation is
blood from the entire body via the two the atria contract, sending blood into much greater than resistance through
venae cavae. This blood is transferred the ventricles. In ventricular systole, the the lungs. Therefore, the left side of the
to the right ventricle, then pumped ventricles contract, pumping blood into heart must contract more forcibly than
to the lungs via the pulmonary artery the blood vessels. the right; for this reason, the left side
to be oxygenated and lose carbon diox- For the heart to function efficiently, has greater muscular bulk.
ide. The left atrium of the heart receives the muscular contractions must occur
oxygenated blood from the lungs (via in a precise sequence. This sequence is heart, artificial
the pulmonary veins); this is trans- regulated by electrical impulses that An implantable mechanical device that
ferred to the left ventricle and pumped emanate from the sinoatrial node (an takes over the action of the heart. How-
to all body tissues. One-way valves at area of specialized muscle at the top of ever, the term is also used to describe
the chamber exits ensure that blood the right atrium), the heart’s natural devices that assist the heart in maintain-
flows in one direction (see heart valves). pacemaker. The electrical impulses are ing the circulation.

365
 HEART ATTACK

STRUCTURE OF THE HEART

The heart is positioned centrally in

the chest, with its right margin directly
underneath the right side of the Trachea
sternum (breastbone). The rest of the
heart points to the left, with its lowest
point (the apex) located underneath Superior
the left nipple. Aorta
vena cava
The heart acts as a dual pump.
Deoxygenated blood from the body
arrives, via the two venae cavae, in the Pulmonary Left atrium
artery
right atrium (upper heart chamber), is
transferred to the right ventricle (lower Aortic valve
chamber), and is then pumped via the Right
pulmonary artery to the lungs. There it bronchus
is reoxygenated and returns, via the Pulmonary
pulmonary veins, to the left side of valve
Right
H the heart. It enters the left atrium, is
transferred to the left ventricle, and is
atrium
Mitral valve
then pumped, via a large vessel (the
aorta), to all parts of the body. Tricuspid Left
valve ventricle
Left coronary
artery Right Septum
ventricle

Inferior vena cava Aorta

Right
coronary
artery

Circumflex artery

Left anterior descending artery

Right coronary artery
Blood supply
Although the heart muscle is continually
pumping blood, it cannot obtain much oxygen Angiogram of coronary arteries
from this flow, so it needs its own blood supply. This image (left) gives a view of the heart from
This is provided by the two coronary arteries, the rear and clearly shows the coronary arteries.
which arise from the aorta. These arteries, with The image was achieved by angiography: an X-
their branches, supply the entire heart muscle. ray of the heart was taken after the coronary
A network of veins, called coronary veins (not arteries had been injected with a contrast
shown), drains blood back into the right atrium. medium (a fluid that shows up on X-rays).

An intra-aortic balloon pump, compris- Problems with artificial hearts include of the right atrium. Each heartbeat con-
ing a balloon in the aorta that inflates the formation of blood clots within the sists of three phases, which occur in a
with each heartbeat, increases the vol- device and infection. They are therefore cycle: the diastole (resting phase), the
ume of blood entering the circulation. used as a temporary measure until a atrial systole (contraction of the heart’s
This is a commonly used means of heart transplant can be performed. upper chambers), and the ventricular
mechanical circulatory support and may systole (contraction of the lower cham-
be used for the first few days after a heart attack bers). The rate at which contractions
myocardial infarction (heart attack) until See myocardial infarction. occur is called the heart rate.
the heart is able to maintain blood The term pulse refers to the character
pressure unassisted. A left ventricular heartbeat and rate of the heartbeat when felt at a
assist device takes blood from the left A contraction of the heart that pumps point on the body, such as the wrist.
ventricle and pumps it electrically into blood to the lungs and the rest of the
the abdominal aorta. True artificial body. The different parts of the heart heart block
hearts are mechanical hearts, which contract in a precise sequence that is A common disorder of the heartbeat
are powered from outside the body by regulated by electrical impulses eman- that is caused by an interruption to the
battery packs. ating from the sinoatrial node, at the top passage of electrical impulses through

366
 HEART DISEASE, CONGENITAL

the heart’s conducting system. Heart

block may be congenital or may be due HEART CYCLE
to heart disease, such as coronary artery
There are three main phases in each heartbeat. The beat is generated by electrical
disease. Other causes include overdose
waves that emanate from the heart’s own pacemaker, the sinoatrial node. The
of a digitalis drug (used in the treatment images in this box show blood flow, an electrocardiogram tracing, and the
of heart disease) and rheumatic fever. direction of electrical impulses at each stage of the cycle.
TYPES
There are two main types of heart Diastole Atrial systole Ventricular systole
block: atrioventricular block, a blockage in In this resting phase, the heart In this second phase, the two The two ventricles contract to
the heart’s conducting system between fills with blood. Deoxygenated atria (upper chambers of the pump deoxygenated blood
blood flows into the right side heart) contract, squeezing into the pulmonary artery and
an atrium (upper chamber of the heart) of the heart; at the same time, more blood into the ventricles oxygenated blood into the
and a ventricle (lower chamber of the oxygenated blood flows into (lower chambers) and filling aorta. Once the heart is
heart); and bundle branch block, in the left side. them completely. empty, diastole begins again.
which the block is confined to conduc- Heart fills
Left
tion within the ventricles. with blood Left atrium
ventricle
contracts
Atrioventricular block There are three Right atrium contracts
contracts
degrees of atrioventricular heart block.
In first degree block, there is an
increased delay between contraction of H
the atria and that of the ventricles. In
Right
second degree heart block, some atrial ventricle
beats fail to reach the ventricles. In contracts
complete heart block, there is a total
blockage in the heart’s conducting sys-
Atrial Ventricular
tem that prevents atrial beats from Diastole systole
systole
being conducted to the ventricles. The
two chambers therefore beat at their
own intrinsic rate, with the ventricles
beating very slowly and completely in-
dependently of the atria. Atrioventricular
Bundle branch block Each ventricle has its Sinoatrial node
node
own conduction system, known as the
right and left bundle branches. These
work together. Blockage in one or other
of the bundle branches (or, less com-
monly, both) leads to an abnormal pattern
of conduction through the ventricles.
Right bundle branch block can some-
times be seen in a healthy heart. It may
In diastole, the heart muscle is As the electrical impulse After a momentary pause,
also be due to certain conditions, such at rest. Towards the end of this spreads through the two atria, waves of electrical activity
as congenital heart disease (see heart dis- phase, the sinoatrial node it causes them to contract. By from the atrioventricular node
ease, congenital). Left bundle branch block emits an electrical impulse, the end of atrial systole, the pass along special fibres to
is more serious and is always a sign of an which starts to spread through impulse reaches another node, all parts of the ventricles,
the heart muscle. the atrioventricular node. producing ventricular systole.
underlying cardiac disorder. It is usually
caused by coronary artery disease but may
also occur as a result of hypertension
(high blood pressure) or aortic stenosis. DIAGNOSIS AND TREATMENT is often brought on by lying down or
SYMPTOMS Both types are usually diagnosed on an bending forwards. It may be caused by
First degree heart block and left or right ECG (electrocardiogram) trace. Heart eating rich or spicy food, or by drink-
bundle branch block alone usually block with no symptoms may not ing alcohol. Recurrent heartburn is a
cause no symptoms. However, in more require any treatment. Heart block symptom of oesophagitis (inflammation
severe atrioventricular heart block, the causing symptoms is usually treated by of the oesophagus), which is usually
rate of ventricular contraction does not fitting a permanent artificial pacemaker. caused by acid reflux.
increase in response to exercise. This Drugs to increase the heart rate and the
may cause breathlessness as a result of strength of the heart’s contractions may heart disease, congenital
heart failure (reduced pumping efficien- be given temporarily. Any underlying A term that is used to describe any
cy) or chest pains due to angina pectoris heart disease is treated as necessary. abnormality of the heart that is present
(caused by reduced blood supply to the from birth. Congenital defects (see
heart muscle). If the ventricular beat heartburn Types of congenital heart disease box,
becomes very slow, or if it stops altoge- A burning pain in the centre of the overleaf) may affect different parts,
ther for a few seconds, episodes of loss chest, which may travel from the tip of including the chambers, valves, or main
of consciousness may occur. the breastbone to the throat. Heartburn blood vessels of the heart.

367
 HEART DISEASE, ISCHAEMIC

Developmental errors leading to defects Possible complications resulting from smaller or may disappear of their own
arise early in the life of the embryo. an untreated heart defect include under- accord. Other defects will require sur-
Rubella (German measles) in the mother development of the limbs and muscles, gical correction. Narrowed heart valves
is the most common known cause, but and pneumonia after even mild respira- can often be treated by balloon valvulo-
in most cases the reasons for the defects tory infections.With prolonged cyanosis, plasty. In other cases, open heart surgery
are not known. clubbing (thickening and broadening) or a heart transplant may be required.
Hereditary factors do not seem to be of the ends of fingers and toes may deve- OUTLOOK
significant. If a couple have an affected lop. If there is insufficient capacity in the Following successful surgery, the child’s
child, there is little increased risk of a heart to increase blood flow on effort, health often improves dramatically, with
second child being affected. People born the child may rapidly tire during physi- resumed growth, increased activity, and
with heart defects have little increased cal exercise. In some untreated cases, a a near-normal life expectancy.
risk of having an affected child. serious complication called Eisenmenger Children with heart defects (correct-
SYMPTOMS AND COMPLICATIONS complex (increased resistance of the lungs ed or uncorrected) are at an increased
Symptoms of congenital heart disease to blood flow) develops. risk of bacterial endocarditis, a potential-
arise from either insufficient or exces- DIAGNOSIS AND TREATMENT ly dangerous infection of the heart
sive circulation of blood to the lungs or Antenatal diagnosis, using specialized lining and heart valves. To prevent this,
the body. Defects in heart anatomy can ultrasound scanning, is possible for most such children are given antibiotic drugs
also cause some deoxygenated blood to defects. After birth, any suspected defect before all surgical procedures, including
H be pumped to the body instead of the is investigated using chest X-rays, ECG, or dental treatments.
lungs or some oxygenated blood to echocardiography.
the lungs instead of the body. Some Oxygen and various drug treatments heart disease, ischaemic
heart anomalies cause cyanosis (blue- may improve the symptoms. Some con- The most common form of heart dis-
ness of the skin) and breathlessness, but ditions, such as small septal defects or ease. In ischaemic heart disease, there is
others may go undetected. patent ductus arteriosus, may become narrowing or obstruction of the coro-

DISORDERS OF THE HEART

Heart disorders are by far the most Tumours monoxide in tobacco smoke are
common cause of death in developed Tumours arising in the heart tissues are thought to encourage the development
countries. They also affect the quality of rare. The main types are noncancerous of atherosclerosis, which can lead to
life of millions of people. A wide range myxomas, which develop inside the heart coronary artery disease.
of conditions can affect the heart’s chambers, and cancerous sarcomas.
structure and/or disrupt its action. Secondary tumours, spreading from Drugs
elsewhere in the body, are more common Certain medications, such as the
Congenital defects than primary tumours. anticancer drug doxorubicin, tricyclic
Structural abnormalities in the heart are antidepressants, and even drugs used to
among the most common birth defects. Arterial disorders treat heart disease, may disturb the
They result from errors of development The coronary arteries (supplying blood to heartbeat or damage the heart muscle.
in the fetus and include septal defects the heart) may become narrowed due to
(“holes in the heart”) and some types atherosclerosis. Areas of heart muscle may Other heart disorders
of heart valve abnormalities (see heart be starved of oxygen, and angina pectoris or, Many disorders may be complications
disease, congenital). eventually, myocardial infarction may result. of an underlying condition, such as
cardiomyopathy or a congenital defect.
Genetic disorders Nutritional disorders They include cardiac arrhythmia; some
Genetic factors do not usually play a Obesity is an important factor in heart cases of heart block; heart failure; and cor
large part in causing heart disorders. disease, probably through its effect on pulmonale, which is a failure of the right
They do, however, contribute to hyper- other risk factors, such as hypertension, side of the heart due to lung disease.
lipidaemias, which predispose affected diabetes mellitus, and cholesterol.
people to atherosclerosis and coronary Malnutrition may cause the heart muscle
artery disease. to become thin and flabby from lack of INVESTIGATION
protein and calories. Thiamine (vitamin B1)
Techniques used for investigating heart
Infection deficiency, common in alcoholics, causes
disorders include auscultation (listening
Infection of the lining of the heart and beriberi with congestive heart failure.
to the heart); ECG (electrocardiography);
of the heart valves (see endocarditis) imaging techniques such as chest X-ray,
can result in malfunction of the heart Poisoning echocardiography, coronary angiography,
valves. Viral infections can lead to The most common toxin affecting the CT scanning, and MRI; cardiac
some types of cardiomyopathy heart is alcohol. Excessive drinking catheterization (see catheterization,
(malfunctioning of the heart muscle) over many years may cause a type of cardiac); blood tests; and, rarely, by a
or myocarditis (inflammation of the cardiomyopathy. Another common source biopsy of the heart muscle.
heart muscle). of toxins is smoking; nicotine and carbon

368
 HEART FAILURE

TYPES OF CONGENITAL HEART DISEASE

The major malformations are atrial

and ventricular septal defects;
coarctation of the aorta; transposition
of the great vessels; patent ductus
arteriosus; tetralogy of Fallot;
hypoplastic left heart syndrome;
pulmonary stenosis; and aortic
stenosis (not shown). Affected areas
are shown in dark blue.
Aorta Pulmonary 5% 10% 8%
artery
Pulmonary stenosis Coarctation of the aorta Patent ductus arteriosus
Pulmonary Aortic valve This is a narrowing of the In this disorder, localized The ductus arteriosus fails to
valve pulmonary valve, or (rarely) narrowing of the aorta close after birth and blood
of the upper right ventricle, reduces the supply of from the aorta continues to
and reduces the blood flow blood to the lower part flow through it into the
to the lungs. of the body. pulmonary artery.
H
Right Left
ventricle ventricle

Ventricular septum

25% 7% 14%
How blood circulates
Deoxygenated blood (grey) is pumped from the Ventricular septal defect Tetralogy of Fallot Transposition of the
right ventricle through the pulmonary arteries This is a hole in the wall This defect includes a hole great vessels
into the lungs, where it exchanges carbon dioxide (septum) between the in the ventricular septum, Oxygenated blood passes
for oxygen. Oxygenated blood (blue) enters the ventricles, causing blood to pulmonary stenosis, a back to the lungs, instead
left side of the heart; it is pumped from the left flow from the left ventricle to displaced aorta, and a of through the aorta to the
ventricle through the aorta to the body tissues. the right and into the lungs. thickened right ventricle. body tissues.

nary arteries, usually due to atheroscler- by an increase in the size of the left side may awaken at night with attacks of
osis, that results in a reduced blood and in the thickness of its muscular walls, breathlessness, wheezing, and sweating.
supply (see coronary artery disease). or by an increase in the heart rate. This Right-sided heart failure Right-sided fail-
compensation is only temporary, how- ure is most often caused by pulmonary
heart failure ever, and heart failure eventually follows. hypertension (raised blood pressure in
Inability of the heart to cope with its Other causes of left-sided heart failure the arteries supplying the lungs). This is
workload of pumping blood to the include coronary artery disease, myocardial itself caused by left-sided heart failure,
lungs and to the rest of the body. Heart infarction (heart attack), cardiac arrhyth- or a lung disease such as chronic
failure can primarily affect either the mias (irregularities of heart rhythm), obstructive pulmonary disease (see pul-
right or the left side of the heart; how- and cardiomyopathy (disease of the heart monary disease, chronic obstructive). Right-
ever, it most commonly affects both muscle). In cardiomyopathy, the pump- sided failure can also be due to a heart
sides. Heart failure can be acute or ing power of the heart is reduced to a valve defect, such as tricuspid incomp-
chronic (congestive). point where it can no longer deal with etence, or to a congenital heart defect.
TYPES AND CAUSES its normal workload. In all types of right-sided heart failure,
Left-sided heart failure Left-sided failure Whatever the underlying cause, in there is back pressure in the circulation
may be due to hypertension (high blood left-sided heart failure the left side of from the heart into the venous system,
pressure), anaemia, hyperthyroidism (over- the heart fails to empty completely with causing swollen neck veins, enlarge-
activity of the thyroid gland), a heart each contraction, or has difficulty in ment of the liver, and oedema (excess
valve defect (such as aortic stenosis, aortic accepting blood that has been returned fluid in body tissues), especially swel-
incompetence, or mitral incompetence), or a from the lungs. The retained blood cre- ling of the legs and ankles. In addition,
congenital heart defect (see heart disea- ates a “back pressure” that causes the the intestines may become congested,
se, congenital). In all of these conditions, lungs to become congested with blood. causing discomfort and indigestion.
the left side of the heart must work This condition leads to pulmonary oedema INVESTIGATION AND TREATMENT
harder than normal to pump the same (excess fluid in the lungs), of which the Investigation of suspected heart failure
amount of blood. Sometimes, the heart main symptom is shortness of breath, may involve a physical examination,
can compensate for the extra workload eventually even when at rest.The patient X-ray, ECG, and echocardiography.

369
 HEART IMAGING

Attacks of acute heart failure may sub- High-speed CT scanning and MRI can tions per minute; the output may
side of their own accord or may require both be used to produce detailed cross- increase to almost 250 ml per beat, pro-
urgent, life-saving treatment. Immediate sectional or three-dimensional images ducing a total output of 50 litres per
treatment of heart failure consists of of cardiac structure. minute. Such changes in heart rate and
bed rest, with the patient sitting up. output are brought about by the action
Diuretic drugs are given to increase the heart–lung machine of heart muscle and by the involvement
output of urine from the kidneys, there- A machine that temporarily takes over of the autonomic nervous system (the part
by ridding the body of excess fluid and the function of the heart and lungs in of the nervous system concerned with
reducing blood volume. Morphine and order to facilitate operations such as automatic control of body functions).
oxygen may be given as emergency open heart surgery, heart transplant, and First, the heart muscle responds auto-
treatment in acute left-sided heart fail- heart–lung transplant. matically to any increase in activity by
ure. Long-term drug treatment usually A heart–lung machine consists of a increasing its output. This increase
involves the use of ACE inhibitor drugs pump (to replace the heart’s function) occurs because active muscles squeeze
and diuretics. Angiotensin-II antagonists, and an oxygenator (to replace the the veins that pass through them, push-
other vasodilator drugs, and beta blocker lungs’ function). It bypasses the heart ing the blood back towards the heart.
drugs may also be required. If heart fail- and lungs. Once the machine is in oper- The more the ventricles are filled with
ure is associated with atrial fibrillation, ation, the patient’s heart can be stopped blood during diastole (the filling phase
digoxin will most likely be prescribed to while surgery is carried out. of the heart’s cycle), the more forcibly
H control the heart rate. The use of a heart–lung machine they contract during ventricular systole
Other possible treatments of heart tends to damage red blood cells and to to expel the blood.
failure include fitting a pacemaker, coro- cause blood clotting. These problems Second, the heart rate is under the con-
nary artery bypass, and heart transplant. can be minimized, however, by the trol of the autonomic nervous system.
administration of heparin, which is an The parts of the system concerned with
heart imaging anticoagulant drug. heart action are a nucleus of nerve cells
Any technique that provides images of called the cardiac centre, in the brainstem,
heart structure. Imaging is used to heart–lung transplant and two sets of nerves called parasympa-
detect disease or abnormalities. A procedure in which the heart and thetic and sympathetic nerves, whose
TYPES lungs of a patient are removed, to be activities, controlled by the cardiac cen-
A chest X-ray, the simplest and most replaced by donor organs. This surgery tre, exert opposing effects on the heart.
widely used method of heart imaging, is used to treat diseases in which lung When a person is at rest, the para-
shows heart size and shape, and the damage has affected the heart, or vice sympathetic nerves (particularly the
presence of abnormal calcification. Pul- versa. Such diseases include cystic fibro- vagus nerve) are active. Signals carried
monary oedema (excess fluid in the sis, fibrosing alveolitis, and some severe along the vagus nerve act on the sinoa-
lungs) and engorgement of the vessels congenital heart defects (see heart dis- trial node to slow the heart rate from its
connecting the heart and lungs are also ease, congenital). A heart–lung machine is inherent rate of about 140 impulses per
usually detectable with X-rays. used to take over the function of the minute to around 70 impulses per
Echocardiography is useful for investi- patient’s heart and lungs during the minute (a process called vagal inhibi-
gating congenital heart defects and operation. A heart–lung transplant is no tion). During or in anticipation of
abnormalities of the valves or heart more dangerous than a heart transplant muscular activity, vagal inhibition lessens
wall. An ultrasound technique that uses and is technically more straightforward and the heart rate speeds up. The speed
the Doppler effect, known as Doppler because blood vessels to the lungs need may increase even more when the sym-
echocardiography, allows measurement not be disturbed. pathetic nerves come into action. These
of blood flow through valves. Angiogra- nerves release the hormone noradrenaline,
phy may be used to assess the condition heart rate which increases heart rate and the force
of the coronary arteries and valves. The rate at which the heart contracts to of contractions. The release of adrenaline
Radionuclide scanning can be used to pump blood around the body. In most and noradrenaline by the adrenal glands
detect myocardial infarction (heart attack), people, heart rate is between 60 and also acts to increase the heart rate.
to measure myocardial function and its 100 beats per minute at rest. It tends to The switch from parasympathetic to
blood supply, or to determine the via- be faster in childhood and to slow sympathetic activity is triggered by any
bility of the heart muscle following slightly with age. Very fit people may influence on the cardiac centre that sig-
disruption to the blood supply. The have a rate below 60 beats per minute. nals a need for increased blood output
information that is obtained depends CHANGES IN HEART RATE AND OUTPUT from the heart. Such influences may
upon the radioisotope used; for exam- The rate at which the heart beats, and include fear or anger, low blood pressure,
ple, thallium-201 may be used to the amount of blood pumped out with or a reduction of oxygen in the blood.
investigate if heart muscle is still viable. each contraction, can vary considerably MEASURING HEART RATE
Radionuclide scans can also be used to according to the body’s demands for Doctors can measure the rate and
produce images of ventricular function. oxygenated blood. At rest, the heart con- rhythm of the heart by feeling the pulse
For example, a MUGA scan is used to tracts at 60 to 80 beats per minute and or by listening to the heart with
determine how much blood the heart each ventricle puts out about 80 ml of a stethoscope. A more accurate record
can pump with each beat and whether blood at each beat (about six litres per can be obtained by ECG (a test in which
different parts of the heart wall are minute). During vigorous exercise, the the electrical activity of the heart is
contracting properly. heart rate may increase to 200 contrac- measured). A resting heart rate above

370
 HEART RATE

HEART–LUNG TRANSPLANT

In this procedure, both the heart and

the lungs of a patient have to be removed 1TheThe donor heart and
lungs must be healthy.
lungs must also match
and are replaced with organs taken from Pic of chest
a brain-dead donor. The donor organs the size of the patient’s
x-ray to chest, as measured by
are then inserted into the patient. The means of chest X-rays.
come
removed heart can sometimes be given
to another patient. A heart–lung
transplant is more straightforward than 2lungsInpatient,
both donor and
the heart and
are reached via an
a heart transplant because blood vessels
incision in the sternum
to the lungs need not be disturbed. (breastbone), and the
Chest X-ray chest is opened up.
Site of incision
Intravenous Tubes carrying blood
fluid from heart to machine
Anaesthetic
machine

H
The patient is
3heart–lung
connected to a
machine.
During the operation,
this machine takes over
the function of heart
and lungs, oxygenating
blood taken from the
Illustrations venae cavae and
pumping it back to the
body via the aorta.

Tube returning
Technician blood to
circulation

Trachea
Heart–lung Aorta
machine
Right atrium/Vena cava

WHY IT IS DONE In both patient and donor, the

4through
heart and lungs are removed
cuts in the aorta, trachea
Subject to the availability of a donor, a heart-lung
transplant can offer hope to someone who is dying of a (windpipe), and the area where the
venae cavae join the heart. The
terminally chronic lung disease, whether or not he or she blood vessels linking the donor
is also suffering from heart disease. The range of diseases heart and lungs are left intact.
that can be treated with this operation include
emphysema, cystic fibrosis, sarcoidosis, and interstitial
pulmonary fibrosis. The record of success for the Tracheal reconnection
heart–lung transplant operation is better than that
for lung transplant alone. Aortic reconnection

Right atrium/Vena cava

reconnection

The donor heart and lungs are

5trachea
inserted into the patient. The
and aorta are joined to
those of the patient, and the right
atrium of the donor heart is joined
Healthy and diseased lung to the patient’s venae cavae. (This
These images are of a healthy lung (left) and a lung damaged by procedure is simpler than attaching
emphysema (right), in which the alveoli (tiny air sacs) have become a donor heart in a heart transplant,
greatly enlarged and the walls surrounding them are damaged. because fewer connections have
to be made.)

371
 HEART SOUNDS

100 beats per minute is termed a tachy-

cardia, and a rate below 60 beats per HEART-VALVE REPLACEMENT
minute is known as a bradycardia. (See
Any one of the four heart valves (aortic, pulmonary, mitral, or tricuspid) may be
also arrhythmia, cardiac.) replaced by a natural or an artificial valve. The procedure shown in the steps below
is for replacement of the aortic heart valve.
heart sounds
The sounds made by the heart during
each heartbeat. In each heart cycle, there
are two main heart sounds that can clear-
ly be heard through a stethoscope. The Aortic valve Pulmonary
valve
first is like a “lubb”. It results from clo-
sure of the tricuspid and mitral valves at the
exits of the atria (upper heart chambers),
Mitral valve
which occurs when the ventricles (lower
heart chambers) begin contracting to
Tricuspid Sites for valve
pump blood out of the heart. The second Site of incision valve
sound is a higher-pitched “dupp” caused replacement
by closure of the pulmonary and aortic
H valves at the exits of the ventricles when
the ventricles finish contracting.
Abnormal heart sounds may be a sign Oxygenated
blood returned
of various disorders. For example, high- to aorta
pitched sounds or “clicks” are due to the
abrupt halting of valve opening, which Site of
can occur in people with certain heart incision
valve defects. Heart murmurs are abnor-
mal sounds caused by turbulent blood
flow. Murmurs may be due to heart valve Deoxygenated
blood to
defects or to congenital heart disease. machine

heart surgery
Any operation that is performed on the
1intoInisthemade
nearly all heart-valve surgery, an incision
through the breastbone (sternum)
chest cavity. The patient is put on a
2 The valve is first examined to determine
whether it can be repaired or whether it
must be replaced. If the latter is necessary (as
heart. Open heart surgery allows the treat- heart–lung machine, the beating of the heart here), the valve is excised. (The dotted line in
ment of most types of heart defect that is stopped, and the heart is opened. this picture shows where the incision is made.)
are present at birth (see heart disease,
congenital) as well as various disorders
of the heart valves. Coronary artery bypass
is performed to redirect blood away
from a blocked coronary artery. Angio-
plasty balloons (see angioplasty, balloon)
can be used to open up narrowed heart
valves in cases where the patient is
unsuitable for open heart surgery (see
valvuloplasty). Heart transplant surgery
can offer hope to people with progres-
sive, incurable heart disease. The replacement valve is sutured into Artificial heart valve in place

heart transplant
3patient
position and the aorta is closed. The
is disconnected from the heart-lung
This chest X-ray shows the metal components
of an artificial heart valve. A ball-and-cage
Replacement of a patient’s damaged or machine and the chest wall is sewn up. The valve has been used to replace the patient’s
operation takes between two and four hours. diseased valve.
diseased heart with a healthy heart
taken from a donor who has just died.
Typically, a transplant patient has ad-
vanced coronary artery disease or car- ed heart has no nerve supply, patients heart valve
diomyopathy (disease of heart muscle). tend to have a high resting heart rate A structure at the exit of a heart cham-
During the operation, the function of and no variation in blood pressure from ber, consisting of two or three cup-
the heart is taken over by a heart–lung day to night. shaped flaps, that allows blood to flow
machine. Most of the diseased heart is After the immediate post-operative out of the chamber but prevents it
removed, but the back walls of the atria period, the outlook is good. Patients do, from washing back. There are four heart
(upper chambers) are left in place. The however, face the long-term problems valves: aortic, pulmonary, mitral, and
ventricles (lower chambers) are then associated with other forms of transplant tricuspid. The opening and closing of
attached to the remaining areas of the surgery, including rejection and infec- the heart valves during each heart cycle
recipient’s heart. Because the transplant- tion. (See heart–lung transplant). produces heart sounds.

372
 HEAT DISORDERS

DISORDERS Heart-valve defects may be diagnosed replacement valve, such as mechanical

Heart valves may be affected by stenosis by auscultation, chest X-ray, ECG, or echo- valves, are more likely to cause clots
(narrowing), in which the heart must cardiography and may be corrected by than other types.
work harder to force blood through, or heart-valve surgery.
by incompetence or insufficiency (leak- heat cramps
iness), which makes the valve unable heart-valve surgery Painful muscle contractions caused by
to prevent regurgitation (backwash) of An operation to correct a heart valve salt loss through profuse sweating. Heat
blood.These defects cause heart murmurs. defect or to remove a diseased or dam- cramps are usually brought on by stren-
Defects of the heart valves may be aged valve. A heart valve may have to be uous activity in extreme heat. They may
present from birth (see heart disease, repaired, widened, or replaced because develop independently or may occur as
congenital) or acquired later in life. The it is either incompetent (leaky), stenotic a symptom of heat exhaustion or heat-
most common congenital valve defects (narrowed), or both. Widening of a stroke. Prevention and treatment consist
are aortic stenosis and pulmonary stenosis. valve may involve valvotomy or valvulo- of drinking plenty of fluids, although
Acquired heart-valve disease is usually plasty. A damaged valve can be replaced heat cramps often resolve themselves.
the result of degenerative changes or by a mechanical one (fashioned from
ischaemia (reduced blood supply) affec- metal and plastic), a valve constructed heat disorders
ting part of the heart and leading to from human tissue, a pig valve, or a The body functions most efficiently at a
aortic stenosis or mitral incompetence. valve taken from a human donor after temperature of about 37°C, and any
Rheumatic fever can cause mitral stenosis, death. A heart–lung machine is used dur- major deviation from this temperature H
mitral incompetence, defects of the ing valve replacement. disrupts body processes. The body has
aortic valve, tricuspid stenosis, and tricus- After heart-valve surgery, there may special mechanisms for keeping its
pid incompetence. Heart valves may also be symptoms of breathlessness for seve- internal temperature constant; any mal-
be damaged by bacterial endocarditis. ral weeks that require continued medi- functioning or overloading of these
Heart-valve disorders commonly lead cation. Some people require long-term mechanisms may cause a heat disorder.
to heart failure, arrhythmias, or symp- treatment with anticoagulant drugs to The mechanisms by which the body
toms that arise from reduced blood prevent the formation of blood clots loses excess heat are controlled by the part
supply to the tissues. around the new valve. Certain types of of the brain known as the hypothalamus.

HEART-VALVE REPLACEMENT TYPES

There are three main types of

replacement heart valve: bioprostheses
(such as the Carpentier–Edwards valve,
right), mechanical valves (such as the
tilting-disc valve, centre right), and
homografts (valves taken from a human
donor, far right). A valve is only
replaced if it cannot be repaired. Heart-
valve replacement (see previous page) Bioprostheses Mechanical valves Homografts
is carried out by open surgery, which These are taken from pigs There are two main types: those These are healthy valves taken
requires a cardiopulmonary bypass. The (as above) or can be made from with one (as above) or more from a person who has died of a
most frequently replaced valves are porcine or bovine tissue and used tilting-discs, and ball-and-cage. disease that does not affect the
with or without a stent (a tube to Mechanical valves are made from heart. Homografts are a type of
the aortic and mitral valves.
help the valve to hold its shape). carbon fibre, metal, and plastic. bioprosthesis.

Examples Bioprosthesis (xenograft) Mechanical Homograft

Made from Bovine or porcine tissue with Metal and plastic Human valve
or without a stent (rigid tube)

Availability Readily available Readily available Limited availability

Suitable age group Over 60 All ages All ages

Duration Up to 15 years Lifetime 15 to 20 years

Post-operative drug therapy Three months’ treatment with Lifelong treatment with Three months’ treatment
anticoagulant drugs anticoagulant drugs with anticoagulant drugs

Possible complications Infection; stroke; tendency to Infection; stroke; calcification; Less prone to infection
become calcified leakage around base of valve

373
 HEAT EXHAUSTION

When blood temperature rises, the hypo- Heatstroke can be prevented by gradual heel, painful
thalamus sends out nerve impulses to acclimatization to hot conditions (see Discomfort resulting from disorders of
stimulate the sweat glands and dilate heat disorders). If it does develop, emer- the calcaneus (heel bone) or the soft tis-
blood vessels in the skin. These changes gency treatment is needed. This consists sues around it. Pain in the heel may result
in the skin cool the body down, but of cooling the victim by wrapping him from a fracture of the calcaneus; a spur (a
excessive sweating may result in an im- or her in a cold, wet sheet, fanning the bony growth on the calcaneus); inflam-
balance of salts and fluids in the body, body, sponging with water, and giving mation of the fluid-filled pad cushioning
leading to heat cramps or heat exhaustion. the person a salt solution to drink. the back of the heel (see calcaneal bursi-
When the hypothalamus is disrupted tis); or inflammation of the tissues at the
(for example, by fever), the body may heat treatment bottom of the heel (called plantar fasci-
overheat, leading to heatstroke. Excessive The use of heat to treat disease, aid itis), which, in some cases, is a feature of
external heat may cause prickly heat. recovery from injury, or to relieve pain. ankylosing spondylitis. In addition, the skin
Most heat disorders can be prevented Heat treatment is useful for certain con- overlying the heel may become blistered
by gradual acclimatization to hot condi- ditions, such as ligament sprains, and painful as a result of walking long
tions and taking salt tablets or solution. because it stimulates blood flow and distances and/or wearing ill-fitting shoes.
A light diet and frequent cool baths or promotes healing of tissues.
showers may also help. Alcohol and Moist heat may be administered by heel prick blood test
strenuous exercise should be avoided. soaking the affected area in a warm bath, See Guthrie test.
H or by applying a hot compress or poultice.
heat exhaustion Dry heat may be administered by a heat- height chart
Fatigue, leading to collapse, that is caused ing pad, a hot-water bottle, or a heat A chart used by a doctor or health visi-
by overexposure to heat. The principal lamp that produces infra-red rays. More tor to record a child’s growth and to
causes of heat exhaustion are insufficient precise methods of administering heat to compare his or her height with the typ-
water intake, insufficient salt intake, and tissues deeper in the body include ultra- ical range in a particular age group. (See
a deficiency in sweat production. In sound treatment and short-wave diathermy. also growth, childhood.)
addition to fatigue, symptoms may in-
clude faintness, dizziness, nausea and hebephrenia height velocity
vomiting, headache, and, when salt loss A form of schizophrenia that usually The rate of children’s increase in height
is heavy, heat cramps. The skin is usually becomes evident in adolescence. It is at a particular age. The measurement is
pale and clammy, breathing is fast and characterized by inappropriate and dis- given in centimetres per year.
shallow, and the pulse is rapid and weak. organized behaviour, withdrawal from
Unless it is treated, heat exhaustion may social contact, and changes in mood. Heimlich manoeuvre
develop into heatstroke. A first-aid treatment for choking. The aim
Treatment of heat exhaustion involves Heberden’s node of the Heimlich manoeuvre is to dislodge
rest and replenishing lost water and salt. A bony enlargement affecting the joint the material that is causing the blockage.
Prevention is usually by gradual acclim- at the end of the finger, adjacent to the The first aider stands behind the victim
atization to hot conditions. nail. The tendency to develop such and places one fist, covered by the other,
nodes is a feature of osteoarthritis and is centrally just below the victim’s rib cage
heat, prickly usually inherited. and pulls sharply inwards and upwards to
See prickly heat. give an abdominal thrust.This action, like
heel coughing, forces air out of the airways and
heatstroke The part of the foot that is situated should help to dislodge any blockage.
A life-threatening condition in which below the ankle and behind the arch.
overexposure to heat, coupled with a The heel consists of the calcaneus (heel Helicobacter pylori
breakdown of the body’s mechanisms bone), an underlying pad of fat that acts A bacterium (see bacteria) now known
for regulating temperature, cause the as a cushion, and a layer of skin, which to be the cause of most peptic ulcers as
body to become overheated. A common is usually thickened and hardened due well as a factor in stomach cancer. The
cause is prolonged, unaccustomed ex- to pressure from walking. infection is probably acquired during
posure to the sun in a hot climate. childhood through person-to-person
Unsuitable clothing, strenuous activity, heel, cracked spread. There is an extremely high
overeating, and overconsumption of Painful cracks that develop in the thick- worldwide incidence of HELICOBACTER
alcohol can also be contributory factors. ened skin over the heels. Regular removal PYLORI infection, with higher rates in
Heatstroke is often preceded by heat of any hard skin using a file or pumice developing countries. Of those infected,
exhaustion, which consists of fatigue stone, combined with the use of moistur- only about 15 per cent develop peptic
and profuse sweating. With the onset of izing cream, can reduce the frequency of ulcer disease, although 95 per cent of
heatstroke, the sweating diminishes and such cracks and the severity of the pain. people with duodenal ulcers are found
may stop entirely. The skin becomes hot Cracked heels may also be caused by a to be infected with HELICOBACTER PYLORI.
and dry, breathing is shallow, and the bacterial infection of the skin on the soles The bacterium is thought to damage the
pulse is rapid and weak. Body tempera- of the feet, also known as pitted keratoly- mucus-producing layer of the stomach
ture rises dramatically and, without sis. The disorder causes small, round pits and duodenum, bringing gastric acid into
treatment, the victim may lose con- to develop in the skin; these pits eventu- contact with the linings of these struc-
sciousness and even die. ally join together to form cracks. tures and cause ulceration.

374
 HEPATIC FAILURE

INVESTIGATION AND TREATMENT occurs in opposite sides of the eyes). ease is most common in young chil-
There are several different ways of diag- The visual loss can be either temporary dren, and may occur after an infection
nosing HELICOBACTER PYLORI infection. A or permanent. such as a sore throat. Henoch–Schön-
breath test relies on the ability of the bac- Hemianopia results from damage to lein purpura may also be due to an
terium to split molecules of radio-tagged the optic nerves or the brain. Transient abnormal allergic reaction.
urea, releasing labelled carbon dioxide, homonymous hemianopia in young The main symptom is a raised pur-
which can then be detected in the breath. people is usually caused by migraine. In plish rash on the buttocks and backs of
Tests to check for the presence of antibod- older people, it occurs in transient the limbs.The joints are swollen and often
ies (proteins produced by the immune ischaemic attacks (brief interruptions of painful, and colicky abdominal pain may
system) to the bacterium may be useful, blood supply to the brain). Permanent occur. In some cases, there is intestinal
but they cannot confirm that infection homonymous hemianopia is usually bleeding, leading to blood in the faeces.
has been eradicated. A biopsy sample caused by a stroke, but it may result The kidneys may become inflamed, resul-
taken from the stomach or duodenal lin- from brain damage by a tumour, injury, ting in blood and protein in the urine.
ing can be used to conduct chemical or infection. Hemianopia may also be The only treatment usually required
tests, for microscopic analysis, or cultured caused by pressure on the optic nerve is bed rest and analgesic drugs (pain-
for the organism. from a pituitary tumour. killers). Complications may arise if
Treatment to eradicate the infection kidney inflammation persists. In severe
with a combined course of acid-sup- hemiballismus cases, corticosteroid drugs may be given.
pressing ulcer-healing drugs and antibiotic Irregular and uncontrollable flinging H
drugs has proved successful in achieving movements of the arm and leg on one heparin
long-term recovery from peptic ulcers. side of the body, caused by disease of the An anticoagulant drug used to prevent
Reinfection is rare. (See also gastritis.) basal ganglia (nerve cell clusters in the and treat abnormal blood clotting. Hep-
brain concerned with muscular coordi- arin is given by injection and is used as
heliotherapy nation). (See also athetosis; chorea.) an immediate treatment for deep vein
A form of phototherapy involving expo- thrombosis or for pulmonary embolism; it
sure to sunlight. hemicolectomy may also be given as a preventative
The surgical removal of half, or a major measure to people immobilized as a
helminth infestation portion, of the colon. (See also colectomy.) result of illness or surgery. Low molec-
Infection by any parasitic worm. (See ular weight heparins, such as tinzaparin,
worm infestation.) hemiparesis which only need to be injected once a
Muscular weakness or partial paralysis in day, are now widely used and can be
helper T-cell one side of the body (see hemiplegia). self-administered at home.
A type of white blood cell, also known as Adverse effects of heparin include rash,
a helper T-lymphocyte (see lymphocyte), hemiplegia aching bones, and abnormal bleeding
that has an important role in the immune Paralysis or weakness on one side of the in different parts of the body. Long-
system. Helper T-cells assist in the body, caused by damage or disease term use may cause osteoporosis.
destruction of abnormal cells (such as affecting the motor nerve tracts in the
cancer cells) in the body by recognizing opposite side of the brain. A common hepatectomy, partial
foreign antigens on the surface of the cause is a stroke. Others include head Surgical removal of part of the liver. This
abnormal cells and subsequently stimu- injury, brain tumour, brain haemorrhage, procedure may be needed to remove a
lating the production of killer T-cells. encephalitis (brain inflammation), multi- damaged area of liver following injury,
ple sclerosis, complications of meningitis, or to treat noncancerous liver tumours
Helweg–Larsen’s syndrome or a conversion disorder (a type of psy- and hydatid disease. Rarely, liver cancer is
An autosomal dominant genetic disorder, chological disorder). Treatment is for treated in this way.
affecting both sexes, that is chiefly char- the underlying cause, and is carried out
acterized by a reduced ability to lose in conjunction with physiotherapy. hepatectomy, total
body heat through sweating. Affected Surgical removal of the liver. Hepat-
individuals have anhidrosis (inability to hemivertebra ectomy is the first stage in a liver
sweat) from birth; they have a very small A birth defect in which half of a vertebra transplant operation.
number of sweat glands, and those that (spinal bone) fails to develop fully.
do exist are abnormally enlarged. This hepatic
defect leads to disturbances in body tem- Hemoccult Relating to the liver.
perature.There are also malformations in A brand name for a type of faecal occult
the skin and nail tissues. In addition, blood test that uses guaiac to screen for hepatic encephalopathy
affected people develop deafness due to gastrointestinal bleeding, a possible sign A brain disorder caused by a build-up
inner ear problems in their 30s or 40s. of colorectal cancer (see colon, cancer of; of toxins in the body as a result of liver
rectum, cancer of). failure. (See also encephalopathy.)
hemianopia
Loss of half of the visual field in each eye. Henoch–Schönlein purpura hepatic failure
Hemianopia may be “homonymous” (in Inflammation of small blood vessels, This is the medical term for liver failure,
which the same side of both eyes is affect- causing leakage of blood into the skin, in which the function of the liver is
ed) or “heteronymous” (in which the loss joints, kidneys, and intestine. The dis- severely impaired.

375
 HEPATITIS

hepatitis (often through contact with used nee- to interferon. In the drug-induced type of
Inflammation of the liver, with accom- dles and syringes); blood transfusions; chronic hepatitis, withdrawal of the
panying damage to liver cells. The con- or sexual contact. After an incubation medication can lead to recovery. For
dition may be acute (see hepatitis, acute) period of one to six months, the onset metabolic disturbances, treatment is for
or chronic (see hepatitis, chronic) and of symptoms, such as headache, fever, the underlying disorder.
may have various causes. (See also and jaundice, may be sudden or gradual;
hepatitis A; hepatitis B; hepatitis C; hepati- sometimes, there are no symptoms. Most hepatitis D
tis D; hepatitis E; hepatitis, viral.) affected people recover, but hepatitis B An infection of the liver caused by the
can be fatal. A vaccine is available; it is hepatitis D virus, which occurs only in
hepatitis A usually given to people at high risk of people who already have hepatitis B
Also known as epidemic hepatitis, this coming into contact with the virus, such infection. People who develop hepatitis
disorder is caused by the hepatitis A as health-care workers or people visit- D will usually suffer from severe chronic
virus, which exists in the urine and fae- ing areas where the disease is common. liver disease. Hepatitis D is also known
ces of infected people and is transmitted In a few cases, the virus continues to as delta hepatitis.
in contaminated food or drink. The cause inflammation and can still be
incubation period lasts for 15–40 days, detected in the blood for longer than six hepatitis E
after which nausea, fever, and jaundice months after infection. People who suffer A type of hepatitis caused by the hepa-
develop. Recovery usually occurs within from persistent infection are at long-term titis E virus, which is transmitted in
H three weeks. Serious complications are risk of liver cancer and cirrhosis and may contaminated food or drink. The disease
rare. Active immunization gives the best need to be treated with interferon. is similar to hepatitis A.
protection against hepatitis A, and may
be advised for people travelling to hepatitis C hepatitis, serum
Mediterranean or developing countries. Caused by the hepatitis C virus and for- The former name for hepatitis B.
An attack of the disease can confer merly known as non-A non-B hepatitis,
immunity against subsequent infection. this infection is often transmitted through hepatitis, viral
sharing needles. Blood transfusions no Any type of hepatitis caused by a viral
hepatitis, acute longer pose a significant risk in the UK infection. Five viruses that attack the liver
Short-term inflammation of the liver. because all blood used for transfusions as their primary target have been identi-
Acute hepatitis usually clears up in one is now routinely screened for the virus. fied. They cause hepatitis A, hepatitis B,
to two months. In some cases, the dis- Hepatitis C has an incubation period hepatitis C, hepatitis D, and hepatitis E.
order may progress to chronic hepatitis of six to 12 months. It begins as a mild
(see hepatitis, chronic), but it rarely leads illness, which may go undetected. In hepatocele
to acute liver failure. about three in four patients, chronic The medical term used to describe the
Acute hepatitis is fairly common. The hepatitis develops (see hepatitis, chronic), protrusion of part of the liver through
most frequent cause is infection with which can progress to cirrhosis of the the wall of the abdomen.
one of the hepatitis viruses (see hepati- liver and an increased risk of hepatoma
tis, viral), but it can arise as a result of (a type of liver cancer). hepatocellular carcinoma
other infections such as cytomegalovirus The most common type of primary liver
infection. It may also occur as a result of hepatitis, chronic cancer that arises from within mature
overdose of halothane or paracetamol, or Inflammation of the liver that persists for liver cells. Hepatocellular carcinoma
because of exposure to toxic chemicals a prolonged period. Eventually, chronic may develop in people who are suffer-
including alcohol (see liver disease, alco- hepatitis causes scar tissue to form and ing from cirrhosis of the liver, especially
holic). Symptoms range from mild to may lead to the development of cirrhosis. following infection with hepatitis B or
severe. They include tiredness; fever; The disorder may develop following hepatitis C. Incidence of hepatocellular
nausea and vomiting; pain in the upper an attack of acute hepatitis (see hepati- carcinoma is far greater in tropical areas
right side of the abdomen; and jaundice. tis, acute) or hepatitis C. It may also of the world. Symptoms of the condition
Blood tests, including liver function occur as the result of an autoimmune dis- include hepatomegaly (enlargement of
tests, may be used for diagnosis. In most order, a viral infection (see hepatitis, the liver), jaundice, and weight loss.
cases of acute viral hepatitis, natural viral), a reaction to certain types of pre-
recovery occurs within a few weeks. If scribed drugs or, more rarely, to a hepatoma
the disorder is caused by exposure to a metabolic disorder, such as haemochrom- A tumour of the liver. A cancerous
chemical or drug, detoxification using atosis or Wilson’s disease. In some cases, hepatoma is also known as a hepatocel-
an antidote may be possible. Intensive no obvious cause can be found. lular carcinoma.
care may be required if the liver is badly Symptoms of chronic hepatitis, such
damaged. Rarely, a liver transplant is the as jaundice and slight fatigue, may alter- hepatomegaly
only way of saving life. In all cases, alco- nate with periods in which there are no Enlargement of the liver, occurring as a
hol should be avoided after the illness. symptoms at all. If left untreated, the result of any liver disorder (see liver, dis-
condition may progress to liver failure. orders of).
hepatitis B Chronic hepatitis is diagnosed by liver
A disorder caused by the hepatitis B virus. biopsy. Autoimmune hepatitis is treated hepatotoxic
The infection is transmitted in blood, with corticosteroid drugs and immunosup- A term for substances, such as certain
blood products, or other body fluids pressants. Viral infections often respond drugs, that cause damage to liver cells.

376
 HERMAPHRODITISM

susceptible people who could catch it

MAIN TYPES OF VIRAL HEPATITIS and pass it on to others. As a result, even
Viral hepatitis type A Viral hepatitis types those people without immunity receive
(epidemic hepatitis) B and C a degree of protection from being part
of an immune population.
Transmission The virus is present in the faeces of These viruses are present in the
of infection infected people and is transmitted by blood and other body fluids of infected
hereditary haemorrhagic
faecal contamination of water and people, many of whom appear to be telangiectasia
food (such as through poor hygiene in in normal health. Infection is spread An inherited condition in which capil-
food handling). Faeces are infective sexually or by sharing hypodermic laries (tiny blood vessels) in the skin and
from two to three weeks before until needles; in the past it was spread
about eight days after the onset of by use of contaminated blood and in the mucous membranes of areas such
jaundice. Local epidemics can occur. blood products. as the nose, mouth, and gastrointestinal
tract are distended and prone to recur-
Groups at Travellers to areas where hygiene Those most at risk are male rent bleeding.The condition can result in
particular standards are poor and prevalence of homosexuals, people with multiple iron deficiency anaemia (see anaemia,
risk the virus is high (such as parts of sexual partners, intravenous drug iron deficiency). Hereditary haemorrhagic
Asia, Africa, or South America) are users, healthcare workers, or babies telangiectasia shows an autosomal domi-
most at risk. born to mothers with the virus.
nant pattern of inheritance (see genetic
Incubation This lasts for 15–40 days after the This lasts for 1–6months (type B) and
disorders). (See also telangiectasia.) H
period virus has entered the body. 6–12 months (type C) after infection.
hereditary spherocytosis
See spherocytosis, hereditary.
Symptoms In many cases there are no Symptoms are similar to those of the
and outlook symptoms. There may be nausea,
vomiting, malaise, and a mild flulike
type A virus, although they may be
more severe. Up to ten per cent of
heredity
illness with jaundice, lasting about adults with type B and up to 70 per The transmission of traits and disorders
two to three weeks. The condition cent with type C develop chronic through genetic mechanisms. Each indi-
never progresses to chronic hepatitis. hepatitis, with continuing illness and vidual inherits a combination of genes
eventual cirrhosis of the liver.
via the sperm and egg cells from which
he or she is derived. The interaction
Preventive Travellers should take advice about Measures include the screening of of the genes determines inherited char-
measures the need for immunization for travel blood donors, treatment of donated acteristics, including, in some cases,
to a given destination. Active blood, and safe sex. Intravenous drug
immunization involves two doses of users should not share needles. disorders or susceptibility to disorders.
the hepatitis A vaccine, given six to Immunization against hepatitis B may (See also genetic disorders; inheritance.)
12 months apart; this provides be offered to people at high risk of
immunity for up to ten years. contracting the virus (such as babies of heritability
infected mothers, healthcare workers, A measure of the extent to which a
and drug users). Travellers should take
advice about the need for immunization disease or disorder is the result of inher-
for their destination. The vaccine is ited factors, as opposed to environ-
given in three doses; the second dose mental influences such as diet and cli-
is given one month after the first, and mate. Certain disorders (such as haemo-
the third six months after the first.
philia or cystic fibrosis) are known to
be caused entirely by hereditary factors.
In contrast, others are caused wholly by
herald patch active substances that may interact with environmental factors. However, existing
A single pink patch with a scaly edge other drugs or affect other medical con- between these extremes are many disor-
that appears on the skin of the trunk. A ditions. Herbal remedies should only be ders (such as schizophrenia) in which
herald patch develops about a week used on the advice of an approved prac- both inheritance and environment prob-
before the full rash of the skin disorder titioner; a patient should always inform ably play a part.
pityriasis rosea breaks out. his or her doctor of any herbal medi- A rough estimate of heritability can
cine he or she is using. be obtained from the known incidence
herbal medicine of a disorder in the first-degree relatives
Systems of medical treatment in which herd immunity (parents or siblings) of affected people
various parts of different plants are used Protection of a whole community from compared with the incidence of the dis-
to promote health and to treat symptoms an infectious disease as a result of order in a population exposed to similar
of illness. Herbal medicine is a form of immunity in a majority, but not all, of environmental influences. Estimates of
complementary medicine. Herbal remedies that community. Such immunity may be heritability are useful in genetic coun-
are also used in treatments such as home- naturally acquired or may be induced selling. (See also genetic disorders.)
opathy and Chinese medicine. by immunization. For example, vaccina-
Although herbal medicine is thought tion of more than 85 per cent of a hermaphroditism
by some to be harmless because it is population against diphtheria will pre- A congenital disorder in which gonads
natural, some herbal remedies contain vent the spread of the disease, should it (testes or ovaries) of both sexes are pre-
significant amounts of pharmalogically occur, due to an insufficient number of sent within one individual, and in

377
 HERNIA

which the external genitalia are not through the abdominal wall. In a hiatus important are inguinal hernias, which
clearly male or female. True hermaph- hernia, the stomach protrudes through mainly affect men; femoral hernias,
roditism is extremely rare and its cause the diaphragm, into the chest. which are more common in overweight
is unknown. A more common condi- CAUSES women; and umbilical hernias, which
tion is pseudohermaphroditism, in which Abdominal hernias may be caused by a occur in babies.
the gonads of only one sex are present, congenital weakness in the wall of the SYMPTOMS AND TREATMENT
but the external genitalia are not clearly abdomen. Hernias may also be the The first symptom of an abdominal
either male or female, or are those of result of damage caused by lifting heavy hernia is usually a bulge in the abdomi-
the opposite sex. objects, persistent coughing, or strain- nal wall. There may also be some
ing to defaecate, or they may develop abdominal discomfort.
hernia following an operation. Sometimes the protruding intestine
Protrusion of an organ or tissue through TYPES can be pushed back into place (known
a weak area in the muscle or tissue that There are several types of abdominal as a reducible hernia). In other cases,
normally contains it. The term is usually hernia, which are classified according however, the hernia bulges out and can-
applied to a protrusion of the intestine to their location in the body. The most not be put back (an irreducible hernia).
This condition is painful, and surgery is
usually necessary to repair the weakened
MAIN TYPES OF ABDOMINAL HERNIA area (see hernia repair).
H Inguinal At least 2 per cent of adult males in the
If the trapped portion of intestine
hernia UK suffer at some time from this kind of becomes twisted, the blood supply to
hernia, in which part of the intestine the area will be impaired. This problem,
bulges through the inguinal canal (the known as a strangulated hernia, needs
passage through which the testes descend urgent treatment, otherwise gangrene of
into the scrotum). The hernia is detected as
a bulge in the groin or scrotum; untreated, the bowel may develop.
the hernia may become stuck, so early Umbilical hernias in babies can usu-
surgery is generally recommended. ally be left untreated as they tend to
disappear naturally by age five.
Femoral This type of hernia occurs most commonly
hernia in obese women; part of the intestine hernia repair
emerges where the femoral vein and Surgical correction of a hernia. Surgery is
artery pass from the abdomen to the thigh.
A femoral hernia is noticed as a swelling usually performed to treat a hernia of the
of the top front of the thigh. Although the abdominal wall that is painful or cannot
hernia itself may be large, its neck is be pushed back into place. A strangulated
narrow, and the condition can only be hernia (in which the blood supply to a
corrected by surgery.
trapped portion of intestine is cut off)
requires an emergency operation.
Epigastric Also called a ventral hernia, an epigastric
During surgery, the protruding intes-
hernia hernia is caused by a weakness in the
muscles of the central upper abdomen; tine is pushed back into the abdomen
the intestine bulges out at a point and the weakened muscle wall strength-
between the navel and the breastbone. ened. Either open or minimally invasive
This form of hernia is three times more surgery, using an endoscope to repair
common in men than in women and is
most likely to occur in people between the hernia from within the abdominal
20 and 50 years old. cavity, may be used.
herniated disc
Umbilical This occurs when part of the intestine
hernia protrudes through the abdominal wall at See disc prolapse.
the navel. Babies are the most common
sufferers; the hernia can be repaired herniorrhaphy
surgically or it may disappear naturally by
about the age of five. A similar problem, See hernia repair.
a parumbilical hernia, occurs mostly in
obese, middle-aged women who have had heroin
several children. A narcotic drug similar to morphine.
When used for medical purposes, it is
Incisional An area of weakness may occasionally generally known as diamorphine. Heroin
hernia develop following a surgical incision may also be abused for its mood-alter-
in the wall of the abdomen. This area
may then develop into an incisional ing effects (see heroin abuse).
hernia. The defect may become so severe
that a large amount of intestine bulges heroin abuse
through the abdominal wall; if this Nonmedical, illicit use of heroin. The
happens, a repair using a piece of mesh
may be necessary. heroin taken by drug abusers is a white or
brownish powder that can be smoked,
sniffed, or dissolved in water and injected.

378
 HERPES SIMPLEX

potence, and the risk of infection with that may be taken include taking anal-
HERNIA REPAIR hepatitis B, hepatitis C, and HIV through gesic drugs and bathing the genital area
sharing needles. Death commonly occurs in a salt solution.
During surgery the hernia is removed
or repositioned and the weakened
from accidental overdose. OUTLOOK
abdominal wall is reinforced with Once the virus has entered the body, it
stitching or mesh.
herpangina stays there for the rest of the person’s
A throat infection caused by coxsackievirus. life. Recurrent attacks may occur, usu-
Herpangina most commonly affects ally during periods when the person is
young children. The virus is usually feeling run down, anxious, or depres-
transmitted via infected droplets coughed sed, or, in some cases, a few days before
or sneezed into the air. Many people har- menstruation. The virus may be shed
bour the virus but do not have symptoms. continuously and can be transmitted to
SYMPTOMS others through sexual intercourse, even
After an incubation period of two to when the infected person has no symp-
seven days, there is a sudden onset of toms. Recurrent attacks tend to become
fever, accompanied by a sore throat and less frequent and less severe over time.
sometimes also headache, abdominal Genital herpes may be passed from a
1someThe protruding sac of intestine is
pushed back into the abdomen or, in
cases (such as strangulation), the sac
discomfort, and muscular pains. The
throat becomes red and a few small
pregnant woman to her baby during
delivery. If the genital herpes develop in H
is removed surgically. blisters appear, which enlarge and late pregnancy, delivery by caesarean
burst, forming shallow ulcers. These section is usually recommended.
symptoms usually clear up within a
week, without specific treatment herpes gestationis
A rare skin disorder of pregnant women
herpes that produces crops of tense, itchy blis-
Any of a variety of conditions that are ters on the legs and abdomen. Herpes
characterized by an eruption of small, gestationis is an autoimmune disorder
usually painful, blisters on the skin. The that is essentially a type of pemphigoid
term “herpes” usually refers to an infec- triggered by pregnancy.
tion with the herpes simplex virus. Two Severe herpes gestationis is treated
forms of this virus, called HSV1 and with corticosteroid drugs in tablet form. An
2edgesThe muscular wall of the abdomen may
then be repaired by overlapping the
of the weakened area and securing
HSV2, are generally responsible for cold affected woman may need to be moni-
sores and genital herpes (see herpes, tored closely as there is an increased risk
them with rows of stitching.
genital), respectively. of fetal prematurity and low birthweight.
A closely related organism, the vari- The disorder may initially worsen after
LARGE HERNIAS
cella–zoster virus, is responsible for two delivery but then clears up. It tends to
other conditions in which skin blisters recur in subsequent pregnancies.
are a feature: chickenpox and herpes
zoster (shingles). herpes simplex
A common viral infection that is char-
herpes, genital acterized by small, fluid-filled blisters.
A sexually transmitted infection caused Herpes simplex infections are contagi-
mainly by HSV2, one form of the herpes ous and are usually spread by direct
simplex virus. Rarely, genital infections contact. Most infections are quite mild.
Alternative method can be due to HSV1 that has been trans- TYPES
For repair of some large or recurrent hernias, mitted by oral contact with the genitals. There are two forms of the virus: HSV1
two mesh leaves are secured by rows of After an incubation period of about a (herpes simplex virus, type 1) and HSV2
stitching, then joined at the centre. week, the virus produces soreness, burn- (herpes simplex virus, type 2). Most
ing, itching, and small blisters in the people are infected with HSV1 at some
genital area. The blisters burst to leave time in their lives, usually during child-
Heroin has an analgesic effect and pro- small, painful ulcers, which heal in hood. HSV1 is usually associated with
duces sensations of warmth, calmness, 10 to 21 days. The lymph nodes in the infections of the lips, mouth, and face;
drowsiness, and a loss of concern for groin may become enlarged and painful, HSV2 is often associated with infections
outside events. Long-term drug use and the person may develop other symp- of the genitals and infections acquired
causes tolerance and psychological and toms such as a headache, fever, and by babies at birth. There is considerable
physical dependence (see drug depen- aching muscles. overlap between the two types; some-
dence; heroin abuse). Sudden withdrawal TREATMENT times, conditions usually due to HSV1
produces shivering, abdominal cramps, Genital herpes cannot be cured, but are caused by HSV2, and vice versa.
diarrhoea, vomiting, and restlessness. early treatment can reduce the severity Type 1 virus The initial infection may be
Heroin addiction has many adverse of symptoms. Antiviral drugs, such as aci- symptomless; alternatively, it may cause a
effects on the user, including injection clovir make the ulcers less painful and flu-like illness with mouth ulcers. There-
scars, skin abscesses, weight loss, im- also encourage healing. Other measures after, the virus remains dormant in nerve

379
 HERPES ZOSTER

cells in the facial area. In many people, heterozygote

the virus is periodically reactivated, caus- A term used to describe a person whose
ing cold sores that invariably erupt in the cells contain two different alleles (forms
same site (usually around the lips). of a particular gene) controlling a spec-
Sometimes the virus can infect a fin- ified inherited trait. A homozygote has
ger after touching a cold sore, causing a identical alleles controlling that trait.
painful eruption called a herpetic whit- (See also inheritance; genetic disorders.)
low. HSV1 may also produce eczema
herpeticum (an extensive rash of skin hexachlorophene
blisters) in a person with a pre-existing An antibacterial drug used in dusting
skin disorder, such as eczema. Eczema powder form to prevent staphylococcal
herpeticum may require hospital admis- Example of herpes zoster infections in newborns, and to prevent
An extensive rash of blisters has spread around
sion. If the virus gets into an eye it may one side of the body, just under the ribs, and on to and treat bedsores.
cause conjunctivitis, which usually lasts the front of the abdomen.
only a few days; more seriously, it may hiatus hernia
cause a corneal ulcer. common in people whose immune sys- A condition in which part of the stom-
Rarely, HSV1 spreads to the brain, tem is weakened by stress or by certain ach protrudes upwards into the chest
leading to encephalitis. The virus may drugs, such as corticosteroid drugs or through an opening in the diaphragm
H cause a potentially fatal generalized anticancer drugs. called the hiatus, which is normally
infection in a person with an immuno- SYMPTOMS occupied by the oesophagus. The cause
deficiency disorder or in someone taking The first indication of herpes zoster is is unknown, but hiatus hernia is more
immunosuppressant drugs. excessive sensitivity in the skin, fol- common in obese people. In some
Type 2 virus HSV2 is the usual cause of lowed by pain, which is often severe. cases, it is present at birth.
sexually transmitted genital herpes (see The infection can be difficult to diag- Many people have no symptoms. In
herpes, genital), in which painful blis- nose at this stage and may be mistaken some people, however, the hiatus hernia
ters erupt in the genital area. In some for a different condition; for example, impairs the efficiency of the oesophageal
people, the blisters tend to recur. pain in the chest wall may be mistaken sphincter, the muscle at the junction
TREATMENT for angina pectoris. After about five between the oesophagus and the stom-
Treatment of herpes simplex depends days, the rash appears as small, raised, ach. Weakness in this muscle allows acid
on its type, site, and severity of symp- red spots that soon turn into blisters. reflux as the stomach acid escapes into
toms. Antiviral drugs, such as aciclovir, Within a few days, the blisters dry, flat- the oesophagus. This problem may lead
may be helpful, particularly if used ten, and develop crusts. Over the next to oesophagitis (inflammation of the
early in an infection. two weeks, the crusts drop off, some- oesophagus) or to heartburn, which pro-
times leaving small pitted scars. duces pain or discomfort in the centre of
herpes zoster The most serious feature of herpes the chest.
An infection of the nerves supplying cer- zoster is pain after the attack, known as Antacid drugs, H2 receptor antagonists,
tain skin areas that is characterized by a postherpetic neuralgia, which affects or proton pump inhibitors (all types of
painful rash of small crusting blisters. about a third of all infected people. This ulcer-healing drug) may be given to
Also called shingles, herpes zoster is pain is caused by nerve damage, and reduce stomach acidity. In severe cases,
especially common among older people. may last for months or years. Herpes surgery may be required to return the
TYPES zoster ophthalmicus may cause a corneal stomach to its normal position and to
Herpes zoster usually affects only one ulcer or uveitis (inflammation of the part
side of the body, and follows the path of of the eye known as the uvea).
a nerve. It commonly develops on a TREATMENT
strip of skin over the ribs, although the If treatment is begun soon after the rash
rash may also appear on the neck, arm, appears, antiviral drugs, such as aciclovir,
or lower part of the body. Sometimes will reduce the severity of the symptoms Oesophagus
the infection involves the face and eye; and minimize nerve damage. Analgesic
this form of the disorder is called her- drugs (painkillers) may also be helpful
pes zoster ophthalmicus. in relieving pain. If postherpetic neuralgia Herniated
CAUSES is a problem, anticonvulsant drugs, such portion of
stomach
Herpes zoster is caused by the vari- as gabapentin, may be helpful.
cella–zoster virus, which also causes
chickenpox. After an attack of chicken- herpetic whitlow
pox, some of the viruses survive and lie A painful swelling on the finger caused Diaphragm

dormant for many years in the nerve by infection with the herpes simplex
cells near the spinal cord. In some peo- virus. (See also whitlow.)
ple, a decline in the efficiency of the Stomach

immune system – especially in old age – heterosexuality

because of disease or severe stress, Sexual attraction of an individual to Common type of hiatus hernia
allows the viruses to re-emerge and members of the opposite sex. (See also Part of the stomach slides into the chest through
cause herpes zoster. The disorder is also bisexuality; homosexuality.) the oesophageal hiatus (opening).

380
 HIP, CLICKING

tighten the oesophageal sphincter. This terol from the circulation and takes it to
can now be carried out by minimally inva- the liver for processing. (See also fats and LOCATION OF HIP
sive surgery through an endoscope. oils; low density lipoprotein.)
The hip is a ball-and-
Hib vaccine high-dependency unit socket joint comprising
the dome at the top of
A vaccine administered routinely at two, A level of hospital inpatient care interme- the femur (thigh bone)
three, and four months of age to provide diate between that of a general ward and and the cup-shaped
immunity to the bacterium HAEMOPHILUS that of an intensive care unit. Also known depression in the
INFLUENZAE type b (Hib). Before the vac- as a “step-down” facility, staff in a high- pelvic bone.
cine was generally available, Hib infection dependency unit provide monitoring and
was a common cause of bacterial menin- support for acutely ill patients. It also has Pelvis Ligaments Sacrum
gitis and epiglottitis in children. facilities for short-term ventilation (use of
a machine to assist breathing) and emer-
hiccup gency resuscitation.
A sudden, involuntary contraction of the
diaphragm followed by rapid closure of hilum
the vocal cords. Most attacks of hiccups last The term that is used to describe a small
only a few minutes, and are not medically indentation on the surface of an inter-
significant. Rarely, they may be due to a nal organ where blood vessels, nerve H
condition, such as pneumonia or pancreati- fibres, or other similar structures enter
tis, that causes irritation of the diaphragm or leave the organ. For example, the
or phrenic nerves. Chlorpromazine, haloper- hilum of the lung is its junction with Hip joint
idol, or diazepam may be prescribed for the main bronchus and the major ves-
frequent, prolonged attacks. sels. A commonly used alternative term
is “hilus”. Right Left
Hickman catheter femur femur
A flexible plastic tube, also known as a hindmilk
skin-tunnelled catheter, that is passed The breast milk that is produced at the
through the chest and inserted into the end of a feed. Hindmilk contains more DISORDERS
subclavian vein, which leads to the fat than foremilk and therefore provides Injuries to the hip joint, such as disloca-
heart. It is often used in people who the baby’s main source of energy. (See tion of the joint, are usually caused by
have leukaemia or other cancers and also breast-feeding.) extreme force, as in a road traffic acci-
need regular chemotherapy and blood dent. Fractures may also occur in the hip
tests. The catheter allows drugs to be hindwaters joint, due to breaks in the head or neck
injected directly into the bloodstream A term for the amniotic fluid that is dis- of the femur (see femur, fracture of). This
and blood samples to be obtained easily. charged behind the presenting part of type of injury is more common in elder-
It is inserted under local anaesthesia. A the baby (usually the head) during preg- ly people, whose bones are weakened by
Hickman catheter can remain in posi- nancy and delivery. In contrast, the osteoporosis (loss of bone density).
tion for months; the external end is forewaters (the “waters”) precede the Osteoarthritis (degeneration of bone
plugged when not in use. presenting part of the baby and may rup- ends within a joint) is a common disor-
ture (or “break”) before or after the der of the hip. It causes symptoms such
hidradenitis suppurativa onset of labour. as pain and stiffness (particularly dur-
Inflammation of the sweat glands in the ing activity), swelling, and restricted
armpits and groin due to a bacterial infec- hinge joint joint movement.
tion. Abscesses develop beneath the skin; A type of mobile joint that allows move- Certain forms of hip disorder occur
the affected area becomes reddened and ment in one plane only (forwards and in babies and children. Developmental
painful and may ooze pus. The condition backwards). Examples of hinge joint are hip dysplasia is a condition that is pre-
tends to be recurrent and can eventually the knee joint and the elbow joint. sent at birth; in this disorder, the hip
cause scarring. Antibiotic drugs may help to socket is malformed and the head of
reduce the severity of an outbreak. hip the femur does not fit correctly into
The joint between the pelvis and the it. Perthes’ disease is a rare condition
hidrosis upper end of the femur (thigh bone).The affecting young children, in which the
The medical term for sweating. (See also hip is a ball-and-socket joint; the smooth, head of the femur breaks down; it cau-
hyperhidrosis; hypohidrosis.) rounded head of the femur fits securely ses limping, pain in the hip, and
into the acetabulum, a cup-like cavity in restricted movement in the joint.
high density lipoprotein the pelvis. Tough ligaments attach the
A type of lipoprotein, made up of pro- femur to the pelvis, further stabilizing the hip, clicking
tein and lipid (fat), that transport lipids joint and giving it the necessary strength A fairly common condition in adults in
in the blood. High levels of high density to support the weight of the body and which a characteristic dull clicking can
lipoprotein (HDL) can help to protect take the strain of leg movements. The be heard and felt during certain move-
against atherosclerosis (fatty deposits on structure of the hip allows a considerable ments of the hip joint. Clicking hip is
artery walls) because it removes choles- range of leg movement. caused by a tendon slipping over the

381
 HIP, CONGENITAL DISLOCATION OF

bony prominence on the outside of the

femur (thigh bone), and does not indi-
PERFORMING A HIP REPLACEMENT
cate disease.
In this operation, the surgeon pushes aside or cuts through the surrounding
Clicking of the hip may sometimes muscles to expose the hip joint. The femur (thigh bone) is cut and the pelvis is
be heard during examination of new- drilled to make room for the two components of the artificial joint. These parts
born babies; in this instance, it indicates are secured in place, the femur is repaired, and the muscles and tendons are
possible dislocation of the hip (see replaced and repaired.
developmental hip dysplasia).
Alternative
hip, congenital dislocation of sites of incision Ball

See developmental hip dysplasia.

Pelvis
hip dysplasia, developmental
Socket
See developmental hip dysplasia.
Trochanter
hippocampus
A structure in the limbic system of the Shaft
brain. The hippocampus, consisting of a Femur
H band of grey matter, is involved with
some learning processes and long-term Components
memory storage. An artificial hip joint has two parts. The ball
and shaft are metal; the socket may be metal
Hippocratic oath or plastic.
A set of ethical principles that are
Before After
derived from the writings of the Greek This X-ray shows This X-ray shows
physician Hippocrates that is concerned a hip joint that the artificial hip
with a doctor’s duty to work for the has been badly joint in position
good of the patient. damaged by after surgery.
arthritis.
hip replacement
A surgical procedure to replace all or Diseased Replacement
joint joint
part of a diseased hip joint with an arti-
ficial substitute. The replacement is
most often carried out in older people
whose joints are stiff and painful as a
result of osteoarthritis. It may also be
needed if rheumatoid arthritis has spread
to the hip joint or if the top end of the
femur (thigh bone) is badly fractured Femur Femur
(see femur, fracture of).
Hirschsprung’s disease
A congenital disorder in which the
rectum, and sometimes the lower part of
the colon, lack the ganglion cells that hirsutism hirudin
control the intestine’s rhythmic contrac- Excessive hairiness, which particularly An anticoagulant contained in the saliva
tions. The affected part of the colon appears in women. The additional hair of leeches (see leech) that prevents
becomes narrowed and blocks the move- is coarse in texture and grows in a male blood from clotting.
ment of faecal material. pattern on the face, trunk, and limbs.
The disease is rare and tends to run Hirsutism can be a symptom of certain histamine
in families. It occurs about four times conditions, such as polycystic ovary A chemical present in cells (mainly mast
more often in boys. Symptoms, which syndrome and congenital adrenal hyper- cells) throughout the body that is
include constipation and bloating, usu- plasia, in which the level of naturally released during an allergic reaction (see
ally develop in the first few weeks of occurring male hormones in the blood allergy). Histamine activates two main
life. The child usually has a poor is abnormally high. Hirsutism can also types of receptors: H1 and H2. H1 activa-
appetite and may fail to grow properly. be a result of taking anabolic steroids tion is responsible for the swelling and
A barium X-ray examination can show the (see steroids, anabolic). More commonly, redness that occur in inflammation. It also
narrowed segment of the intestine. A however, hirsutism is not a sign of any narrows the airways in the lungs and
biopsy may also be taken. Treatment of disorder at all; it occurs mildly in many causes itching. H2 activation stimulates
Hirschsprung’s disease involves removing normal women, especially after the acid production by the stomach, but in
the narrowed segment and rejoining the menopause, in which hormone balance large amounts it can irritate the stomach
normal part of the intestine to the anus. is upset (See also hypertrichosis.) lining, causing gastritis or peptic ulcers.

382
 HIV

Allergic reactions caused by H1 can be HLA types occur more frequently in HIV
controlled by antihistamine drugs. Over- people with particular diseases. For The abbreviation for human immuno-
production of stomach acid due to H2 example, HLA-B27 is associated with deficiency virus. HIV is a retrovirus that
can be counteracted by H2-receptor several forms of arthritis, particularly infects and gradually destroys cells in
antagonists (see ulcer-healing drugs). ankylosing spondylitis, and HLA-DR2 and the immune system and may eventually
an HLA-DQ type with narcolepsy. HLA lead to AIDS (acquired immunodeficien-
histamine1-receptor antagonists testing can help to confirm the diagno- cy syndrome). There are two closely
See H1-receptor antagonists. sis in someone who may have one of related viruses: HIV-1, which is the
these conditions. most common cause of AIDS through-
histamine2- out the world; and HIV-2, which is
receptor antagonists histology largely confined to West Africa.
See H2-receptor antagonists. The study of tissues, including their cel- METHODS OF TRANSMISSION
lular structure and function. The main HIV is transmitted in body fluids, such
histiocytosis X application of histology in medicine is as blood, semen, and vaginal secretions.
A rare childhood disease, now more in the diagnosis of disease. This process It most commonly gains access to the
commonly known as Langerhans cell often involves obtaining a sample of tis- body during sexual activity (either vagi-
histiocytosis, in which there is an over- sue (see biopsy) and examining it under nal, anal, or oral), particularly when
growth of a type of tissue cell called a a microscope to detect any abnormali- contaminated body fluids come into
histiocyte. The cause is unknown, but ties, such as cancerous cells or areas of contact with broken skin. Other sources H
the condition probably results from a scar tissue. Examination of tissue sam- of infection are nonsterile needles (for
disturbance of the immune system. In the ples may also be performed to example, among people who abuse
mildest form, rapid cell growth occurs determine the extent of a disease, such intravenous drugs and share needles
in one bone only, usually the skull, a as cancer, once it has been detected. If a and syringes) and, in some parts of the
clavicle, a rib, or a vertebra, causing cancerous tumour is found, for exam- world, contaminated blood transfu-
swelling and pain. In the most severe, ple, it may be removed, together with sions. In addition, if a pregnant women
and least common, form, there is a rash an area of surrounding tissue; by exam- is infected, the virus can pass to the
and enlargement of the liver, spleen, and ining this material, doctors can tell fetus via the placenta. It is not transmit-
lymph nodes, as well as lung involve- whether the whole of the diseased area ted by everyday physical contact such as
ment. In these cases, treatment is with has been removed or whether cancer- shaking hands or hugging.
anticancer drugs, but the outlook is poor. ous cells have spread beyond the edges EFFECTS OF THE VIRUS
of the tumour. HIV infects cells that have a special
histocompatibility antigens structure, called a CD4 receptor, on their
A group of proteins that have a role in histopathology surface. This includes immune system
the immune system. Certain types of his- A branch of histology concerned with cells called CD4 lymphocytes, which
tocompatibility antigen are present on the effects of disease on the microscop- defend the body against cancerous and
every cell in the body; they are essential ic structure of tissues. infected cells, as well as certain cells in
for the immunological function of killer other tissues, such as the brain.The virus
T cells, which help to defend the body histoplasmosis multiplies within the cells, killing them
against disease. The antigens act as a An infection caused by inhaling spores in the process; the dead cells then
guide enabling the killer T cells to dis- of the fungus HISTOPLASMA CAPSULATUM, release more virus particles into the
tinguish between self and nonself and which is found in soil contaminated blood. If the virus is untreated, the num-
to kill abnormal or foreign cells. with bird or bat droppings. Histoplas- ber of CD4 lymphocytes falls. This
The main group of histocompatibility mosis occurs in parts of the Americas, results in a reduced ability to fight off
antigens is the human leukocyte anti- the Far East, and Africa. Treatment is by infections and certain types of cancer.
gen (HLA) system, which consists of intravenous infusion of antifungal drugs. HIV is extremely successful at with-
several series of antigens. There are six standing any attempt by the body to
different genes known as HLA-A, HLA-B, history-taking destroy it. Every time HIV replicates, it
HLA-C, HLA-DP, HLA-DQ, and HLA-DR. The process by which a doctor gathers changes its antigen makeup, thereby
Each of these has many different forms, information from patients regarding ensuring that it is extremely difficult for
or alleles; for example, HLA-B has over the symptoms of their illnesses and the body to mount an effective immune
40 different numbered alleles. A per- details of any previous disorders. (See response to it.
son’s tissue type (the particular set of also diagnosis.) SYMPTOMS
HLAs in the body tissues) is unique, Initially, some people who are infected
except in the case of identical twins, histrionic personality disorder with HIV may have no symptoms.
who have identical sets of HLAs. A psychiatric disorder characterized by However, between six and eight weeks
HLA analysis has some useful appli- exaggerated emotional reactions and after exposure, some people develop a
cations. Comparison of HLA types may attention-seeking behaviour. Affected flulike illness similar to glandular fever
show that two people are related, and it people also constantly demand praise or (see mononucleosis, infectious), with
has been used in paternity testing. The reassurance, and require immediate sat- fever, fatigue, sore throat, aching mus-
HLA system is also used in tissue-typing isfaction of their demands. The disorder cles, and swollen lymph nodes. These
to help match recipient and donor tis- usually first appears in early adulthood, symptoms usually clear up after a few
sues before transplant surgery. Certain and is more common in women. weeks. Some people may then develop

383
 HIVES

inhibitors, such as indinavir and lopinavir, hoarseness can result from formation of
HOW HIV MULTIPLIES and reverse transcriptase inhibitors, such as tissue on the vocal cords. In young chil-
zidovudine. These drugs can slow the dren, it may be a symptom of croup.
HIV capsule
course of the disease and may prevent the Occasionally, persistent hoarseness in
development of full-blown AIDS. adults has a more serious cause, such as
In wealthier countries, HIV infection cancer of the larynx (see larynx, cancer
is no longer necessarily a fatal disease. It of), thyroid cancer, or lung cancer.
Nucleic acid
remains life-threatening, however, and TREATMENT
Lymphocyte
the most effective strategy for defeating In cases where voice strain or laryngitis
it is prevention of infection. is the cause, resting the voice often
HIV (human immunodeficiency virus),
1 like any virus, consists of some nucleic
acid inside a capsule made of protein. The
PREVENTION
The risk of infection with HIV can most
helps recovery. If hoarseness persists for
more than two weeks, a doctor should
virus invades a lymphocyte (a type of white easily be reduced by practising safer sex. be consulted. A laryngoscopy (examina-
blood cell). Intravenous drug users should take care tion of the larynx with a mirror or
The strand of
not to share needles. Others who may be with a more specialized viewing instru-
2escapes
nucleic acid
from the
at risk, such as healthcare workers who
may come into contact with infected
ment) may be performed to exclude
any serious underlying causes.
capsule and uses body fluids or needles, should observe
H the host cell’s
resources to make
recommended safety regulations. Hodgkin’s disease
copies of itself. An uncommon cancerous disorder in
hives which there is a proliferation of cells in
Each copy An alternative name for urticaria. lymphoid tissue (which is found main-
3capsule
forms a ly in the lymph nodes and spleen). This is
and HIV test also known as a lymphoma. Men are
leaves the host
cell, which A blood test that is used to detect the affected more commonly than women.
eventually ceases presence in the blood of antibodies to The cause is unknown.
to function HIV, the virus that can lead to AIDS. SYMPTOMS AND SIGNS
efficiently in Antibodies are proteins manufactured The most common sign is the painless
fighting disease. by the immune system in response to a enlargement of lymph nodes, typically
foreign protein (antigen) in the body, in the neck or armpits. There may be a
although they may not develop for general feeling of illness, with fever,
persistent enlargement of the lymph three months after initial infection with weight loss, and night sweats. There
nodes and sometimes of the spleen, as HIV. A positive result, in which these may also be generalized itching and,
well as features of AIDS-related complex, antibodies are detected, indicates the rarely, pain in the swollen lymph nodes
such as weight loss and fever. presence of HIV. after drinking alcohol. As the disease
Minor features of infection with HIV progresses, the immune system becomes
include skin disorders such as sebor- HLA increasingly impaired.
rhoeic dermatitis. More severe features The abbreviation for human leukocyte DIAGNOSIS AND TREATMENT
include persistent herpes simplex infec- antigen. A diagnosis of Hodgkin’s disease is usu-
tions, oral candidiasis (thrush), herpes ally made by performing a biopsy
zoster (shingles), tuberculosis, and shigel- HLA types (removal of a small sample of tissue for
losis (bacterial infection of the intestine). See histocompatibility antigens. microscopic analysis) of an enlarged
HIV may also affect the brain, causing a lymph node. The identification of char-
variety of neurological disorders, includ- hoarseness acteristic cells, called Reed–Sternberg
ing dementia. A rough, husky, or croaking voice. cells, in the biopsy confirm the diagno-
If HIV infection is untreated, the Hoarseness is usually due to irritation sis. The extent of the disease (its stage)
infected person may eventually develop of, or strain on, the larynx (voicebox). can be assessed by chest X-ray, CT scan-
full-blown AIDS. In this condition, the CAUSES ning, or MRI of the abdomen and a bone
immune system is severely weakened, Short-lived hoarseness is often due to marrow biopsy. The disease can usually
resulting in severe infections caused by overuse of the voice, which strains the be cured with radiotherapy, chemotherapy,
organisms that are usually harmless as muscles in the larynx. It is also com- or a combination of the two treatments.
well as in certain types of cancer. monly caused by inflammation of the (See also lymphoma, non-Hodgkin’s.)
DIAGNOSIS, TREATMENT, AND OUTLOOK vocal cords in acute laryngitis.
HIV is diagnosed through an HIV test, a Persistent hoarseness may be due to hole in the heart
blood test that detects the presence of chronic irritation of the larynx, which can The common term for a septal defect.
antibodies (proteins manufactured by the be caused by smoking, excessive alco-
immune system) to HIV in the blood. hol consumption, chronic bronchitis, or holistic medicine
People infected with HIV should have constant dripping of mucus from the A form of therapy that treats the whole
regular monitoring in order to determine nasal passages. Polyps (harmless growths) person rather than the specific disease
when specific treatments, such as anti- on the vocal cords may also cause symptoms. A holistic approach is em-
retroviral drugs, are necessary. The main hoarseness. In people with hypothyroidism phasized by many practitioners of
types of antiretroviral used are protease (underactivity of the thyroid gland), complementary medicine.

384
 HOOKWORM INFESTATION

Holmes–Adie pupil Homeopathy is based on a principle homocystinuria

Also known as Adie’s syndrome, a dilated defined as “like cures like”. According to A rare, inherited condition caused by
pupil (the circular opening in the centre this theory, the substances that provoke a an enzyme deficiency. Homocystinuria
of the iris), usually only in one eye, that particular symptom in a healthy person is a type of inborn error of metabolism
may be irregular in shape. The pupil can also cure sicknesses that produce (see metabolism, inborn errors of) in
does not respond, or may respond only that symptom. Homeopathy involves ad- which there is an abnormal presence of
very slowly, to bright light; in addition, ministering minute doses of these homocystine (an amino acid) in the
it responds only partially when focusing substances as medicines; it is believed blood and urine. Affected people may
on different distances. The condition, that the medicinal substances become be very tall, with long limbs and fin-
which is most common in young more potent the more they are diluted. gers. Some have skeletal deformities
women, is of unknown cause and has and abnormalities of the eye lens. The
no detrimental effects. homeostasis condition is incurable, but it may be
The automatic processes by which the improved by a special diet.
Holmes–Rahe questionnaire body maintains a constant internal en-
A survey, devised in the 1960s, that is vironment despite changes within or homosexuality
used to determine the comparative outside it. Homeostasis is vital for the Sexual attraction to people of the same
stress levels caused by certain common body, because tissues and organs can sex. (See also bisexuality; heterosexuality.)
life events, such as the death of a part- only function efficiently within a nar-
ner, changes in financial or social row range of physical conditions. The homozygote H
circumstances, and serious illness. body regulates conditions such as tem- A term used to describe a person
Each potentially stressful event on the perature and acidity by means of whose cells contain two identical alleles
scale is allotted a specific score, with the negative feedback; for example, when (forms of a gene) controlling a speci-
death of a partner given the maximum the body overheats, sweating is stim- fied inherited trait. The cells of a
(100) and the other stressors ranked in ulated until the temperature returns to heterozygote contain two different alleles
order of their scores. People undergoing normal. Homeostasis also involves the controlling that trait. (See also inheri-
the test select all of the stressful events regulation of blood pressure and the lev- tance; genetic disorders.)
that apply to them from the scale, then els of natural chemicals such as glucose.
add together the scores for these stressors Homeostatic mechanisms sometimes hookworm infestation
to determine their overall stress level. malfunction. In diabetes mellitus, for An infestation of the small intestine
example, blood glucose levels can no by small, round, bloodsucking worms
Holter monitor longer be regulated properly because of of the NECATOR AMERICANUS or ANCYLO-
A wearable device used in ambulatory elec- a malfunction in insulin production. STOMA DUODENALE species. Infestation with
trocardiography (ECG) to record the heart’s
electrical activity continuously for 24
hours or longer.The monitor records this HOOKWORM LIFE-CYCLE
activity by means of electrodes attached
Infestation begins with larvae that penetrate the skin or are ingested and enter the
to the chest and allows the detection of bloodstream. They migrate throughout the body, particularly to the small intestine.
intermittent arrhythmias (irregularities in Adult worms develop and lay eggs, which leave the body in faeces and eventually
the heartbeat). (See also telecardiography.) hatch into larvae.
Holt–Oram syndrome
In t h
A genetic disorder in which there is an and the e inte
atrial septal defect (a hole in the wall gs ed. fem st
lun llow ale ine
h e swa sp s
dividing the upper chambers of the as t
an t

d
he out
up to

heart) together with various malforma-

s
ed el

lar in th
u gh trav

va e f

tions of the upper limbs, particularly of

e d aece
are co rvae

the hands and forearms.

eve
The la

lop in and hatch i ms. Eg g

homeopathy
s
to ad ult wor

A holistic system of complementary medi- Head of hookworm

cine that aims to treat the whole person The hookworm uses its
rather than only the symptoms of a sharp, curved, tooth-like
Larvaef a per
skin o

structures to cling to the

nto l

condition. Homeopathy works on the

principle that the mind and body are so bowel wall.
ar v s pro
bur son

closely linked that physical conditions

row ’s

e in uce

cannot be successfully treated without

th fee

so d
d
ro

il. by

an understanding of a person’s con- g

u

t. h th
stitution and character. The particular e
remedy chosen to give to a patient with
a condition may depend on a variety of
factors, such as the patient’s tempera-
ment, state of mind, and lifestyle.

385
 HORDEOLUM

hookworm occurs mainly in the tropics, hormone antagonist additional progestogen drug for ten to
particularly in areas where sanitation is A drug that is used to block the action 13 days of the 28-day cycle. The pro-
poor or where human faeces is used as of a hormone. gestogen drug provokes bleeding which
fertilizer for agriculture. is similar to that of menstruation.This is
The larvae enter the body by penetra- hormone replacement therapy necessary to prevent excessive thicken-
ting the skin of the feet or by ingestion. (HRT) ing of the lining of the uterus and the
They migrate throughout the body and COMMON DRUGS risk of it becoming cancerous.
grow to maturity in the small intestine. OESTROGEN DRUGS • Conjugated oestrogens Alternatively, in cases in which more
Adult worms are about 12 mm long • Estradiol • Estriol • Estrone • Estropipate than one year has passed since the
and have mouths with hooked teeth; PROGESTOGEN DRUGS • Dydrogesterone woman’s last menstrual period, contin-
they feed by attaching themselves to the • Levonorgestrel • Medroxyprogesterone uous bleed-free HRT, or a single drug
intestinal wall and sucking blood. The • Norethisterone • Norgestrel with both oestrogenic and progesto-
female worms lay eggs, which then pass OTHERS • Tibolone genic effects (such as tibolone), can be
out in the faeces. used. Women who have had a hysterec-
When larvae penetrate the skin, a red, The use of a synthetic or natural hor- tomy need only take oestrogen drugs.
itchy rash may develop on the feet. In mone to treat a hormone deficiency. Oestrogen drugs can be given in the
light infestations, there may be no fur- Most commonly, the term HRT refers to form of tablets, skin patches, gels, or
ther symptoms. However, in heavier the use of female hormones to replace implants; progestogen drugs are given
H infestations, migration of the larvae those lost after the menopause. This loss as tablets, skin patches, or vaginal gel.
through the lungs may produce cough- may occur naturally or as a result of
ing and, in some cases, pneumonia; adult treatment such as radiotherapy or the horn, cutaneous
worms in the intestines may cause removal of the ovaries. A hard, noncancerous protrusion occa-
abdominal discomfort.The most impor- BENEFITS AND RISKS sionally found on the skin of the elderly.
tant problem is iron-deficiency anaemia The benefits of HRT have to be weighed Caused by overgrowth of keratin, they
due to loss of blood. against the risks. In the short term, HRT vary in colour from yellow to brown or
Diagnosis is made by microscopic ex- relieves symptoms of oestrogen with- black.They may develop where there was
amination of the faeces for worm eggs. drawal, particularly night sweats, hot previously a wart and may grow slowly.
Anthelmintic drugs kill the worms. (See flushes, and vaginal dryness. The mini- Left untreated, they can grow consider-
also larva migrans.) mum effective dose should be used for ably; surgical removal may be advised.
the shortest duration, however.
hordeolum In the long term, HRT may give pro-
The medical name for a stye. tection against osteoporosis (the loss of
bone density that can lead to fractures).
hormonal contraception However, HRT is now only used for this
See contraception, hormonal methods of. purpose in women who are unable to
take other treatments, such as bisphos-
hormonal disorders phonate drugs; when other treatments
Conditions caused by malfunction of an have been unsuccessful; or in women
endocrine gland. who have gone through a premature
menopause (before the age of 40).
hormone Minor adverse effects of HRT include
A hormone is a chemical messenger nausea, breast tenderness, fluid reten-
Appearance of cutaneous horn
that is released into the bloodstream by tion, and leg cramps. HRT may increase The horny protuberance that has developed
a gland or tissue in order to have a spe- the risk of abnormal blood clotting; the on this woman’s face results from an overgrowth
cific effect on tissues elsewhere in the likelihood of deep vein thrombosis (see of keratin (a skin protein).
body, altering their activity. Hormones thrombosis, deep vein) and pulmonary
control a wide variety of body func- embolism developing may also increase. Horner’s syndrome
tions, including metabolism of cells, Women taking HRT have an increased A group of physical signs (such as nar-
growth, sexual development, and the risk of developing breast cancer compared rowing of the eye pupil, drooping of the
body’s response to stress or illness. to women who are not taking it, and the eyelid, and absence of sweating) affecting
Many hormones are produced by risk increases the longer it is continued. one side of the face that indicates dam-
endocrine glands. The primary function Whether or not HRT is appropriate age to part of the sympathetic nervous
of the major endocrine glands (the depends on the individual woman con- system (see autonomic nervous system).
pituitary, thyroid, parathyroid, and cerned. Women who are considering
adrenal glands and the pancreas, ovar- HRT should consult their doctor, who horseshoe kidney
ies and testes) is the production of will discuss their specific circumstances. A congenital abnormality in which the
various hormones. Hormones are also Once it has been started, the therapy two kidneys are fused at the base,
secreted by other organs (see Sources should be reviewed regularly by a doctor. forming a so-called horseshoe shape.
and effects of particular hormones table, TYPES OF HRT The joined kidneys usually function
opposite), including the brain, kidneys, In women with a uterus, HRT involves normally, but this condition may be
intestines, and, in pregnant women, taking a continuous dose of an oestro- associated with other kidney problems,
the placenta. gen drug, which is combined with an such as urinary tract infection.

386
 HORSESHOE KIDNEY

SOURCES AND EFFECTS OF PARTICULAR HORMONES

The various glands of the hormonal system constitute a parts of the body. Hormones are carried in the bloodstream
control and communications network that is complementary to their targets, where they exert their specific effects. The
to the nervous system. However, instead of using nerve table below lists the hormones that are secreted by different
impulses, the glands secrete chemical messages (in the form parts of the body and gives a description of their wide-
of hormones) to affect other glands and tissues in various ranging actions.

Gland or hormone- Hormone secreted Effects

secreting tissue

Hypothalamus Releasing or inhibiting hormones Stimulate or suppress hormone secretion by pituitary gland

Pituitary gland Growth hormone Stimulates growth and metabolism

Prolactin Stimulates milk production after childbirth
ACTH (adrenocorticotrophic hormone) Stimulates hormone production by adrenal glands
TSH (thyroid-stimulating hormone)
FSH (follicle-stimulating hormone);
Stimulates hormone production by thyroid gland
Stimulate gonads (ovaries or testes)
H
LH (luteinizing hormone)
ADH (antidiuretic hormone) Acts on kidneys to conserve water
Oxytocin Stimulates contractions of uterus during labour and milk let-down
reflex in breast-feeding
MSH (melanocyte-stimulating hormone) Acts on skin to promote production of skin pigment (melanin)

Brain Endorphins; enkephalins Alleviate pain; boost mood

Thyroid gland Thyroid hormones Increase metabolic rate; affect growth

Calcitonin Lowers level of calcium in blood

Parathyroid glands Parathyroid hormone Increases level of calcium in blood

Thymus Thymic hormone Stimulates lymphocyte development

Heart Atrial natriuretic factor Lowers blood pressure

Adrenal glands Adrenaline (epinephrine); noradrenaline (norepinephrine) Prepare body for physical and mental stress
Hydrocortisone Affects metabolism
Aldosterone Regulates sodium and potassium excretion by kidneys
Androgens Affect growth and sex drive (in both males and females)

Kidneys Renin Regulates blood pressure

Erythropoietin Stimulates production of red blood cells

Pancreas Insulin Lowers blood sugar level

Glucagon Raises blood sugar level

Placenta Chorionic gonadotrophin (HCG); Maintain pregnancy

oestrogens; progesterone

Gastrointestinal tract Gastrin; secretin; cholecystokinin Regulate secretion of some digestive enzymes

Testes Testosterone Affects development of male secondary sexual characteristics and

genital organs

Ovaries Oestrogens; progesterone Affect development of female secondary sexual characteristics

and genital organs; control menstrual cycle; maintain pregnancy

387
 HOSPICE

hospice eczema, and allergic rhinitis (see rhinits, housemaid’s knee

A hospital or part of a hospital devoted allergic) in susceptible people. Also known as prepatellar bursitis,
to the care of patients who are termi- The mites are most abundant in warm, inflammation of the fluid-filled sac that
nally ill (see dying, care of the). humid conditions. Effective control of acts as a cushion over the kneecap.
mites involves lowering air humidity;
hospitals, types of increasing ventilation; and limiting the HPV
Most of the hospitals in the UK are part habitats of mite colonies by frequent The abbreviation for human papil-
of the National Health Service. Each and thorough cleaning of critical areas, lomavirus.
NHS district has a general hospital pro- including carpets, mattresses, and bed
viding services that include medicine, frames. Placing soft toys and furnish- HRT
surgery, gynaecology, obstetrics, and pae- ings in the freezer or tumble drier is See hormone replacement therapy.
diatrics. Some more specialist services another effective method of destroying
are concentrated in fewer centres. Many the mites. (See also mites and disease.) 5HT1 agonists
of the UK’s private hospitals cater for Another name for serotonin agonists.
nonemergency surgery, obstetric care, household poisons
or inpatient care for the mentally ill. Toxins that are commonly found and used 5HT3 antagonists
in the home. Accidental poisoning with Another name for serotonin antagonists.
host such chemicals accounts for about one in
H In medical terminology, an organism, 50 of all serious domestic injuries. The HTLV
either animal (including human) or most frequent victims are young children. The abbreviation for human T-lympho-
plant, in which a parasite lives for part Swallowed household poisons com- tropic virus.
or all of its life cycle. monly include cleaning products such
as detergents, bleach, and stain remov- Hughes’ syndrome
hot abscess ers; prescription and over-the-counter A potentially serious condition, also
An abscess (a collection of pus) that is medicines (see drug poisoning); cosmet- called antiphospholipid syndrome, that is
of relatively brief duration, but which ics, including nail varnish, perfumes, characterized by an increased tendency
causes severe, painful inflammation that and skin lotions; paints, paint strippers, for the blood to clot inside the blood ves-
is red, swollen, and hot to the touch. and varnishes; and rodent bait and insec- sels (see thrombosis). The syndrome is
(See also cold abscess.) ticides. Powerful domestic chemicals, sometimes referred to as “sticky blood”.
such as oven cleaner, can cause poison- CAUSE
hot flushes ing when absorbed through the skin. Hughes’ syndrome is thought to be an
Temporary reddening of the face, neck, Vapour from aerosol sprays and autoimmune disorder, in which the
and upper trunk that is accompanied by fumes from many cleaning and DIY immune system attacks fatty molecules
a sensation of heat and is often followed products can be poisonous if they are called phospholipids, which are found
by sweating. Hot flushes are usually the inhaled, especially if they are concentra- throughout the body (particularly in cell
result of decreased oestrogen production ted within a confined space. Improperly membranes). The condition may occur
during or following the menopause, and maintained fuel-burning appliances, alone or with another autoimmune dis-
they sometimes occur following the re- such as hot-water heaters, can produce ease, such as systemic lupus erythematosus.
moval of the ovaries (see oophorectomy). carbon monoxide, a poisonous gas that is It is most common in women.
If they are severe, hot flushes can often be potentially fatal if inhaled. SYMPTOMS AND COMPLICATIONS
alleviated by hormone replacement therapy All drugs, cleaning materials, and Thrombi (clots) may form in both arter-
(HRT), but this is not advised in the long other household chemicals should be ies and veins anywhere in the body. The
term. Alternatively, they can be treated kept well out of the reach of children. legs are most commonly affected (see
with clonidine, an antihypertensive drug. Chimneys and flues, as well as heating deep vein thrombosis). In the brain, a clot
systems and gas appliances, should be can cause areas of tissue to be starved of
hot spot checked annually for carbon monoxide blood, leading to headaches, migraines,
An area of increased radionuclide uptake buildups. For extra protection, carbon and memory loss. In the lungs, they can
as seen on a radionuclide scan. A hot spot monoxide alarms can also be fitted. cause shortness of breath, chest pain, or
usually indicates an abnormal area in In the event of ingestion of a house- coughing up blood. Other possible
which there is increased activity in the hold poison, an ambulance should be symptoms include dizziness or distur-
tissue. The term may be used in relation called, the victim’s breathing and pulse bances in balance; visual disturbances;
to any radionuclide scan, but it is com- monitored continuously, and emergency and “pins and needles”.The blood vessels
monly applied to a bone scan in which first aid given if necessary (see rescue under the skin may also be affected, par-
the hot spot may indicate an abnormali- breathing; cardiopulmonary resuscitation). ticularly on the wrists and knees, causing
ty such as an infection or a tumour. Even if there are no symptoms, a doctor a red, lacy rash called livedo reticularis.
should always be consulted and pro- Clotting within an artery may lead to
house dust mite vided with as much information as life-threatening complications such as
A microscopic organism commonly possible about the ingested substance. myocardial infarction (heart attack), pul-
found in homes that may cause a variety The victim should be given nothing to monary embolism, transient ischaemic
of allergic reactions. Inhalation of dust drink, and vomiting should not be attack, or stroke. These disorders may
containing the faeces of the house-dust induced unless trained medical person- occur at an unusually young age (under
mite is a common cause of asthma, nel instruct otherwise. age 45). In pregnant women, clots may

388
 HUNGER

develop in the placenta, disrupting the ly, by killing abnormal cells, but people
blood supply to the fetus and causing tend to survive for only a few months LOCATION OF HUMERUS
miscarriage; affected women may have to a few years.
several consecutive miscarriages. Another condition associated with The humerus is the bone of the
upper arm, located between the
TREATMENT AND OUTLOOK HTLV-1 is myelopathy (spinal cord dis- shoulder and elbow joints.
Hughes’ syndrome is treated with drugs ease). This condition causes pain in the
that reduce the tendency of the blood to lower back and legs, together with pro-
Clavicle
clot: aspirin, heparin, or warfarin. Treat- gressively worsening weakness of the
ment is long-term or even lifelong, but legs and difficulty in walking.
greatly improves the outlook. It enables
people to lead a completely normal life humerus
and, in women of childbearing age, dras- The bone of the upper arm. The dome-
tically reduces the risk of miscarriage. shaped head of the bone lies at an angle
to the shaft and fits into a socket in the
human chorionic gonadotrophin scapula (shoulderblade) to form the
See gonadotrophin, human chorionic. shoulder joint. Below its head, the bone
narrows to form a cylindrical shaft,
human gamma-globulin which has a spiral groove housing the
See gamma-globulin. radial nerve (one of the main nerves in the Scapula H
arm, running from the shoulder to the
human genome hand). It flattens and widens at its lower Humerus
See genome, human. end, forming a prominence on each side
called an epicondyle. At its base, it artic-
human leukocyte antigen (HLA) ulates with the ulna and the radius (the
A protein that belongs to the group of bones of the forearm) to form the elbow. Ulna
proteins called histocompatibility antigens,
which play a role in the immune system. humerus, fracture of Radius
The humerus (upper arm bone) is most
human papillomavirus commonly fractured at its neck (the
A type of virus that is responsible for upper end of the shaft, below the head), humoral immunity
warts and genital warts.There are over 70 particularly in elderly people. Fractures of A state of protection against disease that
subtypes of human papillomavirus. At the shaft occur in adults of all ages. Frac- is brought about by the production of
least two of these subtypes are thought tures at the lower end of the humerus antibodies by the immune system to
to be a causative factor in cervical cancer occur most commonly in children. combat infection. In contrast, cellular
and anal cancer. COMPLICATIONS immunity is the direct response of lym-
Certain complications may arise if the phocytes (a type of white blood cell) to
human T-cell lymphotropic virus broken bone ends are displaced and dam- infection and abnormal cells in the body.
A type of retrovirus, also called human age surrounding tissues. A fracture in the
T-cell leukaemia virus or HTLV. There shaft of the humerus can result in dam- humours
are several types of HTLV, the most age to the radial nerve; in severe cases, A term that describes any liquid or jelly-
common of which is HTLV-1, which is this damage may lead to wrist-drop. Frac- like substance in the body. Humours
endemic in tropical regions, including tures may also be associated with damage usually refers to the aqueous humour and
southern Japan, the Caribbean, South to the brachial artery, which runs down vitreous humour that occur in the eye.
America, and West Africa. The virus can the inner side of the upper arm. If such
be transmitted by sexual contact, breast- damage goes undetected, the blood cir- hunchback
feeding, a transfusion of contaminated culation to the forearm and hand may be See kyphosis.
blood, or by intravenous drug users impaired, resulting in a deformity called
who share contaminated needles. Volkmann’s contracture. hunger
SYMPTOMS AND TREATMENT Some supracondylar fractures (breaks A disagreeable feeling caused by the
Most people who become infected with just above the elbow) fail to heal prop- need for food; it is different from
HTLV-1 have no symptoms, but a small erly despite treatment. As a result, the appetite, which is a pleasurable sensation
percentage (less than one in 20) may elbow may be deformed and there is an caused by the presence of food. Hunger
develop serious disorders. One such increased risk that osteoarthritis may occurs when the stomach is empty and
disorder is the cancerous condition subsequently develop in the joint. the blood glucose level is low, which
adult T-cell leukaemia, which may DIAGNOSIS AND TREATMENT may occur several hours after the last
appear up to 20 years after infection. In An X-ray can show a fracture of the meal or following strenuous exercise.
this disease, there is a rapid and abnor- humerus. A fracture at the neck of the In response to these stimuli, messages
mal turnover of white blood cells in the bone usually requires only a sling to from the hypothalamus in the brain cause
bone marrow and of cells in lymphoid immobilize the bone; a fracture of the the muscular stomach wall to contract
tissue. Typically, lymph nodes, the liver, shaft or lower bone normally needs a rhythmically; these contractions, if they
and the spleen are enlarged. Anticancer plaster cast. Most fractures of the are pronounced enough, can produce
drugs may halt the condition temporari- humerus heal in six to eight weeks. hunger pains.

389
 HUNTINGTON’S DISEASE

Hunger can also occur in thyrotoxicosis hyaline cartilage hyaluronic acid

(a disorder of the thyroid gland), and The most common type of cartilage. A component of connective tissue and
in diabetes mellitus when there is an Hyaline cartilage is also known as the fluid surrounding most joints (see
incorrect balance between insulin and intra-articular cartilage. This type of synovium). Synthetic hyaluronic acid can
carbohydrate intake that causes abnor- cartilage is a smooth, tough, connec- be injected into joints affected by
mally low blood glucose levels (see tive tissue that covers and protects the osteoarthritis and may help to relieve
hypoglycaemia). bone surfaces that are in contact with pain for up to six months.
each other within a joint.
Huntington’s disease hyaluronidase
An uncommon disease that causes hyaline casts A type of enzyme (a protein that regu-
degeneration of the basal ganglia Cylinders of semi-transparent matter that lates a chemical reaction in the body)
(paired nerve cell clusters in the brain). may be seen in urine viewed under a that occurs naturally in the testes, the
The disease is due to a defective gene microscope. Hyaline casts are moulded spleen, and certain other body tissues.
and is inherited in an autosomal domi- in the same shape as the kidney tubules Hyaluronidase increases tissue perm-
nant manner (see genetic disorders). and are composed of protein derived eability and is used in pharmaceutical
Symptoms of Huntington’s disease from the breakdown of cells. Although preparations to enhance the body’s
do not usually appear until age 35 to they may be present in people with kid- absorption of injected fluids.
50, although they can develop in child- ney disease, hyaline casts may also be a
H hood. The main symptoms are chorea normal finding, particularly if an indi- HyCoSy
(rapid, jerky, involuntary movements) vidual has exercised prior to giving the See hysterocontrast sonography.
and dementia (progressive mental im- urine sample.
pairment). The chorea usually affects hydatid disease
the face, arms, and trunk, resulting in hyaline membrane disease A rare infestation that is caused by the
random grimaces and twitches, and A lung condition affecting premature larval stage of the small tapeworm
clumsiness. Dementia takes the form of babies that is more commonly known ECHINOCOCCUS GRANULOSUS (see tapeworm
irritability, personality and behavioural as respiratory distress syndrome. infestation). Larvae usually settle in the
changes (including outbursts of aggres-
sive, antisocial behaviour), memory loss
(especially short-term memory), and ORIGINS OF HYDATID DISEASE
apathy. The disease progresses slowly;
affected people live for about ten to 20 The infestation is generally confined to dogs and sheep, but occasionally a child
swallows eggs from dog faeces. The worm eggs hatch into larvae, which migrate
years after the onset of symptoms. through the body, especially to the liver or lungs, to form slow-growing cysts.
At present, there is no cure for Hunt- Symptoms may not appear until years later.
ington’s disease. Treatment is aimed at
reducing symptoms with drugs; for
example, antipsychotic drugs may help to cle A child
a cy r. m
from a ay ac
control the abnormal muscle move- d in h othe dog c
ain e
eac . Th iden
ments. Speech therapy and occupational int ect ey tal
ha ly
ma inf tch pi
therapy may also be of benefit. Genetic ll y ich in
wh
ck
gs a

t
do su

testing is available for people with fami-

up rvae
o
,
nd s u

la
an in
ly members affected by the condition.
pa ni

d i the
hee tatio

ng
However, because there is no effective
est intesti
s
involv rm in fe

treatment for Huntington’s disease, this

w or nes.

may raise difficult ethical questions.

ing s

m eg
The wo

Hurler’s syndrome
gs

A rare, inherited condition caused by an

enzyme defect. The syndrome is a type of
e brain

inborn error of metabolism (see metabo-

The cys s. Th
sympto

lism, inborn errors of) in which there is an

es th

abnormal accumulation of substances

ts gr e in
m

called mucopolysaccharides in the body

ns . etim
ow fes

tissues (see mucopolysaccharidosis).

rga om
slo ta

Affected children may appear normal

eo ds
wl tio

es an

at birth; however, at six to 12 months of

ya n

th gs,
nd i s

age, they develop cardiac abnormalities,

un

ve
,l
e

no ntu er n
umbilical hernia, skeletal deformities, t p ally e liv ts i
as ca h s
and enlargement of the tongue, liver, se us o t cy
db e te t rm
and spleen. Growth is limited and men- ac k e mig ra nd fo
to a
nima The larva gans, a
r
tal development slows. If the condition ls. or other o
is diagnosed in early infancy, a bone
marrow transplant may be curative.

390
 HYDROCHLOROTHIAZIDE

liver, lungs, or muscle, causing the procedure is carried out under general
development of cysts. In rare cases, the anaesthetic (see anaesthesia, general).
brain is affected. There is a small risk that the condi-
The infestation is generally confined tion may occur in a subsequent
to dogs and sheep, but may be passed pregnancy. Women who have had a
on to humans through accidental inges- hydatidiform mole should have their
tion of worm eggs from materials levels of HCG monitored for at least two
contaminated with dog faeces. years, and should not conceive again
SYMPTOMS, DIAGNOSIS, AND TREATMENT until their HCG levels have been normal
The cysts grow slowly, and symptoms for at least one year.
may not appear for some years. In many
cases, there are no symptoms. hydralazine
Cysts in the liver may cause a tender An antihypertensive drug that is used
lump or lead to bile duct obstruction and principally as an emergency treatment Baby with hydrocephalus
The skull enlargement is due to pressure from
jaundice. Cysts in the lungs may press on for hypertension (high blood pressure). excess fluid within the cavities of the brain. To
an airway and cause inflammation; rup- Hydralazine may cause nausea, head- prevent brain damage, the fluid must be drained by
ture of a lung cyst may cause chest ache, dizziness, irregular heartbeat, loss means of a tube inserted into the skull.
pain, the coughing up of blood, and of appetite, rash, and joint pain. Taken
wheezing. Cysts in the brain may cause for the long term and in high doses, it continues to grow rapidly. Other features H
seizures. Ruptured cysts may, rarely, may cause the connective tissue disor- include rigidity of the legs, vomiting,
cause anaphylactic shock, a severe allergic der lupus erythematosus. epilepsy, irritability, lethargy, and the
reaction that can be fatal. absence of normal reflex actions. If it is
Diagnosis of hydatid disease is by CT hydramnios not treated, hydrocephalus progresses to
scanning or MRI (magnetic resonance See polyhydramnios. severe brain damage, which may result
imaging). The cysts are usually drained in death within weeks.
or removed surgically. hydration If hydrocephalus occurs later in life,
In medical terms, either the ingestion when the skull bones have fused, the
hydatidiform mole of water or the amount of water present skull is unable to expand to accommo-
An uncommon noncancerous tumour in an individual or a tissue. (See also date the extra fluid. In this situation, the
that develops from placental tissue early dehydration; rehydration therapy.) raised pressure within the skull causes
in a pregnancy in which the embryo has symptoms including headache, vomit-
failed to develop normally. A hydati- hydrocele ing, loss of coordination, and the
form mole is thought to be the result of A soft, painless swelling in the scrotum deterioration of mental function.
a chromosomal abnormality that occurs caused by the space around a testis filling In most cases, treatment of hydro-
at conception. A pregnancy in which a with fluid. A hydrocele may be caused by cephalus involves a surgical procedure in
hydatiform mole occurs is known as a inflammation, infection, or injury to the which a tube called a shunt is inserted
molar pregnancy. testis; occasionally, the cause is a tumour. into the skull. This tube enables the fluid
The mole, which resembles a bunch More often, there is no apparent cause. from the brain to drain into another part
of grapes within the uterus, is caused Hydroceles commonly occur in middle- of the body, for example, the abdominal
by degeneration of the chorionic villi – aged men, and treatment is rarely cavity, where it can be absorbed. In older
minute, finger-like projections in the necessary. If the swelling is uncomfort- children and adults, treatment is given
placenta. The cause of the degeneration able or painful, however, the fluid may be for any underlying cause of the condition,
is unknown. In a small number of withdrawn through a needle. Recurrent such as a brain tumour.
affected pregnancies, the mole develops swelling may be treated by surgery.
into a choriocarcinoma, a cancerous hydrochloric acid
tumour that can invade the walls of the hydrocephalus A strong acid released by the stomach
uterus if left untreated. An excessive build-up of cerebrospinal lining. This acid forms part of the stom-
SYMPTOMS, DIAGNOSIS, AND TREATMENT fluid within the skull. The condition ach juices and helps in the digestion
Vaginal bleeding and severe morning occurs either because too much cere- of proteins. Excessive production of
sickness generally occur in early preg- brospinal fluid is produced or because hydrochloric acid, which may be trig-
nancy and the uterus may be larger than the fluid does not drain away normally. gered by smoking or stress, can lead to
expected for the duration of the preg- The excess fluid causes an increase in irritation of the stomach lining, and is
nancy. There is no viable fetus. pressure within the skull, which may an important factor in the development
Diagnosis of a hydatiform mole is by lead to brain damage. of peptic ulcers. If the acid escapes from
ultrasound scanning, which will reveal Hydrocephalus may be congenital the stomach into the oesophagus (see
the tumour, and urine and by blood (present at birth), when it is often asso- acid reflux), it can irritate the tissues,
tests to detect excessive amounts of ciated with other abnormalities, such as causing oesophagitis and heartburn.
human chorionic gonadotrophin, or spina bifida. Or it may be a result of
HCG (see gonadotrophin, human chori- major head injury, brain haemorrhage, hydrochlorothiazide
onic), a hormone that is produced by infection (such as meningitis), or tumour. A thiazide diuretic drug that is used to
the tumour. The mole is removed by With congenital hydrocephalus, the reduce oedema (fluid retention) in peo-
emptying the uterus using suction. This main feature is an enlarged head that ple with heart failure, nephrotic syndrome

391
 HYDROCORTISONE

(a kidney disorder), and cirrhosis. It is sis, in which the obstruction develops hydrous ointment
also given for hypertension (high blood slowly, may cause no symptoms until An oil-and-water based greasy skin
pressure). Adverse effects include leg total blockage results in kidney failure. preparation that is used to treat dry or
cramps, dizziness, rash, and impotence. Hydronephrosis also increases the risk of scaling skin conditions such as eczema
The drug may, rarely, cause gout and kidney infection because bacteria can and psoriasis. Such ointment hydrates
may aggravate diabetes mellitus. multiply more easily in stagnant urine. the affected area and can provide relief
Hydronephrosis can be diagnosed from itching.
hydrocortisone using X-rays (see intravenous urography),
Also called cortisol, a hormone produced CT scanning or MRI (techniques that pro- hydroxocobalamin
naturally by the adrenal glands. Synthetic duce cross-sectional or three-dimensional A long-acting synthetic preparation of vit-
hydrocortisone is used as a corticosteroid images of body structures). Following amin B12. Hydroxocobalamin is given by
drug to treat severe allergic conditions; diagnosis, it is usually possible to relieve injection to treat disorders involving vita-
for example, it is given by injection to pressure by draining urine through a min B12 deficiency, particularly pernicious
treat anaphylactic shock. It is also used as a tube either directly onto the surface of anaemia (see anaemia, megaloblastic), in
replacement treatment when the adrenal the skin or by bypassing the blockage. which vitamin B12 cannot be absorbed
glands fail to function (see Addison’s dis- Further treatment will then be needed to from the intestines.
ease). Hydrocortisone is widely given in treat the cause of the blockage.
the form of a cream or ointment, to treat If the blockage can be removed surgi- hydroxyapatite
H inflammatory skin conditions, such as cally, the kidney is likely to function A complex crystalline form of calcium
heat rash, and is effective at reducing normally again. Occasionally, however, a phosphate that occurs naturally in the
itching; however, used to excess, hydro- kidney is so badly damaged that it body as a major component of bones and
cortisone creams may cause thinning of requires removal (see nephrectomy). teeth. A synthetic form of hydroxyapatite
the skin, wrinkles or loss pigmentation. is used as a calcium supplement to reduce
hydrophobia bone loss when the intake of dietary cal-
hydrogen peroxide A popular term, now almost obsolete, cium is inadequate.
A substance used as mild antiseptic sol- for rabies.
ution or cream to treat infections of the 5-hydroxytryptamine
skin or mouth, or used to bleach hair. hydrops Another name for serotonin.
Hydrogen peroxide combines with cata- An abnormal accumulation of fluid in a
lase, an enzyme present in the skin and body tissue (see oedema), cavity, or sac hydroxyzine
mouth, to release oxygen. This reaction (a baglike body structure). A sedating antihistamine drug used to
kills bacteria. Solutions used to treat the relieve itching and, occasionally, in the
skin and mouth usually contain three hydrops fetalis treatment of anxiety.
per cent hydrogen peroxide; those used Serious oedema (swelling of the body
for bleaching hair are stronger. Occa- tissues) that occurs in a fetus before hygiene
sionally, solutions containing hydrogen birth. Hydrops fetalis is often the result The science and practice of preserving
peroxide may irritate the skin. of Rhesus incompatibility (see haemolyt- health.The word “hygiene” is commonly
ic disease of the newborn). In pregnant used of personal cleanliness. It can also
hydronephrosis women who are affected by Rhesus refer to public health – the scientific study
A condition in which a kidney becomes incompatibility, additional ultrasound of various environmental influences on
swollen with urine due to an obstruc- scanning may be carried out to detect health, such as safe sanitation and good
tion in the urinary tract. The excess urine any swelling and help doctors to deter- housing. The terms “industrial hygiene”
causes pressure to build up inside the mine whether any treatment will be and “occupational hygiene” refer to the
kidney and prevents it from functioning necessary for the fetus. scientific discipline of assessing and regu-
normally. Hydronephrosis may affect lating the work environment in order to
one or both kidneys. hydrotherapy prevent occupational disease and injury.
In some cases, hydronephrosis may be A form of physiotherapy in which exercis-
due to a congenital narrowing of the ure- es are performed in water to aid recovery hygiene, oral
ter. In other cases, the obstruction of a from injury or to improve mobility. See oral hygiene.
ureter may be caused by a stone (see cal- Hydrotherapy includes the use of exer-
culus, urinary tract), a kidney tumour, or a cise pools, whirlpool baths, and showers. hygroma, cystic
blood clot. Occasionally, hydronephrosis People who cannot bear their full A lymphangioma (a type of noncancerous
is caused by obstruction to the outflow body weight on a limb (such as people tumour) that occurs around the head
of urine from the bladder by an with arthritis or those who have frac- and neck, the armpits, or the groin and
enlarged prostate gland (see prostate, tured a limb) may undergo exercises in contains clear fluid. Cystic hygromas are
enlarged) in men, or by enlargement of a hydrotherapy pool. The buoyancy of usually present from birth, reach their
the uterus in pregnant women. In such the water supports the person’s body; in maximum size by the time the child is
cases, both kidneys are affected. addition, the water provides gentle about two years old, then gradually dis-
Acute hydronephrosis, in which there resistance that helps to improve muscle appear. The tumour may be surgically
is a sudden blockage of the ureter, causes strength. Warm whirlpool baths can also removed if it is obstructing the airway,
severe pain in the abdomen and the provide a gentle massage to stimulate but the final appearance is usually better
small of the back. Chronic hydronephro- areas of the body and relieve stiffness. if surgery can be avoided.

392
 HYPERBILIRUBINAEMIA

hyper- inflammatory reaction in which the

LOCATION OF HYMEN A prefix that is placed before a word to flow of blood to a particular area
mean “above”, “excessive”, or “greater increases; for example, around a wound
The membrane that forms the hymen
than normal”. or an insect bite. The skin over the
surrounds the opening to the vagina,
inside a woman’s labia minora. affected area may be warm and red.
hyperacidity
A condition in which excess acid is hyperaesthesia
produced by the stomach. Hyperacidity The medical term for an extreme sensi-
Labia majora is often confused with acid reflux or tivity of the skin to normal stimuli,
Clitoris
waterbrash. It occurs in people who have such as touch.
Urethra
a duodenal ulcer (see peptic ulcer) or
Vaginal
Labia minora
Zollinger–Ellison syndrome. hyperaldosteronism
Hymen
entrance An alternative term for aldosteronism, a
hyperactivity metabolic disorder caused by overpro-
A behaviour pattern in which children duction of the hormone aldosterone by
Anus
are overactive and have difficulty in con- the adrenal glands.
centrating. The occasional occurrence of
such behaviour in small children is con- hyperalimentation
sidered to be normal. If a child exhibits Administration of increased amounts H
persistent hyperactivity, however, and of nutrients. Hyperalimentation is usual-
hymen other possible causes (such as a stressful ly given intravenously or through a
The thin membrane around the vaginal home environment or physical illness) stomach tube (see feeding, artificial).
opening. The hymen has a central perfo- have been eliminated, he or she may have
ration which is usually stretched or torn a condition known as attention deficit hyperbaric oxygen treatment
by the use of tampons or during first hyperactivity disorder (ADHD). Assessment A procedure designed to increase the
sexual intercourse. by a paediatrician is needed before a amount of oxygen in the tissues. This
Imperforate hymen is a rare condi- decision on treatment is made. increase is achieved by placing a person
tion in which the hymen has no in a special chamber and exposing him
perforation; as a result, at the onset of hyperacusis or her to oxygen at a much higher
menstruation, menstrual blood collects An excessively sensitive sense of hear- atmospheric pressure than normal.
in the vagina, causing lower abdominal ing. In people who have hyperacusis, Hyperbaric oxygen treatment is used
pain. The condition is easily corrected exposure to loud noises may cause pain to treat any condition in which the
by a minor operation. or discomfort in the ears. body tissues are deprived of oxygen.
For example, it is used to treat carbon
hyoid hyperaemia monoxide poisoning; in this condition,
A small, U-shaped bone that is situated Excess blood in part of the body. Hyper- carbon monoxide attaches to haemo-
centrally in the upper part of the neck. aemia can occur if the outflow of blood globin (the oxygen-carrying pigment in
The hyoid bone is not joined to any other from an area is blocked. The condition red blood cells), preventing the blood
bone but is suspended by ligaments from more commonly arises due to an from carrying sufficient oxygen to the
the base of the skull. It provides an tissues. The treatment is also used for
anchor point for the muscles of the people with decompression sickness due
tongue and for the muscles of the LOCATION OF HYOID BONE to activities such as diving. In addition,
upper front part of the neck. The hyoid the treatment may be used for people
The U-shaped hyoid bone provides
bone may be fractured as a result of an anchor for the muscles at the
who have suffered severe soft tissue
deliberate strangulation. back of the tongue. injuries, such as deep burns and crush
injury, in which oedema (a buildup of
hyoscine fluid in the tissues) hinders the passage
An anticholinergic drug prescribed in two of oxygen from the blood to the tissues.
distinct forms: hyoscine butylbromide Another use for hyperbaric oxygen
which is used to relieve the symptoms treatment is to treat gas gangrene. This
of irritable bowel syndrome, and hyoscine condition is caused by bacteria that
hydrobromide, which is used to control thrive in an oxygen-free environment;
motion sickness. Hyoscine hydrobromide Muscles the bacteria cannot survive once oxygen
eye-drops may be given to dilate the of tongue is supplied to the affected tissues. The
pupil before an eye examination or use of hyperbaric oxygen in the treat-
surgery. An injection of hyoscine hydro- ment of multiple sclerosis has not been
bromide may be given as part of a shown to be effective.
premedication because it dries secretions Hyoid bone
in the mouth and lungs. hyperbilirubinaemia
Possible adverse effects of both forms A raised level of bilirubin (a breakdown
of the drug include a dry mouth, blur- product of red blood cells) in the
red vision, drowsiness, and constipation. blood. Mild hyperbilirubinaemia may

393
 HYPERCALCAEMIA

be undetectable except by a blood test, of LDL receptors, which remove choles- or anxiety. In some cases it is due to an
but if the blood bilirubin rises to twice terol from the bloodstream. (See also infection, thyrotoxicosis, hypoglycaemia,
the normal level, jaundice develops. hyperlipidaemias.) or a nervous system disorder. Usually,
however, it has no known cause and
hypercalcaemia hyperemesis begins at puberty, disappearing by the
An abnormally high level of calcium in The medical term for excessive vomiting. person’s mid-20s or early 30s.
the blood. Hypercalcaemia may be a Hyperemesis may cause dehydration If hyperhidrosis in a particular area,
result of hyperparathyroidism (overpro- and weight loss. such as the armpits, is persistent and
duction of parathyroid hormone, a The condition may occur during cannot be controlled by antiperspirants,
substance that normally helps to control pregnancy, when it is known as hyper- surgery may be considered to destroy
the level of calcium in the blood). emesis gravidarum. Unlike morning the nerve centres that control sweating
Cancer may also cause hypercalcaemia, sickness, the vomiting is so severe that in that area (see sympathectomy).
either by spreading to the bones or by the affected woman cannot keep down
producing abnormal hormones that any food or fluid. The cause is not hyperkalaemia
cause the bones to release calcium. Less known, but a contributing factor is Abnormally high blood levels of potassi-
commonly, the condition occurs as a thought to be an excess of the hormone um, often due to failure of the kidneys
result of intaking excessive amounts of human chorionic gonadotrophin (HCG), to excrete it. Hyperkalaemia can lead to
vitamin D or of certain inflammatory dis- which is due to the existence of more a fatal heart irregularity if severe.
H orders, such as sarcoidosis. than one fetus or to a hydatidiform mole.
SYMPTOMS Psychological stress may aggravate the hyperkeratosis
Hypercalcaemia causes nausea, vomit- symptoms. If left untreated, hypereme- Thickening of the skin’s outer layer due
ing, lethargy, depression, thirst, and sis gravidarum may be life-threatening to an increased amount of keratin, a
excessive urination. Higher blood levels for the mother and fetus. (See also vom- tough protein that is the major com-
of calcium produce confusion, extreme iting in pregnancy.) ponent of the outer skin layer. The most
fatigue, and muscle weakness. If the dis- common forms of hyperkeratosis affect
order is left untreated and the calcium hyperglycaemia small, localized areas of skin and in-
levels continue to rise, hypercalcaemia An abnormally high level of glucose in clude corns, calluses, and warts. A rare,
can be extremely serious, causing car- the blood that occurs in people with inherited form affects the whole of the
diac arrhythmias (irregularities of the untreated or inadequately controlled soles and palms.The term “hyperkerato-
heartbeat), kidney failure, coma, and may diabetes mellitus. Hyperglycaemia may sis” may also be used to describe
even lead to death. also occur in people with diabetes as a thickening of the nails.
Long-standing hypercalcaemia may result of an infection, stress, or surgery.
cause nephrocalcinosis (calcification of Features of hyperglycaemia include hyperlipidaemias
the kidney) or kidney stones (see calcu- the passing of large amounts of urine, A group of metabolic disorders that are
lus, urinary tract). thirst, glycosuria (glucose in the urine), characterized by high levels of lipids
DIAGNOSIS, AND TREATMENT and ketosis (accumulation in the body (fats) in the blood.
Diagnosis is by blood tests to measure of organic substances called ketones). If CAUSES
the blood level of calcium and further it is severe, hyperglycaemia can lead to Some hyperlipidaemias are inherited,
tests to help reveal the cause. Treatment confusion and coma, which requires resulting from inheritance of an abnor-
involves rehydration and, if necessary, emergency treatment with insulin and mal gene (unit of hereditary material).
reduction of dangerously high calcium intravenous infusion of fluids. Hyperlipidaemias may also be associ-
levels with drugs such as bisphospho- ated with another disorder, such as
nate drugs or corticosteroid drugs. At the hypergonadism hypothyroidism (underactivity of the
same time, the underlying cause is Overactivity of the gonads (testes or thyroid gland), diabetes mellitus, kidney
treated if possible. ovaries) that results in overproduction failure, or Cushing’s syndrome (high lev-
of androgen hormones or oestrogen hor- els of corticosteroid hormones in the
hypercapnia mones. Hypergonadism may be caused blood). Sometimes they may result
An excess of carbon dioxide in the by disorders of the gonads or a disorder from the use of corticosteroid drugs.
blood. The condition is caused by fail- of the pituitary gland that results in over- Hyperlipidaemias are classified accord-
ure of internal mechanisms, such as production of gonadotrophin hormones. ing to which forms of lipids have
breathing rate, that normally control If hypergonadism develops during child- elevated levels in the blood. Lipids are
blood carbon dioxide levels. Hypercap- hood, it results in premature sexual carried in the blood in several forms,
nia leads to respiratory acidosis. development (see precocious puberty) principally cholesterol and triglycerides
and excessive growth. in the form of lipoproteins (lipid mol-
hypercholesterolaemia ecules linked to protein molecules).
A condition in which there is an hyperhidrosis Lipoproteins are classified according to
increased concentration of cholesterol in A term used to describe excessive sweat- their density, which depends on their
the blood. Hypercholesterolaemia is ing. Hyperhidrosis may be localized relative proportions of cholesterol and
thought to be associated with high lev- (affecting only the armpits, feet, palms, protein: the higher the proportion of
els of low density lipoprotein (LDL) in the or face), or it may affect all body areas cholesterol, the lower the density of the
blood; the condition may be caused by supplied by sweat glands. The condition lipoprotein. Elevated levels of low density
a genetic defect in which there is a lack may be caused by hot weather, exercise, lipoproteins (LDLs) and very low density

394
 HYPERPARATHYROIDISM

lipoproteins (VLDLs) contribute to hyp- hypermagnesaemia Hypermetropia is caused by the eye

erlipidaemias. High density lipoproteins An abnormally high level of magnesium being too short from front to back,
(HDLs) are not involved. in the blood. The most common cause which results in images not being clearly
RISKS AND SYMPTOMS of hypermagnesaemia is kidney failure, focused on the retina. The error is pre-
Hyperlipidaemias are associated with an although the condition may also be sent from birth, but symptoms do not
increased risk of atherosclerosis (nar- caused by excessive magnesium intake; generally appear until later life because
rowing of the arteries as a result of fatty hypothyroidism (underactivity of the thy- the focusing power of accommodation,
deposits) and coronary artery disease. roid gland); Addison’s disease; and it which compensates for hypermetropia,
The symptoms depend on the partic- may be associated with hypercalcaemia. declines with age.
ular type of hyperlipidaemia; they may Hypermagnesaemia may lead to lethar- Glasses or contact lenses with convex
include fatty yellow nodules in the skin gy, weakness, and irregularities with the lenses reinforce focusing power.
on the back of the hands, on the ten- electrical activity of the heart. As levels
dons around the ankles and on the wrist of magnesium increase, the condition hypernephroma
joints; a white line around the rim of may result in coma. Treatment of hyper- A type of kidney cancer, also known as
the cornea; and abdominal pain. magnesaemia is of the underlying cause. renal cell carcinoma.
DIAGNOSIS AND TREATMENT
A diagnosis is made using blood tests. hypermetropia hyperparathyroidism
Treatment is designed to reduce blood Commonly known as longsightedness, Overproduction of parathyroid hor-
lipid levels, usually by means of weight hypermetropia is an error of refraction mone (PTH) by the parathyroid glands. H
loss, a low-fat diet, and lipid-lowering (the focusing of light rays within the Normally, PTH, together with vitamin D
drugs. Early treatment can reduce the eye) that initially causes difficulty in and another hormone called calcitonin,
risk of a heart attack. There is no known seeing near objects and goes on to controls the level of calcium in the body.
cure for inherited hyperlipidaemias. affect distance vision. The condition An excess of PTH raises the level of cal-
(See also hypercholesterolaemia.) tends to run in families. cium in the blood (see hypercalcaemia)

HYPERPARATHYROIDISM

In this disorder, the parathyroid glands produce too much and calcinosis (the formation of calcium deposits in
parathyroid hormone. Symptoms, signs, and complications of different tissues). Surgical removal of abnormal parathyroid
the disorder occur as a result of an increased calcium tissue is carried out to prevent complications.
level in the blood and urine, the loss of calcium from bones,

Brain Joints and soft tissues

Hypercalcaemia may Calcinosis may occur
cause depression, (for example, in joints)
abnormal behaviour, and may cause an Tendon
personality disturbance, inflammatory
drowsiness, fatigue, condition called
Urinary tract excessive thirst, pseudogout (a type Ligament
Excess calcium in confusion, seizures of arthritis). Muscle
the blood and or coma. weakness may
urine may greatly also develop.
increase urine
output, lead to
urinary tract Parathyroid Muscle
Calculus calculi, and cause glands
in kidney kidney failure.

Pancreas Duodenum Obstruction

Thinning
of bone

Femur Bone weakens

and breaks

Bone Gastrointestinal tract

The loss of calcium from bone leads to Nausea, vomiting, constipation, abdominal
weakening of the bones. As a result of pain, and flatulence may occur as a result
this condition, a minor fall may lead to a of hypercalcaemia. There is also a risk of
fracture. The abnormal bone structure pancreatitis or of the formation of a peptic
caused by calcium loss shows up on X-ray. ulcer in the duodenum.

395
 HYPERPHOSPHATAEMIA

by removing calcium from bones. This aemia is the formation of calcium phos- in various tissues. On second exposure,
activity can lead to bone disorders, such phate crystals in the blood and soft the antigen and antibodies combine,
as osteoporosis. In an attempt to bring tissue. This can cause arteriosclerosis, causing the mast cells to disintegrate
the high calcium level back to normal, which may lead to myocardial infarction and release chemicals that cause the
the kidneys excrete large amounts of (heart attack) or stroke. Treatment is of symptoms of asthma, allergic rhinitis
calcium in the urine, which can lead to the underlying cause. (hay fever), urticaria (nettle rash), ana-
the formation of kidney stones (see cal- phylactic shock (a severe allergic reac-
culus, urinary tract). hyperpigmentation tion), or other allergic illnesses.
CAUSES Abnormally dark coloration of the skin. TYPE II
Hyperparathyroidism is most often Hyperpigmentation is usually seen in In type II reactions, antibodies bind to
caused by a small noncancerous tumour scar tissue and damaged areas of skin, antigens on the surfaces of cells in
of one or more of the parathyroid such as in areas affected by acne. The particular tissues, leading to possible
glands, in which case is known as pri- condition results in permanent changes destruction of those cells. Type II reac-
mary hyperparathyroidism. This usually in skin colour and is more obvious in tions may lead to certain autoimmune
develops after the age of 40 and is darker skin. Hyperpigmentation is also disorders (in which antibodies attack
twice as common in women as in men. a feature of Addison’s disease. the body’s own tissues). They may also
Hyperparathyroidism may also occur be responsible for some cases of haemol-
when all the glands become enlarged hyperplasia ysis (destruction of red blood cells)
H for no known reason. It may also deve- Enlargement of an organ or tissue due triggered by certain drugs.
lop in response to a condition that to an increase in the number of its cells. TYPE III
causes abnormally low levels of cal- However, unlike the cells of a tumour, In type III reactions, antibodies com-
cium, such as chronic kidney failure, in the new cells are normal. Hyperplasia is bine with antigens to form particles
which case it is known as secondary usually the result of hormonal stimula- known as immune complexes. These
hyperparathyroidism. tion. It may occur normally (such as in particles lodge in various tissues and
SYMPTOMS the enlargement of breast tissue in activate further responses form the
Hyperparathyroidism may cause mus- pregnancy) or it may indicate a disor- immune system, leading to tissue dam-
cular aches and pains, depression, and der. (See also hypertrophy.) age. This type of reaction is responsible
abdominal pain. Often however, the for serum sickness, allergic alveolitis (a
only symptoms are those that are hyperplasia, gingival lung disease caused by exposure to the
caused by kidney stones. If hypercal- Abnormal enlargement of the gums. spores of certain fungi), and the large
caemia is severe, there may be nausea, Causes include gingivitis (inflammation swellings that sometimes form after a
tiredness, excessive urination, confu- of the gums), ill-fitting dentures, persis- person has a booster vaccination.
sion, and muscle weakness. tent breathing through the mouth, and TYPE IV
DIAGNOSIS AND TREATMENT taking the anticonvulsant drug pheny- In type IV reactions, sensitized T-lympho-
The condition is diagnosed by X-rays of toin. Surgical treatment may be needed. cytes (a class of white blood cell) bind to
the hands and skull and by blood tests to antigens and release chemicals known
measure levels of calcium and PTH. hyperpyrexia as lymphokines, which promote an in-
If the hyperparathyroidism is only A term used to refer to extremely high flammatory reaction. Type IV reactions
mild, no treatment may be needed; body temperature (see hyperthermia). are responsible for contact dermatitis and
instead, the affected person’s blood cal- the rash that occurs in measles; they
cium levels and kidney function will be hypersensitivity may also play a part in some “allergic”
monitored annually. More serious cases Overreaction of the immune system reactions to drugs.
may need treatment with drugs to (defence against infection) to an antigen TREATMENT
lower the blood calcium levels. If a (a protein that is recognized as foreign). Treatment of hypersensitivity depends
parathyroid tumour is found, the affect- Hypersensitivity reactions occur only on the type, cause, and severity. When
ed gland will be surgically removed; on second or subsequent exposures to possible, exposure to the offending
this usually cures the condition. If the particular antigens, after the first expo- antigen should be avoided.
remaining tissue is unable to produce sure has sensitized the immune system.
enough PTH, treatment for hypoparathy- Such reactions have the same mecha- hypersplenism
roidism (underactivity of the para- nisms as those of protective immunity; Overactivity of the spleen that results in,
thyroid glands) is required. however, while the latter may protect and which is associated with, blood
against disease, hypersensitivity reac- disease. One of the functions of the
hyperphosphataemia tions lead to tissue damage and disease. spleen is to break down blood cells as
An abnormally high level of phosphates There are four main types of hyper- they age and wear out. An overactive
in the blood. Hyperphosphataemia is sensitivity reaction. spleen may begin to destroy cells
usually caused by decreased phosphate TYPE I regardless of their age and condition,
excretion as a result of impaired kidney Type I is associated with allergy. After causing a deficiency of any of the types
function or kidney failure. It may also first exposure to an antigen (which may of blood cell. In most cases, the spleen
be associated with hypoparathyroidism be a harmless substance such as grass will also be enlarged.
(underactivity of the parathyroid gland) pollen), antibodies (substances that can If the condition occurs for no reason
or hypocalcaemia (low blood calcium recognize and bind to the antigen) are it is called primary hypersplenism. More
levels). A side effect of hyperphosphat- formed. These antibodies coat mast cells commonly, however, it is secondary to

396
 HYPERTENSION

another disorder, such as Hodgkin’s dis-

ease or malaria. in which the spleen has HYPERTENSION
become enlarged.
Hypertension (high blood pressure)
Signs of hypersplenism include anae- affects ten to 20 per cent of adults in
mia and thrombocytopenia (deficiency of Stress
the UK. It is diagnosed if a person’s
platelets). There may also be decreased resting blood pressure is persistently
resistance to infection. Primary hyper- raised. Blood pressure is expressed Nerve signals
splenism is treated with splenectomy by two values – the systolic and
(removal of the spleen). Treatment of diastolic pressures – and measured in
secondary hypersplenism is aimed at millimetres of mercury.
control of the cause. Although hypertension rarely causes
symptoms, it is a serious condition.
hypertension It may cause excessive strain on the
Persistently raised blood pressure (the arteries. Left untreated, it increases the
risk of stroke and other disorders. In
pressure of blood in the main arteries).
many cases there is no obvious cause
Blood pressure goes up temporarily as a for hypertension, but in some people Stress and hypertension
normal response to stress and physical there is a specific cause, such as a Acute stress or pain act on the nervous system,
activity, and it rises naturally with in- causing blood vessels to constrict and the heart
creasing age and weight. A person with
kidney disorder, pregnancy, or the use
of oral contraceptives. Hypertension
to work harder. Both lead to a brief rise in blood
pressure. Hence, pressure should be measured
H
hypertension, however, has persistently is linked to obesity and, in some when a person is relaxed. It is possible (but
high blood pressure even when at rest. people, to a high salt intake. Smoking unproven) that frequent stress may eventually
Because the condition itself causes no compounds the risks of the condition. cause hypertension.
symptoms, a large number of people Fatty
deposits Atheroma
have hypertension without realizing it; Hypertension and Normal active People with
however, because hypertension causes atherosclerosis, in people hypertension
the risk of developing serious cardio- which arteries are

Prevalence
vascular disorders to increase, regular narrowed by fatty
medical checks are advised in order to deposits called
atheroma (left), are Obese
detect the condition at an early stage. closely linked both people
Hypertension is very common, particu- to each other and
larly in men, and its incidence is to obesity.
highest in the middle-aged and elderly. Contracted
Blood pressure is measured as two muscle Low Medium High
values, each expressed as millimetres Constriction Blood pressure
(mm) of mercury (chemical symbol Factors such as
Hg) or mmHg. The systolic value (the nicotine in tobacco Variation in blood pressure
cause constricted In any population, blood pressure varies over a wide range
higher value) is the pressure when arteries (left) and in the same way as height. Many people are considered to
blood surges into the aorta from the a short-term rise be hypertensive because they are at the top end of this
heart; the diastolic value is the pressure in blood pressure range (see above). In obese people, the range is similarly
when the ventricles (lower chambers that may worsen wide but shifted towards the top end: hence, more obese
of the heart) relax between beats. A Artery wall hypertension. people are hypertensive.
blood pressure consistently exceeding
about 140 mmHg (systolic) and 90 COMMON FACTORS AND PREVENTIVE MEASURES
mmHg (diastolic) at rest is defined as
hypertension. Factors • Age (incidence higher in the elderly)
SYMPTOMS AND COMPLICATIONS
associated with • Family history of the condition
essential • Gender (incidence higher in men than in women)
Hypertension is usually symptomless, hypertension
and generally goes undiscovered until
detected during a routine physical Factors that may • Smoking • Obesity • Excess alcohol intake
examination. However, if it is severe or aggravate • Diabetes mellitus • High salt intake
accelerated (see malignant hypertension) hypertension
it may cause headaches, breathlessness,
and visual disturbances. The condition Self-help and • Regular screening of blood pressure is important for early
puts considerable strain on the heart treatment diagnosis and can help to prevent complications.
and blood vessels, increasing the risk of • Sufferers from essential hypertension should:
stroke, coronary artery disease, and heart Reduce weight; Not smoke; Reduce or stop alcohol intake
failure. Hypertension may eventually lead Reduce salt intake; Take regular exercise; Learn relaxation.
to kidney damage and retinopathy (dam-
age to the retina at the back of the eye). • Antihypertensive drugs, prescribed by a doctor, can usually
keep high blood pressure under control.
CAUSES
In many cases, there is no obvious
cause, in which case the condition is

397
 HYPERTENSION, MALIGNANT

called essential hypertension. Genetic the patient is monitored by having reg- The patient’s body temperature rises
factors are important, although hyper- ular blood pressure checks, so that soon after the anaesthetic is given,
tension is not attributed to a specific adjustments to drug type or dosage can sometimes as high as 42°C (107.6°F).
gene. Other factors that are associated be made if necessary. It may be possible At the same time, large amounts of lac-
with hypertension include high alcohol for the patient to monitor his or her tic acid pass from the muscles into the
intake, a high-salt diet, obesity, diabetes own blood pressure at home, but the blood, causing acidosis and possibly
mellitus, a sedentary lifestyle, and smok- individual’s machine should be checked leading to kidney damage. There are
ing.There is also evidence that low birth regularly and calibrated against the doc- signs of greatly increased metabolism,
weight increases the risk of developing tor’s machine. such as an increase in heart rate and
hypertension in later life. In many cases, drug treatment must breathing rate. The muscles stiffen and
If hypertension results from a specific continue for life, but this may help to the patient turns blue (see cyanosis).
disorder, the condition is known as sec- extend life expectancy significantly. (See Without emergency treatment, seizures
ondary hypertension. Causes include also intracranial hypertension, benign; por- and death may follow rapidly.
various kidney disorders; certain disor- tal hypertension; pulmonary hypertension.) Malignant hyperthermia may be sus-
ders of the adrenal glands; pre-eclampsia pected if a patient does not relax
(a complication of pregnancy); coarcta- hypertension, malignant normally in the early stages of anaesthe-
tion of the aorta (a congenital heart See Malignant hypertension. sia. If it occurs, the anaesthetic is
defect); and the use of certain drugs. stopped immediately and the patient’s
H Taking the combined contraceptive pill hypertensive arteriosclerosis body is cooled with ice packs. Oxygen
(see oral contraceptives) can lead to Thickening and loss of flexibility in the and repeated intravenous injections of
hypertension in susceptible women. walls of arteries (see arteriosclerosis) as dantrolene sodium are given until the
DIAGNOSIS a result of persistent hypertension (high body temperature returns to normal.
The patient’s blood pressure is mea- blood pressure). The patient will also receive care in an
sured at rest on several occasions in intensive care unit.
order to make a diagnosis. If there is hypertensive encephalopathy If a person is known to be susceptible
any doubt, an ambulatory blood pres- A variety of symptoms, including head- to malignant hyperthermia, or has a
sure device is fitted to monitor blood ache, seizures, and loss of consciousness, family history of the condition, the
pressure over a 24 hour period. This caused by malignant, or accelerated, anaesthetist must be informed before
may detect a condition known as white hypertension (high blood pressure). (See any surgical procedure, even if the pati-
coat hypertension, in which blood pres- also encephalopathy.) ent has previously undergone general
sure is raised during a test by a doctor, anaesthesia with no problems. The pati-
but it is otherwise normal and does not hypertensive retinopathy ent may be given dantrolene sodium
require treatment. The eyes may also be Damage to the retina (the light-sensitive before surgery to prevent hyperthermia.
examined for evidence of longstanding layer at the back of the eye) caused by
hypertension. If secondary hyperten- persistent hypertension (high blood hyperthyroidism
sion is suspected, blood tests, X-rays, and pressure) affecting the blood vessels in Production of excess thyroid hormones
other appropriate tests are carried out the eyes. Any changes visible in the reti- by an overactive thyroid gland (speeding
to exclude any potential causes. na reflect those occurring in small up body functions). The most common
TREATMENT blood vessels throughout the body. form of hyperthyroidism is Graves’ dis-
With mild to moderate hypertension, if Examination of the retina is therefore ease, which is an autoimmune disorder
no underlying cause is found, lifestyle important in the assessment of hyper- (in which the immune system attacks
changes are recommended as the first tension. (See also retinopathy.) the thyroid tissue). Less commonly, the
line of treatment. For example, smokers condition is associated with enlarged
should give up their habit and drinkers hyperthermia nodules in the thyroid gland.
should reduce their consumption of A medical term for very high body tem- SYMPTOMS AND SIGNS
alcohol. Any overweight person with perature. The characteristic signs of hyperthyroid-
hypertension should try to lose weight ism include increased appetite, weight
by modifying the diet and introducing hyperthermia, malignant loss, increased sweating, heat intolerance,
gradually increasing amounts of exercise Also known as malignant hyperpyrexia, rapid heart rate, and protruding eyes (in
into the daily routine. Biofeedback train- a sudden rise in body temperature to a people with Graves’ disease). In severe
ing and relaxation techniques can also dangerously high level, which is brought cases, the thyroid gland often becomes
help to reduce blood pressure. on by general anaesthesia (see anaesthe- enlarged (see goitre) and there is physi-
If self-help measures have no effect, sia, general). The condition is caused by cal and mental hyperactivity and muscle
or if hypertension is severe, antihyper- exposure to inhaled anaesthetics such as wasting (see Symptoms and signs of hyper-
tensive drugs may be given. There is a halothane and enflurane, or to the mus- thyroidism box, overleaf).
large range of drug treatments available cle-relaxant drug succinylcholine. In most DIAGNOSIS, TREATMENT, AND OUTLOOK
and the treatment chosen depends on cases, susceptibility to malignant hyper- The diagnosis of hyperthyroidism is
the presence of other disorders, such as thermia is inherited, with an autosomal confirmed by measuring the level of
diabetes mellitus. The response of the dominant pattern of inheritance (see thyroid hormones present in the blood.
condition to treatment, as well as any genetic disorders). People with certain The condition can be treated with drugs
side effects it has provoked, may muscle disorders may also be at risk. that inhibit the production of thyroid
prompt a change of treatment. Usually, The condition is rare. hormones (see antithyroid drugs) or by

398
 HYPERTROPHIC PULMONARY OSTEOARTHROPATHY

SYMPTOMS AND SIGNS OF HYPERTHYROIDISM

Hyperthyroidism (oversecretion of One form of the condition, called

thyroid hormones) produces a range of Graves’ disease, may cause HYPERTHYROID HEART RATE
symptoms associated with overactivity bulging eyes. In severe cases of
of the body’s metabolism. Early signs hyperthyroidism, the thyroid gland is Excessively high levels of thyroid
of the condition include weight loss, often enlarged, causing a visible hormones may speed up the heart
increased appetite, intolerance to heat, swelling (goitre) in the neck, and there rate and may also cause an irregular
and increased sweating; there may tends to be physical and mental heart rhythm.
also be tremors and a rapid heart rate. hyperactivity and muscle wasting.
Protruding eyes
This symptom (known as
exophthalmos) affects
30–50 per cent of people Healthy heartbeat
with Graves’ disease. This diagram of an ECG trace shows a normal
heart rate and rhythm.

Thyroid gland enlargement

This symptom (known as goitre) may be
due to hyperthyroidism; however, it may
also be associated with hypothyroidism H
(underactivity of the thyroid gland). Hyperthyroid heartbeat
This trace shows the fast, irregular rate and
rhythm seen in hyperthyroidism.
Muscle wasting
Severe hyperthyroidism may cause
wasting of both skeletal and heart muscle.

Increased appetite
This symptom is a result of metabolic Appearance of exophthalmos
overactivity, causing increased energy use.
In people with Graves’ disease, overactivity of the
Despite increased appetite, the affected
person may lose weight. thyroid may cause swelling of the tissues around one
or both eyes, resulting in a staring appearance.

the removal of part of the thyroid into the solution (see osmosis). If the become abnormally thickened, prevent-
gland. People suffering from hyperthy- solution is too concentrated, the body’s ing the heart from pumping efficiently.
roidism may be given radioactive iodine cells may lose too much water. Fluids This may lead to breathlessness, chest
to destroy part of the thyroid tissue. used for intravenous infusion are usually pain, and palpitations.
Many people recover fully after treat- isotonic (having the same concentration Hypertrophic cardiomyopathy is most
ment, but their hormone levels need to as the fluids in cells); if they are being commonly inherited, and it shows an
be monitored regularly so that any fur- used to treat dehydration, infused fluids autosomal dominant pattern of inheri-
ther abnormal changes can easily be are mildly hypotonic. tance (see genetic disorders). Family
detected and treated. Treatment with members can be screened (see familial
radioactive iodine may result in devel- hypertrichosis screening) by means of echocardiogra-
opment of hypothyroidism (underactivity Growth of excessive hair, all over the phy, although the condition may not
of the thyroid gland). body, even in places that are not nor- become apparent until after puberty.
mally hairy. Hypertrichosis often occurs Hypertrophic cardiomyopathy is some-
hypertonia as a result of taking certain drugs times a cause of sudden death (see
Increased rigidity in a muscle. Hyperto- (including ciclosporin and minoxidil). It death, sudden) in young people.
nia may be caused by damage to the may also be associated with anorexia ner- Treatment is with antiarrhythmic drugs
nerves supplying the muscle or by vosa. In addition, the term “hyper- and, in some cases, an implantable
changes within the muscle itself. The trichosis” is used to describe hair defibrillator (see defibrillation).
condition causes episodes of continu- growth in a mole (see naevus).
ous muscle spasm. Persistent hypertonia Hypertrichosis is not the same as hir- hypertrophic pulmonary
in limb muscles following a stroke or sutism, which is excessive hair growth osteoarthropathy
head injury leads to spasticity. (particularly in women) due to abnor- A condition in which severe pain and
mal levels of male hormones. swelling of the wrists and ankles is
hypertonic solution associated with clubbing of the ends of
A fluid that is more concentrated than hypertrophic cardiomyopathy the fingers and toes. The most common
blood plasma or the fluid within cells. If A disease of the heart muscle (see car- cause of the condition is lung cancer.
a hypertonic solution is introduced into diomyopathy) in which the walls of the X-rays of the affected bones show new
the body, water will pass from the cells left ventricle (the heart’s lower chamber) bone formation in the long bones near

399
 HYPERTROPHY

the painful joints. Hypertrophic pulm- Controlled hyperventilation of patients, hypnotherapy

onary osteoarthropathy may sometimes using mechanical ventilators, is often The use of hypnosis as part of a psycho-
improve with treatment of the under- part of the treatment for cerebral oedema logical therapy.
lying lung cancer. (swelling of the brain) after injury or
surgery to the brain. hypnotic drugs
hypertrophy Drugs that induce sleep (see sleeping
Enlargement of an organ or tissue due hypervigilance drugs).
to an increase in the size, rather than A feature of post-traumatic stress disorder
number, of its constituent cells. For involving a continuously heightened hypo-
example, skeletal muscles enlarge in state of arousal and an exaggerated star- A prefix meaning “under”, “below”, or
response to increased physical demands. tle reaction. “less than normal”.
(See also hyperplasia.)
hypervitaminosis hypoaldosteronism
hyperuricaemia Any condition caused by an excess intake A rare condition that is characterized by
An abnormally high level of uric acid in of one or more vitamins (usually from a deficiency of the hormone aldo-
the blood. Hyperuricaemia may lead to unnecessary use of vitamin supplements). sterone, which is produced by the
gout due to the deposition of uric acid Hypervitaminosis is most likely to arise adrenal glands. The condition may be
crystals in the joints; it may also cause with vitamin A and vitamin D because caused by damage or disease affecting
H kidney stones (see calculus, urinary tract) excess amounts of these vitamins are the adrenal glands. It may occur in Addi-
and collections of crystals in other body stored in the body rather than excreted. son’s disease, in which the adrenal
tissues (see tophus). glands are damaged, often as a result of
CAUSES hyphaema an autoimmune process. Hypoaldostero-
Hyperuricaemia may be caused by an Blood in the front chamber of the eye, nism may produce muscle weakness. It
inborn error of metabolism (see metab- usually caused by an injury that rup- is treated by the drug fludrocortisone.
olism, inborn errors of), by the rapid de- tures a small blood vessel in the iris or
struction of cells in a disease such as ciliary body. Initially, there may be hypocalcaemia
leukaemia, or by any medication that blurred vision, but the blood usually An abnormally low level of calcium in
reduces the excretion of uric acid by the disappears completely within a few days the blood. The most common cause is
kidneys, such as diuretic drugs. Large and vision is restored. vitamin D deficiency. More unusual caus-
amounts of purine (a nitrogen-contain- es include chronic kidney failure and
ing substance) in the diet may also hypoparathyroidism (underactivity of the
cause hyperuricaemia. parathyroid glands).
TREATMENT In mild cases, hypocalcaemia is
Drugs such as allopurinol or sulfinpyra- symptomless; in severe cases, it leads to
zone may be prescribed for the duration tetany (painful muscle spasms and
of the patient’s life. Purine-rich foods, twitches, especially in the hands and
such as liver, poultry, and dried pulses, feet). It may also result in bone soften-
should be avoided. ing, causing rickets in children and
osteomalacia in adults.
hyperventilation Appearance of hyphaema
Blood that has collected in the front chamber of the
The term used to describe abnormally eye is clearly visible in front of the iris. This case, hypocapnia
deep or rapid breathing. Hyperventila- like most instances, was caused by injury. Abnormally low carbon dioxide levels in
tion is usually caused by anxiety. It may the blood. Hypocapnia may be caused
also develop as a result of uncontrolled hypnagogic by hyperventilation (abnormally deep or
diabetes mellitus or kidney failure; oxygen A term that refers to the state of transi- rapid breathing); it can result in a pins-
deficiency; some lung disorders; or tion between wakefulness and sleep. and-needles sensation and painful
abuse of stimulant drugs. Hypnagogic images are vivid mental muscle cramps and spasms.
Hyperventilation causes an abnormal pictures that occur just before sleep. Dis-
loss of carbon dioxide from the blood, tressing hypnagogic hallucinations may hypochondriasis
which can lead to an increase in blood feature in narcolepsy (a sleep disorder). A disorder that is characterized by a
alkalinity (see alkalosis). Symptoms of person’s unrealistic belief that he or she
hylperventilation include numbness of hypnosis is suffering from a serious illness, despite
the extremities, faintness, tetany (painful A trance-like state of altered awareness medical reassurance to the contrary. In
muscle cramps and twitches, especially characterized by extreme suggestibility. its mildest form, hypochondriasis cau-
in the hands and feet), and a sensation Some psychoanalysts induce a hypnotic ses people to worry constantly about
of not being able to take a full breath. state as a means of helping patients their health and interpret any symptom,
If the hyperventilation is due to anxi- remember and come to terms with dis- however trivial, as evidence of disease.
ety, the affected person may find it turbing events. More often, hypnosis is In its most severe form, hypochondria-
helpful to breathe in and out of a paper used to help patients to relax. It may be sis may dominate the person’s life; he or
bag. This action reduces the loss of car- useful in people suffering from anxiety, she may constantly seek medical advice
bon dioxide and may help to relieve the panic attacks, or phobias, or in those and may undergo numerous tests and
symptoms of alkalosis. wishing to correct addictive habits. treatments for disease.

400
 HYPOHIDROSIS

The likelihood of hypochondriasis oc- hypoglossal nerve At the first sign of a hypoglycaemic
curring is increased in people who have The 12th cranial nerve, which controls attack, an affected person should con-
had past experience of a serious disor- movement of the tongue. sume a sugary food or drink. If the
der (particularly during childhood) or person has lost consciousness, emer-
have seen such disorders in relatives. gency medical help is required; the
Other predisposing factors include social LOCATION OF patient must receive an injection of glu-
HYPOGLOSSAL NERVE
stresses and personality type. The con- cose solution or the hormone glucagon.
dition may also be a complication of The hypoglossal nerve arises in (See also reactive hypoglycaemia.)
other psychological disorders such as the medulla oblongata (part of the
phobia, obsessive–compulsive disorder, brainstem), passes through the base hypoglycaemics, oral
generalized anxiety disorder, and brain of the skull, and runs around the COMMON DRUGS
diseases such as dementia. throat to the tongue. SULPHONYLUREA DRUGS • Chlorpropamide
Where possible, treatment is de- • Glibenclamide • Gliclazide • Glimepiride
signed to relieve the underlying mental • Glipizide • Gliquidone • Tolbutamide
Skull
disorder. Hypochondriasis without an OTHERS • Acarbose • Glucagon
underlying cause is difficult to treat. • Insulin • Insulin lispro • Metformin
• Pioglitazone • Repaglinide • Rosiglitazone
hypochondrium Brainstem

The area on each side of the upper A group of antidiabetic drugs that are H
abdomen, below the lower ribs. used to reduce the blood glucose levels
of people with type 2 diabetes mellitus.
hypodermic Oral hypoglycaemics have many dif-
A term that means “under the skin”. ferent modes of action. Sulphonylurea
The word is usually used to describe Surface
drugs act by increasing the body’s
injections that are delivered into the of insulin production. Metformin increases
layer of fat beneath the skin, as well as tongue the uptake of glucose into body tissues
for the needles and syringes used to and increases its use by the body, there-
administer these injections. by helping to reduce blood glucose
Tongue muscles
levels. Other oral hypoglycaemics work
hypogammaglobulinaemia in a variety of ways. For example, acar-
Hypoglossal nerve
An abnormally low blood level of bose and guar gum reduce or slow
immunoglobulins (proteins produced by absorption of carbohydrate from the
immune system cells to fight infection; intestines after meals; repaglinide stim-
also called antibodies) that belong to a hypoglycaemia ulates the release of insulin from the
group called gamma-globulins. Hypo- An abnormally low level of glucose in pancreas; and rosiglitazone and pioglita-
gammaglobulinaemia is associated with the blood. Almost all cases of hypogly- zone reduce resistance to the effects of
an increased susceptibility to infections. caemia occur in people with Type 1 insulin in the tissues.
The condition may be either inherited diabetes mellitus, in whom the pancreas Too high a dose of hypoglycaemic
or acquired. fails to produce enough insulin, result- drugs may provoke the onset of hypogly-
Inherited hypogammaglobulinaemia ing in an abnormally high glucose level. caemia (abnormally low blood sugar
is an X-linked disorder (see genetic dis- To lower the level, insulin is given. Too levels), causing symptoms such as dizzi-
orders) that results in susceptibility to high a dose of insulin can reduce the ness, nausea, and sweating. The use of
infections from approximately three to blood glucose to an excessively low metformin, acarbose, or guar gum does
six months of age. This condition level. Hypoglycaemia can also occur if a not usually result in this condition.
requires repeated treatment with intra- diabetic person misses a meal or takes
venous immunoglobulin. strenuous exercise. hypogonadism
There are several types of acquired Less commonly, the condition may Underactivity of the gonads (testes or
hypogammaglobulinaemia. Common va- occur in people with Type 2 diabetes ovaries). Hypogonadism may be caused
riable hypogammaglobulinaemia may mellitus (in which body cells are resis- by disorders of the gonads or a disorder
appear during childhood or may occur tant to the effects of insulin). Rarely, the of the pituitary gland that causes deficient
later in adult life and requires regular condition can result from drinking too production of gonadotrophin hormones.
replacement of immunoglobulin. Immu- much alcohol or from an insulin-pro- In men, hypogonadism causes the symp-
noglobulin A (IgA) deficiency is a very ducing pancreatic tumour. toms and signs of androgen hormone
common form of hypogammaglobulin- Symptoms include sweating, hunger, deficiency; in women, it causes those of
aemia that may have no symptoms and dizziness, trembling, headache, palpita- oestrogen deficiency.
may carry no heightened risk of infec- tions, confusion, and sometimes double
tion. Secondary hypogammaglobulin- vision. The person’s behaviour is often hypohidrosis
aemia occurs in connection with a irrational and aggressive. Coma may Reduced activity of the sweat glands.
number of other diseases, including occur in severe cases. Hypoglycaemia Hypohidrosis is a feature of hypohidrotic
multiple myeloma and chronic lympho- may also be the cause of seizures and ectodermal dysplasia, a rare, inherited,
cytic leukaemia (see leukaemia, chronic jittery behaviour in newborn babies incurable condition that is characterized
lymphocytic). (see neonatal hypoglycaemia). by reduced sweating and is accompanied

401
 HYPOKALAEMIA

by dry, wrinkled skin, sparse hair, small, ment of hypophosphataemia involves breathless. Hypoplastic left-heart syn-
brittle nails, and conical teeth. Other replacement of phosphates and, if pos- drome can be treated surgically, some-
causes of hypohidrosis include exfoliative sible, treatment of the underlying cause. times by heart transplant.
dermatitis and some anticholinergic drugs.
hypophysectomy hyposensitization
hypokalaemia The surgical removal or destruction (by A preventive treatment of allergy to spe-
A deficiency of potassium in the blood. radiotherapy) of the pituitary gland. Hy- cific substances, such as grass pollens
Hypokalaemia is usually caused by pophysectomy may be performed to and insect venom. Hyposensitization in-
excess fluid loss due, for example, to treat a pituitary tumour. Life-long hor- volves giving gradually increasing doses
severe diarrhoea, but may be the result mone treatment is necessary following of the allergen (substance to which the
of treatment with diuretic drugs. hypophysectomy because hypopituitarism person is allergic) so that the immune
is an inevitable result. system becomes less sensitive to that
hypomagnesaemia substance. The treatment, which may
An abnormally low level of magnesium hypopigmentation need to be repeated annually for a
in the blood. Hypomagnesaemia may A lack or absence of normal colour in number of years, carries the risk of
result from malabsorption, malnutrition, the skin. The condition is due to under- anaphylactic shock.
alcohol abuse (see alcohol-related disor- production of melanin, the brown
ders), severe diarrhoea, or some kidney pigment in skin, hair, and eyes. It may hypospadias
H diseases. Magnesium deficiency causes be the result of inflammation, scarring, A congenital defect of the penis, in
impaired nerve and muscle function or the skin condition vitiligo. which the opening of the urethra is on
and may lead to seizures. Treatment of the underside of the glans (head of the
hypomagnesaemia is by injection of hypopituitarism penis) or shaft. In some cases, the penis
magnesium salts. Underactivity of the pituitary gland, curves downwards, a condition that is
resulting in inadequate production of known as chordee. Hypospadias can usu-
hypomania one or more pituitary hormones. The ally be corrected by surgery.
A mild degree of mania. effects depend on which hormones are
affected. Possible causes are a pituitary hyposplenism
hypoparathyroidism tumour, an abnormality affecting the A condition characterized by dimin-
Insufficient production of parathyroid hypothalamus (part of the brain), or ished functioning of the spleen. If the
hormone by the parathyroid glands. A injury to the pituitary gland. Hypopi- spleen suffers a loss of function, there is
deficiency of this hormone results in tuitarism may also follow surgery or a resultant reduction in production of
low levels of calcium in the blood (see radiotherapy of the pituitary gland (see the antibodies, lymphocytes, and phago-
hypocalcaemia). hypophysectomy). Treatment involves re- cytes that act to destroy invading
The most common cause of hypopara- placing the deficient hormones. microorganisms. Hyposplenism there-
thyroidism is damage to the parathyroid fore results in increased susceptibility to
glands during surgery. Occasionally, the hypoplasia certain severe infections. Those people
glands are absent from birth or may The failure of an organ or a body tissue whose spleen has been removed (see
cease to function for no apparent reason. to develop fully and to reach its normal splenectomy) or is failing to function
A low level of calcium in the blood adult size. normally are advised to have pneumo-
may lead to tetany (increased excitability coccal immunization and long-term
of the nerves, causing uncontrollable, hypoplasia, enamel antibiotic drugs.
painful, cramplike spasms, especially in A defect in tooth enamel (see enamel,
the hands and feet). Occasionally, dental), sometimes due to amelogenesis hypostasis
seizures similar to those of an epileptic imperfecta. It may also be caused by vita- The pooling of blood in the lowest
attack may occur. min deficiency, injury, or infection of areas of limbs or organs, due to gravity.
The condition is diagnosed by blood a primary tooth that interferes with Hypostasis usually occurs as a result of
tests. To relieve an attack of tetany, cal- enamel maturation. poor circulation. The condition also
cium may be injected slowly into a occurs after death, when blood settles
vein. To maintain the blood calcium at a hypoplastic left-heart syndrome in the parts of the body that were low-
normal level, a lifelong course of calci- A very serious form of congenital heart est at the time of death.
um and vitamin D tablets is necessary. disease (see heart disease, congenital), in
which a baby is born with a poorly hypotension
hypophosphataemia formed left ventricle (pumping cham- The medical term for low blood pressure.
An abnormally low level of phosphates ber), often associated with other heart In its most common form, known as
in the blood. Hypophosphataemia may defects. The aorta is malformed and postural hypotension, symptoms occur
be associated with hyperparathyroidism, blood can reach it only via a duct (the when a person abruptly stands or sits up.
osteomalacia, rickets, and certain kidney ductus arteriosus) that links the aorta to Normally, blood pressure is maintained
abnormalities, such as Fanconi’s syn- the pulmonary artery. with changes in posture; in people with
drome. It may cause symptoms such as At birth, the baby may seem healthy. postural hypotension, it falls. Postural
fatigue, muscle weakness, haemolysis However, within a day or two the duc- hypotension may be a side effect of anti-
(premature breakdown of red blood tus arteriosus naturally closes off and depressant drugs or antihypertensive drugs.
cells), confusion, and seizures. Treat- the baby collapses, becoming pale and It may also occur in people with diabetes

402
 HYPOTHERMIA

The area connects with the pituitary

HYPOPLASTIC LEFT-HEART SYNDROME gland through a short stalk of nerve
fibres and controls hormonal secretions
The heart defects associated with this syndrome are shown on the right and
compared with those of the normal heart, on the left. Neither the left ventricle
from this gland. One form of control is
(pumping chamber) nor the aorta is properly formed. through direct nerve connections. The
other is through specialized nerve cells,
Malformed aorta which secrete hormones called releasing
Aorta
Pulmonary factors; these factors enter specialized
Ductus
artery arteriosus blood vessels and pass to the pituitary
(opens into gland. In this way, the hypothalamus
aorta)
converts nerve signals into hormonal
signals; therefore, it indirectly controls
Left many endocrine glands, including the thy-
Right ventricle Pulmonary
ventricle
artery
roid gland; the cortex of the adrenal
glands; and the ovaries or testes.
DISORDERS
Disorders of the hypothalamus are usu-
Defect of the heart Malformed
ally due to an intracerebral haemorrhage
In a normal heart, blood is pumped by the left
ventricle to the body via the aorta. If the left
left
ventricle or a hypothalmic or pituitary tumour. H
ventricle is poorly formed, blood can reach the They have diverse effects, ranging from
body only via the ductus arteriosus, which Right hormonal disorders to disturbances in
closes soon after birth. ventricle
temperature regulation, and increased
or decreased need for food and sleep.

mellitus. Acute hypotension is a feature of from internal sense organs regarding hypothermia
shock, and may be caused by serious the body’s water content and the level A fall in body temperature to below
injury or a disease such as myocardial of glucose in the blood; if these are too 35°C. Hypothermia most often occurs
infarction (heart attack) or adrenal failure. low the hypothalamus stimulates thirst in sick, elderly people who are exposed
Treatment depends on the cause. In and appetite for food. (See feedback to low temperatures. The body loses its
the absence of serious disease, low mechanism.) The hypothalamus is also sensitivity to cold as it ages, becoming
blood pressure is associated with a de- involved in regulating sleep, motivating less able to reverse a fall in temperature.
creased risk from cardiovascular disorders sexual behaviour, and determining Hypothyroidism (underactivity of the
and stroke. Symptomless hypotension mood and emotions. thyroid gland) also predisposes an indi-
does not require treatment. A further role of the hypothalamus is vidual to hypothermia. Babies may also
to coordinate the functions of the ner- have an increased risk of hypothermia
hypothalamus vous and endocrine (hormonal) systems. because they lose heat rapidly and can-
A region of the brain, roughly the size of not easily reverse a fall in temperature.
a cherry, situated behind the eyes and The condition is also common in
under another area of the brain called LOCATION OF THE climbers and walkers who are inade-
the thalamus. The hypothalamus has HYPOTHALAMUS quately dressed for cold weather.
nerve connections to most other regions This small area of the forebrain, SYMPTOMS AND SIGNS
of the nervous system. shown in blue, lies under the thalamus A person suffering from hypothermia is
FUNCTION and above the pituitary gland. usually pale and listless. The heart rate is
The hypothalamus controls the sympa- slow, the body is cold, and the victim is
Cerebrum Hypothalamus Thalamus
thetic nervous system (part of the often drowsy and confused. In severe
autonomic nervous system). In response hypothermia, breathing becomes slow
to sudden alarm or excitement, signals and shallow, the muscles are stiff, the
are sent from higher regions of the victim may become unconscious, and
brain to the hypothalamus, initiating may actually appear dead. Eventually,
sympathetic nervous system activity. the heart may stop beating.
This causes a faster heartbeat, widening TREATMENT
of the pupils, an increase in breathing Hypothermia is a medical emergency.
rate and blood flow to muscles (togeth- Treatment varies according to the age of
er called the “fight or flight” response). the victim. A baby or child can be
Other groups of nerve cells in the warmed by direct skin-to-skin contact;
hypothalamus are concerned with the for example, by being held inside an
control of body temperature. When adult’s clothing. A young person may be
blood flowing to the brain is hotter or Pituitary placed in a warm bath. An elderly vic-
cooler than normal, the hypothalamus Optic nerve
tim is usually warmed gradually by
switches on mechanisms that regulate being covered with layers of heat-reflect-
Brainstem
body temperature (including sweating ing material in a room temperature of
and shivering). It receives information 25°C. If the person is fully conscious,

403
 HYPOTHERMIA, SURGICAL

they may be given a warm non-alco- hypotonia surgery. Hypovolaemia may also be due
holic drink. Alcohol should not be Abnormal muscle slackness. Normally, a to loss of fluid from diarrhoea and vomit-
given as it can exacerbate the condition. muscle that is not being used has a cer- ing. Untreated, it can lead to shock.
In cases where hypothermia is life- tain inbuilt tension, but in a number of
threatening, victims may be admitted to disorders affecting the nervous system hypoxaemia
an intensive care unit for controlled this natural tension is reduced. An abnormally low level of oxygen in
warming in which warmed fluids are the arterial blood (the blood that carries
administered intravenously. hypotonia in infants oxygen to the body tissues). This condi-
Most people suffering from hypo- Also known as floppy infant syndrome, tion may lead to hypoxia.
thermia make a full recovery – the excessive limpness in infants. Hypoton-
outlook is best in the case of young, ic babies cannot hold their limbs up hypoxia
otherwise healthy individuals. against gravity and tend, therefore, to lie An inadequate supply of oxygen to the
flat with their arms and legs splayed. tissues. Temporary hypoxia may result
hypothermia, surgical Hypotonia may be caused by Down’s from strenuous exercise. More serious
The deliberate reduction of body tem- syndrome or hypothyroidism (underpro- causes include impaired breathing (see
perature to prolong the period for which duction of thyroid hormones) and may respiratory failure), ischaemia (reduced
the vital organs can safely be deprived of be an early feature of cerebral palsy. It blood flow to part of the body), and
their normal blood supply during open occurs in disorders of the spinal cord, severe anaemia. A rare cause is carbon
H heart surgery. Cold reduces the rate of such as Werdnig–Hoffman disease, and in monoxide poisoning. Severe, prolonged
metabolism in tissues and thus increases some children with muscular dystrophy. hypoxia may lead to tissue death.
their tolerance to lack of oxygen. Cool- Hypoxia in muscles forces the muscle
ing may be achieved by continuously hypotonic solution cells to produce energy by anaerobic
instilling cold saline at about 4°C into A fluid that is less concentrated than processes, which can lead to cramps. In
the open chest cavity. blood plasma or the fluid within cells. If heart muscle, it may cause angina pec-
a hypotonic solution is introduced into toris. In the brain, it causes confusion,
hypothyroidism the body, the water in the fluid will pass dizziness, and loss of coordination; and
The underproduction of thyroid hormones through cell walls and into the cells (see may lead to unconsciousness and death
by an underactive thyroid gland. These osmosis). If the solution is too weak (for if it is persistent.
hormones are important in metabolism example, if it is pure water), the body’s Hypoxia can be assessed by using an
and a deficiency therefore causes many cells will become over-filled and will oximeter to measure the oxygen concen-
of the body’s functions to slow down. rupture. Fluids used for intravenous tration of blood in the tissues. Severe
Most cases are caused by an autoimmune infusion are isotonic (having the same hypoxia may require oxygen therapy or
disorder such as Hashimoto’s thyroiditis. concentration as the fluids in cells), artificial ventilation.
More rarely, however, hypothyroidism except when they are being used to
results from the removal of part of the treat dehydration, in which case they hypromellose
thyroid gland to treat hyperthyroidism are mildly hypotonic. A substance that is included in artificial
(overactivity of the thyroid). tears (see tears, artificial). Hypromellose
SYMPTOMS AND SIGNS hypoventilation is applied as eye-drops.
Symptoms of hypothyroidism include A condition in which too little air
tiredness, lethargy. and cold intolerance. enters the alveoli (tiny air sacs) in the hysterectomy
There may also be muscle weakness, lungs. Hypoventilation is due to breath- Surgical removal of the uterus. Hysterec-
cramps, a slow heart rate, dry skin, hair ing that is too shallow or slow, or to tomy may be performed to treat fibroids
loss, constipation, a husky voice, and a reduction in lung function (for (noncancerous tumours of the uterus),
weight gain. Women may experience example, from a disorder such as and cancer of the uterus (see uterus, can-
heavy menstrual periods. A syndrome emphysema). The inadequate air supply cer of) or cervix (see cervix, cancer of). It
called myxoedema, in which the skin and leads to insufficient oxygen passing may also be performed to treat endo-
other tissues thicken, may develop. from the alveoli into the bloodstream metriosis (displaced fragments of the
Enlargement of the thyroid gland may (see respiration), and as a result too little uterine lining) and to remove a pro-
also occur (see goitre). If the condition oxygen reaches the body tissues (see lapsed uterus (see uterus, prolapse of).
occurs in childhood, it may retard hypoxia) and carbon dioxide builds up. Hysterectomy used to be performed
growth and normal development. frequently to relieve heavy menstrual
DIAGNOSIS AND TREATMENT hypovitaminosis bleeding, but alternative treatments,
The disorder is diagnosed by measuring Any condition that results from the such as endometrial ablation or insertion
the level of thyroid hormones in the deficiency of one or more vitamins. of a progestogen IUD, are now increas-
blood. Treatment consists of replace- Hypovitaminosis may be due to an ingly used in these instances.
ment therapy with the thyroid hormone inadequate dietary intake or a digestive TYPES
thyroxine, usually for life. In adults, disorder that causes malabsorption. The most common type of hysterec-
the symptoms usually improve about tomy is a total hysterectomy, in which
three weeks after the start of treat- hypovolaemia both the uterus and the cervix are re-
ment. Hormone treatment is monitored An abnormally low volume of blood in moved. Occasionally, the fallopian tubes
regularly so that the correct dosage the circulation, usually following blood and ovaries are removed as well. For
is maintained. loss due to injury, internal bleeding, or the treatment of cervical cancer, a rad-

404
 HYSTEROSCOPY

hysterocontrast sonography
PERFORMING A HYSTERECTOMY (HyCoSy)
Ultrasound examination of the uterine
Hysterectomy may be performed
through the abdomen or the vagina.
cavity and the fallopian tubes. A contrast
For an abdominal hysterectomy, the medium visible on ultrasound is intro-
incision is made in the lower abdomen duced into the uterine cavity through
(see below). In vaginal hysterectomy, the vagina and the cervix. Hysterocon-
the uterus is removed through an trast sonography is a technique that is
incision at the top of the vagina. used to investigate infertility; the advan-
tage that this method has over
hysterosalpingography is that is does not
involve X-rays.
Abdominal hysterectomy
The uterine vessels are clamped. Traction is hysterosalpingography
placed on the top of the uterus and the vessels An X-ray procedure in which a dye
are tied and then divided. In some cases, the (radiopaque contrast medium) is intro-
fallopian tubes are cut and the tubes and duced into the cavity of the uterus
Site of incision for ovaries left in place.
through the cervix to make the uterus
abdominal hysterectomy
The incision is made in the lower abdomen and fallopian tubes visible on X-rays. H
(in this case horizontally) level with the top of Hysterosalpingography is used to inves-
the pubic hair. tigate infertility.
Fallopian tube Uterus

Incisions Ovary
The dotted Vaginal hysterectomy
Site of
lines show the incision After a vaginal incision is made, the uterus and
incisions for cervix are removed. (The ovaries cannot be
removing only Vagina removed in a vaginal hysterectomy.) The upper
the uterus. end of the vagina is repaired by stitching.

Hysterosalpingography
This image shows the uterus (centre) and fallopian
ical hysterectomy (in which the uterus, and six weeks; sexual intercourse can be tubes. The right tube (left on image) is blocked near
cervix, and pelvic lymph nodes are resumed about a month after surgery. the uterus, allowing no contrast medium into it; the
removed) is performed. The recovery period after an abdominal other is obstructed further down and has dilated.
Hysterectomy may be performed hysterectomy may be longer and may
through the vagina or through an inci- also require a longer stay in hospital. hysteroscopy
sion in the abdomen. A procedure Following a hysterectomy, a woman A technique that uses a hysteroscope (a
known as laparoscopically assisted vagi- is unable to bear children; she does not type of endoscope) to view the inside of
nal hysterectomy is carried out partly have menstrual periods and does not the uterus and fallopian tubes for the
through the vagina and partly using need to use contraception. If a woman’s purposes of diagnosing disorders. Hys-
minimally invasive surgery. Vaginal hyster- ovaries have also been removed before teroscopy can be performed under local
ectomy has the advantage of needing no or around the woman’s menopause, anaesthesia. Minor surgery, such as the
external incision, and, as a result, the hormone replacement therapy (HRT) may removal of fibroids (noncancerous tu-
patient usually recovers more rapidly. be given. It is not uncommon for a mours of the uterus), may also be per-
However, a vaginal hysterectomy cannot woman to suffer from depression after formed using a hysteroscope.
be performed if the uterus is significant- a hysterectomy if she has not not ade-
ly enlarged or if the hysterectomy is a quately counselled beforehand.
treatment for cancer.
RECOVERY AND OUTLOOK hysteria
After the operation, a drainage tube may An old-fashioned term encompassing a
be inserted at the site of the incision to wide range of physical or mental symp-
aid healing. For a few days there may be toms that are attributed to mental stress.
some vaginal bleeding and discharge, as Symptoms formerly grouped under this
well as tenderness and pain. A vaginal term are now included in the more spe-
hysterectomy requires a short hospital cific diagnostic categories of conversion
stay; any further stay depends on the age disorder; somatization disorder; dissocia-
and health of the woman and whether tive disorders; and factitious disorders.The
there are any postoperative problems. term is still used loosely to describe
Full recovery usually takes between three irrational behaviour.

405
 IATROGENIC

IDDM

I
The low temperature causes the blood
vessels to constrict (narrow), thus reduc- The abbreviation for insulin-dependent
ing the blood flow. diabetes mellitus (type 1 diabetes).
Ice-packs are used to relieve pain in a
variety of disorders, including severe ideas of reference
headache. They are used on sports An individual affected by ideas of ref-
injuries to minimize swelling and erence finds personal significance in
bruising, and they can also be used to casual remarks made or action taken by
help stop bleeding from small vessels, other people. The individual may feel
as in a nosebleed. that people in public places are talking
about, or laughing at, him or her. The
iatrogenic ichthammol condition falls short of a delusion
A term meaning “physician-produced”. A drug used in skin preparations for the because affected individuals are aware
It may be applied to any medical condi- treatment of eczema, to reduce itching. that they are not actually noticed more
tion, disease, or adverse event resulting than others; however, they may be
from medical treatment. Ichthopaste unable to discuss these feelings.
A brand name for a medicated bandage
IBS that is impregnated with the drug identical twins
See irritable bowel syndrome. ichthammol and zinc paste. Ichthopaste Two offspring, also known as monozy-
is used in the treatment of chronic gotic twins, who developfrom a single
I Ibugel eczema, to reduce itching. fertilized ovum (egg) and
share identical
A brand name for a topical gel con- genes. (See also twins.)
taining ibuprofen that is used for ichthyosis
relieving muscle pain. A rare, inherited condition in which the identification
skin is dry, thickened, scaly, and darker A term used in psychology to refer to the
Ibuleve than normal due to abnormal produc- process of unconsciously taking on
A brand name for a topical gel con- tion of keratin. Ichthyosis usually another person’s traits or behaviour. In
taining ibuprofen that is used to relieve appears at, or shortly after, birth and children, identification with an older
muscle pain. usually improves during childhood. person, usually a parent, is considered a
Commonly affected areas are the thighs, normal part of development.
ibuprofen arms, and backs of the hands.
A nonsteroidal anti-inflammatory drug There is no particular treatment, but identity crisis
(NSAID) used as a painkiller to treat lubricants and emulsifying ointments A colloquial term used to describe feel-
conditions such as headache, menstrual may be applied to help relieve the dry- ings of uncertainty about one’s own
pain, and injury to soft tissues. The ness, and bath oils may also be used to personality and characteristics. Experi-
drug’s anti-inflammatory effect also moisten the skin. encing an “identity crisis” is common
helps to reduce the joint pain and stiff- in periods of emotional turmoil, such
ness that occurs in types of arthritis. ICP as adolescence.
Side effects may include abdominal The abbreviation for intracranial pressure.
pain due to inflammation of the stomach idiopathic
lining; nausea; heartburn; and diarrhoea. ICSI A term that is used to refer to a medical
See intracytoplasmic sperm injection. condition that has no known cause. As
ICD science advances, causes may be found
The commonly used abbreviation for icterus for conditions previously considered to
International Classification of Diseases, A term for jaundice. be idiopathic.
a list of all known diseases that is pub-
lished by the World Health Organization. ICU idiopathic epilepsy
An updated version is produced approx- The abbreviation for intensive care unit. A term used to describe epilepsy that has
imately every ten years. ICD enables no known physical cause (such as brain
countries and organizations to gather id injury, for example).
statistical information on the frequency One of the three constituents of the
of a disease and causes of death. personality (together with the ego and idiopathic hypertension
superego) described by Sigmund Freud. See essential hypertension.
Icelandic disease The id is defined as the primitive,
A previously used term for chronic unconscious energy store from which idiopathic thrombocytopenic
fatigue syndrome. come the instincts for food, love, sex, purpura (ITP)
and other basic needs. It thus guides An autoimmune disorder in which
ice-packs behaviour and also fuels the turmoil platelets are destroyed, leading to
A means of applying ice (wrapped in a leading to the conflict and guilt of bleeding beneath the skin (see purpura).
towel or other material) to the skin neurosis. The id seeks simply to gain ITP may be acute or chronic. Acute
in order to reduce inflammation or pleasure and avoid pain. (See also psy- ITP mainly affects children, is usually
swelling, relieve pain, or stem bleeding. choanalytic theory.) mild, and disappears without treatment.

406
 ILEOSTOMY

Chronic ITP generally affects adults ileal pouch wall and formed into an artificial
and is much more serious. Initial treat- A reservoir constructed from loops of opening called a stoma. Waste is dis-
ment is with corticosteroid drugs; if this the ileum (lower part of the small intes- charged from the remaining ileum
fails, a splenectomy (surgical removal of tine) to replace a rectum that has been into a disposable bag (stoma bag) or
the spleen) is required. Immunosuppres- surgically removed. If an ileal pouch drained into a pouch made from the
sant drugs may be given if all other cannot be created, a permanent ileosto- end of the ileum and situated beneath
treatment fails. my will be required. the skin (a procedure called a conti-
nent ileostomy). In the latter situation,
idoxuridine ileitis, regional faeces draining into the pouch are
An antiviral drug used in skin prepara- An outdated name for Crohn’s disease. emptied regularly through a soft
tions to treat the blistering rashes caused catheter. An ileostomy may be either
by herpes simplex and herpes zoster ileostomy permanent or temporary.
(shingles) infections. Recently devel- An operation in which the ileum (lower WHY IT IS DONE
oped antiviral drugs, such as aciclovir, part of the small intestine) is cut and Permanent ileostomy is usually perfor-
are more effective and idoxuridine is the end brought through the abdominal med on people who have severe,
now used less often.
Ig PROCEDURE FOR ILEOSTOMY
The abbreviation for immunoglobulin.
Two incisions are made in the abdominal Sites of
wall (usually on the right side): a small incisions
IgA nephropathy circular cut for the stoma (usually sited I
A kidney disease that causes haematuria about 5 cm below the waist and away
(passage of blood in the urine) and in from the hip bone and groin crease)
which deposits of IgA immunoglobulins and a vertical cut to give access to the
(certain proteins produced by the intestine and the mesentery. The site
immune system to combat infection) are of the stoma is discussed with the
found within the kidneys. Excessive patient prior to surgery.
amounts of IgA are sometimes pro-
duced in response to a throat infection. Clamp Skin edge Mesentery Suture
In such cases, IgA complex collects in
the filtering units of the kidneys. IgA
nephropathy is the most common form
of glomerulonephritis.
Colon
The condition mainly affects children (removed)
and young men. It may cause either
microscopic haematuria (in which Ileum
blood is passed in the urine but cannot
be seen by the naked eye) or episodes
of macroscopic haematuria (in which
blood can be seen in the urine). In Rectum
(removed)
some cases, nephrotic syndrome develops;
in this condition, large amounts of pro-
tein are passed in the urine, leading to 1the After removal of the colon, the cut end
of the ileum is clamped and part of
mesentery is cut to free a short length
The free end of the ileum is pushed
2abdomen;
out through the circular incision in the
the mesentery is then stitched to
raised blood pressure and oedema of ileum for the stoma. the inner abdominal wall.
(swelling of the tissues).
Treatment of IgA nephropathy may Clamp Ileum
involve corticosteroid drugs and immuno- Suture Suture
suppressant drugs, in addition to treat-
ment to relieve any symptoms. Overall, Stoma
the prognosis for IgA nephropathy is
good. In some cases, however, kidney
function deteriorates and, in up to one
in five people, kidney failure develops
after many years.
ileal conduit
A section of the ileum (the final part of forms a protruding spout of ileum (right).
the small intestine) used by a surgeon
to provide a substitute channel for
3endThe main vertical incision is closed, and
the clamp is removed from the protruding
of the ileum (left). This end is then turned
After the intestine begins to function
normally, an ileostomy bag is fitted around
urine outflow when the bladder has back and attached to the abdominal surface the stoma. The bag is attached to the skin
been removed. (See urinary diversion; with sutures (middle). When completed, it by adhesive seals.
see also cystectomy.)

407
 ILEUM

uncontrolled ulcerative colitis. The oper- DISORDERS illusion

ation is done after a total colectomy Occasionally, the ileum becomes ob- A distorted sensation that is based on
(removal of the colon and rectum). structed – for example, by pushing the misinterpretation of a real stimulus
Temporary ileostomy is sometimes through a weakness in the abdominal (for example, a pen is seen as a dagger).
performed at the same time as partial wall (see hernia) or by becoming caught Illusion differs from a hallucination, in
colectomy (removal of part of the colon) up with scar tissue following abdominal which a perception occurs without
to allow the colon to heal before waste surgery (see adhesion). Other disorders any stimulus. Usually, illusions are brief
material passes through it. It may also of the ileum include Meckel’s diverticu- and can be understood when they are
be done as an emergency treatment for lum (a pouch in the ileum wall that may explained. They may be caused by
an obstruction in the intestine. The become ulcerated) and diseases in tiredness or anxiety, to drugs, or to
stoma is created from a loop of the which the absorption of nutrients is forms of brain damage. Delirium tremens
intestine that is brought to the skin sur- impaired, such as Crohn’s disease, coeliac (a condition usually arising from alco-
face. Once the intestine has healed, a disease, tropical sprue, and lymphoma. hol withdrawal in alcoholics) often
second operation is carried out to close brings on illusions.
the temporary ileostomy. ileus, gallstone
RECOVERY PERIOD The blockage of the small intestine by image, body
During convalescence, patients are given a gallstone that has travelled from the See body image.
counselling and are taught the practical biliary tract. Gallstone ileus is some-
aspects of stoma care or drainage of times a complication of cholecystitis imaging techniques
continent ileostomies. Full recovery from (inflammation of the gallbladder). Techniques that produce images of
I the operation takes about six weeks. Symptoms may include severe abdomi-
nal pain and bloating, vomiting, and
structures within the body (see Imaging
the body box).
ileum lack of bowel movements. Surgery is X-RAY TECHNIQUES
The final, longest, and narrowest sec- usually needed to remove the stone. The most commonly used and simplest
tion of the small intestine. It is joined at The gallbladder is generally removed at techniques are the X-rays (sometimes
its upper end to the jejunum and at its the same time. called plain X-rays) used to view dense
lower end to the large intestine (cae- structures such as bone. Simple X-ray
cum, colon, and rectum). The ileum‘s ileus, paralytic examinations include those of the
function is to absorb nutrients from A disorder in which the muscles of the chest, skull, and limbs following injury.
food that has been digested in the stom- intestines are unable to contract normal- Contrast X-rays involve the introduc-
ach and the first two sections of small ly, and as a result the intestinal contents tion into the body of a medium that is
intestine (the duodenum and jejunum). cannot pass out of the body. Paralytic opaque to X-rays.The techniques include
ileus is usually a temporary condition. It barium X-ray examinations (used to exam-
commonly follows abdominal surgery ine the oesophagus, the stomach and
LOCATION OF THE ILEUM and may also be induced by severe the intestine); cholecystography (used to
abdominal injury, peritonitis (inflamma- visualize the gallbladder and common
The ileum is situated
between the jejunum
tion of the membrane lining the bile duct); bronchography (to view the
(the middle part of the abdomen), acute pancreatitis (inflamma- airways connecting the windpipe to the
small intestine) and the tion of the pancreas), major disturbances lungs); angiography and venography (to
caecum (the first part of in blood chemistry (such as diabetic provide images of the blood vessels);
the large intestine). ketoacidosis), or interference with the intravenous urography (to visualize the
blood or nerve supply to the intestine. kidneys and urinary tract); and ERCP (in
Symptoms include a swollen abdomen, which the pancreatic duct and biliary
Duodenum Liver Stomach Jejunum
vomiting, and failure to pass faeces. system are examined after introducing a
The condition is treated by resting contrast medium through an endoscope).
the intestine. A tube passed through the Many X-ray techniques have now
nose or mouth into the stomach or been superseded by newer procedures
intestine removes accumulated fluids that are simpler to perform and safer
and keeps the stomach empty. Body and more comfortable for the patient.
fluid levels are maintained by intra- ULTRASOUND TECHNIQUES
venous infusion (drip). Ultrasound scanning involves the passing
of high-frequency sound waves through
ilium the body using a transducer placed
The largest of the hip bones that form against the skin. The waves are reflected
part of the pelvis. to varying degrees by structures of
different density; the pattern of echoes
illness is recorded electronically on a screen.
Perception by a person that he or she is Ultrasound scanning can now be used
not well. Illness is a subjective sensa- to produce three-dimensional images
Ilio-caecal Colon (large tion; it may have both physical and as well as moving images to show, for
Caecum valve Ileum intestine)
psychological causes. The term “illness” example, the opening and closing of a
is also used to mean disease or disorder. valve or blood flow within a vessel.

408
 IMAGING TECHNIQUES

IMAGING THE BODY

Over the past two decades many

methods of imaging the body have X-RAYS
been developed and are now widely
used. These techniques have made it Radiopaque contrast media may be utilized to give distinct X-ray images of soft
possible to visualize internal structures tissues, as in intravenous urography, which is used to give clear images of the
in a variety of ways. Today, in addition kidneys and urinary tract.
to conventional X-rays (which primarily
Left ureter Intravenous urogram
show bones), techniques such as CT This intravenous urogram
scanning, radionuclide scanning, shows the renal pelvises
ultrasound scanning, MRI, and PET Right renal
pelvis (urine-collecting areas of the
scanning are used to provide detailed kidneys) and the ureters,
diagnostic pictures of soft tissues and Stone
which have been filled with
organs. The examples given here show contrast medium. In the right-
some of the different ways in which hand renal pelvis and ureter
the kidneys can be imaged. (on the left of the urogram),
Right ureter
the medium has been
retained due to a kidney
stone blocking the ureter; the
Bladder stone appears as a small gap
in the ureter.
I
SCANNING TECHNIQUES
The body, particularly the soft tissues, can be imaged using Others, such as ultrasound scanning and radionuclide
a variety of modern techniques. Some of these techniques, scanning, can produce images without the need of a
such as CT scanning and MRI, rely on computers to process computer for image processing, although one may be
the raw imaging data and produce the actual image. used for image enhancement.
Kidney Cyst
Left kidney

Medulla of
kidney

Cortex of
kidney

Right kidney

Radionuclide scanning Ultrasound scanning

A radioactive substance is introduced into will appear brighter, than underactive cells. Ultra-high-frequency sound waves reflected from
the body, and the radiation emitted is This scan (taken from the back) shows healthy tissues in the body are converted into an image
detected by a gamma camera, which then kidneys. In each kidney, the medulla (central by special electronic equipment. This scan shows
converts it into an image. Active or overactive part) has absorbed more of the radioactive a fluid-filled cyst inside a kidney; the cyst
cells will take up more of the substance, and substance than the cortex (outer part). appears as a dark area on the image.

Spleen
CT scanning and MRI
Liver Left kidney These techniques produce cross-sectional images
(slices) or three-dimensional images of body structures.
This CT scan shows a cross-section through the body,
Cyst in left as seen from below; the front of the body is at the top
Right kidney kidney
(with tumour) of the image. The right kidney (shown on the left of
the image) is enlarged and distorted by a tumour. The
Spine left kidney has a cyst.

409
 IMDUR

COMPUTER-ASSISTED SCANNING imipramine ing inflammation, tissue damage, and

Many scanning techniques use comp- A tricyclic antidepressant drug that is specific immune complex diseases
uters to process the raw imaging data most commonly used in the long-term (which are also known as type III hyper-
and produce the actual image. In CT treatment of depression. Possible adverse sensitivity reactions).
scanning (computed tomography scan- effects of imipramine include excessive One example of an immune complex
ning), X-rays are passed through the sweating, blurred vision, dizziness, dry disease is extrinsic allergic alveolitis –
body at different angles. The computer mouth, constipation, nausea, and, in farmer’s lung, for example. In this disor-
analyses the data to produce cross-sec- older men, difficulty passing urine. der, immune complexes form after
tional images (“slices”) of the tissues that exposure to allergens such as fungal
are being examined. Newer CT scanners immersion foot spores; they then collect in the lungs,
can use a spiral technique to produce A type of cold injury, also called trench causing inflammation of the alveoli
three-dimensional images of structures. foot, occurring when the feet are wet (tiny air sacs). Other conditions caused
In MRI (magnetic resonance imag- and cold for a long time. Initially, the by immune complexes include some
ing), the patient is placed in a strong feet turn pale and have no detectable forms of glomerulonephritis (inflamma-
magnetic field within the scanner pulse; later, they become red, swollen, tion of the tiny structures in the kidneys
and radiofrequency waves are passed and painful. If the condition is ignored, that help to filter blood); certain connec-
through the body. A computer analyses muscle weakness, skin ulcers, or gan- tive tissue diseases, including systemic
changes in the magnetic alignment of grene may develop. lupus erythematosus and rheumatoid arthri-
the nuclei in the hydrogen cells to give tis; and adverse reactions to strepto-
either a cross-sectional or a three- immobility kinase, a thrombolytic drug used in the
I dimensional image of the tissues. This
technique provides greater contrast
Reduced physical activity, for example
through disease, injury, or following
treatment of myocardial infarction
(heart attack).
between normal and abnormal tissues major surgery. Immobility is particular-
than that given by CT scanning. ly harmful in elderly people because it immune response
PET scanning (positron emission tomo- causes muscle wasting and progressive The body’s defensive reaction to micro-
graphy scanning) involves the intro- loss of function. organisms, cancer cells, transplanted
duction of very short-lived radioisotopes COMPLICATIONS tissue, and other substances or materials
into the tissues of the brain. A computer Total immobility can produce various that are recognized as antigenic or “for-
analyses the paths of the gamma rays complications including bedsores, pneu- eign”. The immune response consists of
emitted by these radioisotopes, thereby monia, or contractures (deformity caused the production of cells called lympho-
providing information about both the by the shrinkage of tissue). A common cytes; substances called antibodies or
structure and function of the brain. complication that occurs with partial immunoglobulins; and other substances
In radionuclide scanning, a gamma immobility is oedema (fluid retention), and cells that act to destroy the anti-
camera records radiation emitted from which causes swelling of the legs. genic material. (See also immune system).
tissues into which a radioactive sub- Rarely, sluggish blood flow encourages
stance has been introduced. A computer formation of a thrombus (abnormal immune system
transforms the recordings into images blood clot) in a leg vein. A collection of cells and proteins that
and may be used to obtain more infor- TREATMENT works to protect the body from harmful
mation from the results. Certain radio- Regular physiotherapy and adequate microorganisms, such as bacteria, virus-
active substances are taken up, to varying nursing care are important for any per- es, and fungi. The immune system also
degrees, by different tissues, allowing son who is totally immobile. plays a role in the control of cancer and
specific organs to be studied in isolation. is responsible for the phenomena of
immobilization allergy, hypersensitivity, and rejection
Imdur An orthopaedic term that describes after transplant surgery.
A brand name for a slow-release prepa- techniques that are used to prevent NATURAL IMMUNITY
ration of isosorbide mononitrate, a drug movement of joints or displacement of The term “natural (or innate) immuni-
used in the treatment of angina pectoris fractured bones. Immobilization is per- ty” is given to the protection every
(chest pain caused by an inadequate formed so that fractured bones can individual is born with, such as the skin
blood supply to the heart). reunite properly (see fracture). and mucous membranes that line the
mouth, nose, throat, intestines, and
imidazole drugs immune complex vagina. Natural immunity also includes
A specific group of antifungal drugs used A combination of an antigen (any sub- antibodies, or immunoglobulins (protec-
for the treatment of fungal infections stance that the body identifies as foreign tive proteins), that are passed to the
such as candidiasis (vaginal thrush) and and that provokes an immune response) child from the mother via the placenta.
tinea (ringworm). and an antibody (a protein produced by If microorganisms penetrate these
the immune system for the purpose of defences, they encounter “cell-devour-
Imigran attacking foreign substances). Immune ing” white blood cells called phago-
A brand name for sumatriptan, a sero- complexes are normally removed from cytes, and other types of white cells,
tonin agonist drug that is used to treat the circulation by the liver and spleen. such as cell-killing (cytotoxic) cells.
migraine or cluster headaches. Imigran However, they may sometimes continue Microorganisms may also encounter
is available in different forms, including to circulate and eventually become substances that are naturally produced
tablets, injection, and nasal spray. trapped in organs or other tissues, caus- within the body (such as interferon) or

410
 IMMUNE SYSTEM

THE INNATE IMMUNE SYSTEM

Each of us has many inborn defences

against infection. These defences THE INFLAMMATORY RESPONSE
include external barriers such as the
skin and eye surfaces (below), the If microbes break through the body’s outermost barriers, inflammation is the
inflammatory response (right), and second line of defence. Chemicals such as histamine are released, prompting
the action of white blood cells called the effects shown below, including the attraction of phagocytes to the
phagocytes (below right). Others microorganisms and the release of substances such as complement.
include a substance called The symptoms of inflammation are redness, pain, swelling, and heat.
complement (which is activated by and Wound Inflammation
Dirty splinter Swelling Phagocyte
attacks bacteria) and another called
interferon (which has antiviral effects). Blood Fluid leak Widened
Bacterium blood vessels
All of these defences are nonspecific vessel
and quick-acting. By contrast, the
adaptive immune system (see overleaf)
mounts specific attacks against
particular microbes. These cells are
most effective on second exposure
to the organisms.
The two parts of the immune system
work together; antibodies produced by
the adaptive immune system assist
I
phagocyte action. Inflammatory process blood into the tissues. These reactions allow
Following tissue injury (here due to a splinter easier access for immune system components
in the skin) and the entry of bacteria or other that will fight the invaders, including
microbes, blood vessels in the area widen and phagocytes and soluble factors (such as the
Physical and chemical barriers there is an increased leakage of fluid from the group of substances known as complement).
These barriers, briefly described below,
provide the first line of defence against
harmful microbes (bacteria, viruses, Nose
and fungi). Hairs in the nose help to ACTION OF PHAGOCYTES
prevent microorganisms
Eyes from entering on dust
Tears produced by the particles. The process These white blood cells are attracted
lacrimal apparatus help to of expelling dust and to sites of infection, where they adhere
wash away microorganisms; microbes is assisted by
the sneeze reflex. to, engulf, and digest microorganisms
tears contain an enzyme
called lysozyme, which can and debris.
destroy bacteria.
Respiratory tract Phagocyte
Mucus secreted by cells Nucleus
lining the throat, windpipe,
and bronchi traps microbes, Bacterium
which are then swept away
Mouth by cilia (hairs on cells in
Lysozyme present in saliva the lining) or engulfed by Adherence The phagocyte comes into contact
destroys bacteria. phagocytes (types of white
cells). The cough reflex also 1Thiswith a microbe and recognizes it as foreign.
process is assisted by chemicals released
helps to expel microbes.
during inflammation.

Stomach and intestines

Lysosomes
Stomach acid destroys the
vast majority of microbes. Membrane
The intestines contain
harmless types of bacteria Pouch
(commensals) that compete forming
with and control the
harmful microorganisms. Ingestion The phagocyte engulfs the microbe
2particles,
in a pouch formed in its membrane. Fluid-filled
lysosomes, move towards the microbe.
Genito-urinary system
The vagina and urethra also
contain commensals and
are protected by mucus.
Enzymes
released into
Breast-feeding pouch
Antibodies (proteins with a protective Skin Bacterium
role) formed by the mother against particular Intact skin provides an
effective barrier against Digestion Enzymes within the lysosomes are
microbes are transferred to the baby in breast
milk. Breast-feeding provides some extra
most microbes. The
sebaceous glands secrete
3 released into the pouch to help digest the
microbe. Debris from this process is later ejected.
immunity until the baby can form his or her chemicals that are highly
own specific antibodies. toxic to many bacteria.

411
 IMMUNE SYSTEM

a group of blood proteins called the

THE ADAPTIVE IMMUNE SYSTEM complement system, which act to
destroy the invading organisms.
This system is based on white blood cells called lymphocytes. It has two parts.
Humoral immunity relies on the action of B-lymphocytes; these cells produce ACQUIRED IMMUNITY
antibodies, which circulate and attack specific microbes. In cellular immunity, cells The second part of the immune sys-
called T-lymphocytes are activated and attack specific microbes or abnormal cells tem, which is known as “acquired (or
(such as virally infected cells or tumour cells). “adaptive”) immunity”, comes into
play when the body encounters certain
HUMORAL IMMUNITY CELLULAR IMMUNITY organisms that overcome the innate
defences. The acquired, or adaptive,
Normal Killer
Bacterium B-lymphocytes cell T-lymphocyte immune system responds specifically
Surface
to each type of invading organism, and
antigen retains a memory of the invader so
that defences can be rallied instantly in
Abnormal any future invasion.
cell
The acquired immune system first
Shape of antigen must recognize part of an invading
Surface recognized by B-
antigen lymphocyte Shape recognized organism or tumour cell as an antigen
A humoral response is started when an An antigen, here on the surface of an (a protein that is foreign to the body).
1 antigen (foreign protein), here on the 1 abnormal cell (such as a virus-infected cell One of two types of response (humoral
I surface of a bacterium, is recognized by one
type of B-lymphocyte and activates it.
or a tumour cell), is recognized by specific killer
(cytotoxic) T-lymphocytes and activates them.
or cellular) is then mounted against the
invading antigen.
HUMORAL IMMUNITY
Killer Helper
T-lymphocyte T-lymphocyte Humoral immunity is important in the
defence against bacteria. Following a
complex recognition process, certain
Plasma cell
B-lymphocytes multiply and produce
Influence of
helper T-lymphocyte
vast numbers of antibodies that bind to
This particular type of B-lymphocyte
2 multiplies, forming cells called plasma
cells, which make antibodies designed
With the assistance of helper T cells (another
2T-lymphocyte
type of T-lymphocyte), the appropriate killer
the antigens on the invading organism;
the bacterium is then engulfed by
specifically to attack the bacterium. begins to multiply. phagocytes and destroyed. The binding
of antibody and antigen may activate
the complement system, which in-
creases the efficiency of the phagocytes.
CELLULAR IMMUNITY
Cellular immunity is particularly im-
Antibody
portant in the defence against viruses,
a b
some types of parasites that hide with-
After a few days, the antibodies are The killer T-lymphocytes attach themselves
3 released. They attach themselves to the
antigen. This triggers more reactions, which
3 to the abnormal cells (a), leading to the
cells’ destruction (b). The T-lymphocytes survive
in cells, and, possibly, against cancer
cells. Cellular immunity involves two
ultimately destroy the bacterium. and may go on to kill more targets.
Second exposure Second exposure

Some B-lymphocytes remain in the body

4the body
as memory cells; if the bacterium enters
again, they rapidly produce large
4attackSome of the killer T-lymphocytes remain
in the body as memory cells, and quickly
abnormal cells should they reappear (for
amounts of antibodies to halt the infection. example, after reinfection with a virus).

EXAMPLES OF INFECTIOUS ORGANISMS COMBATED

Humoral immunity particularly • Some viruses (e.g. hepatitis)
important against: • Many bacteria (e.g. cholera)
• Some parasites (e.g. malaria)
Lymphocytes
Cellular immunity particularly • Many viruses (e.g. herpes simplex) These types of white blood cells are found in the
important against: • Some bacteria (e.g. tuberculosis) blood and the lymphoid organs (the lymph nodes,
• Some fungi (e.g. candidiasis) spleen, and thymus). The two main types ( B- and
T-lymphocytes) have different functions but look
similar under the microscope.

412
 IMMUNOASSAY

immunization
TYPES OF IMMUNIZATION The process of artificially inducing
immunity as a preventive measure against
Two main types of immunization exist. In passive immunization, antibodies
infectious diseases.
(protective proteins) are injected into the body and provide immediate, but short-
lived, protection against specific disease-causing bacteria, viruses, or toxins. TYPES AND BENEFITS
Active immunization primes the body to make its own antibodies against such Immunization may be active or passive.
microorganisms and confers longer-lasting immunity. In the passive form, antibodies are in-
jected into the blood to provide
PASSIVE IMMUNIZATION ACTIVE IMMUNIZATION immediate but short-lived protection
against specific bacteria, viruses, or tox-
Blood is taken The person to ins. Active immunization, also called
1or, rarely,
from a person
an animal
1inoculated
be protected is
with a
Vaccine vaccination, primes the body to make
its own antibodies and confers longer-
previously exposed killed or modified
to a particular microorganism lasting immunity. It also protects the
microorganism. (vaccine) that does more vulnerable members of a commu-
The blood will not cause disease. nity, such as the very old or the very
contain antibodies young (see herd immunity).
against that Antibody
microorganism. WHO SHOULD BE IMMUNIZED
Routine childhood immunization pro-
grammes exist for diseases such as
Serum
diphtheria, tetanus, pertussis, poliomyel-
itis, and haemophilus influenzae (Hib)
I
An extract from The immune
2 the blood
containing the
2 system is
provoked to make
(see DTaP/IPV/Hib); measles, mumps, and
rubella (see MMR vaccination); meningitis
antibodies (known antibodies against C; and tuberculosis (see BCG vaccination).
as immune serum the modified
or antiserum) is microorganism;
For injections and timings, see Typical
injected into the it also retains childhood immunization schedule, overleaf.
person to be a “memory” of the Additional immunizations may also
protected. organism. be necessary before foreign travel (see
travel immunization).
Antibody
POSSIBLE RISKS
Immunizations are usually given by
The antibodies
3the microorganism
help to destroy 3thenIfmicroorganism
the real

enters the
injection, and most of them have no
after-effects. Some vaccines, however,
if it is present in the blood, antibodies cause pain and swelling at the site of
blood or enters it can be produced injection and may produce a slight
over the following quickly and in fever or flulike symptoms. Others may
few weeks. large numbers.
produce a mild form of the disease.
Very rarely, severe reactions occur as a
Disease-causing Disease-causing result of, for example, an allergy to one
microorganism microorganism
of the vaccine’s components. Not all
immunization provides complete pro-
tection against disease; typhoid fever
types of T-lymphocyte: helper cells, immunity vaccinations, in particular, give only
which play a role in the recognition of A state of protection against disease partial protection.
antigens, and killer cells (the second through the activities of the immune sys- People with immunodeficiency disorders
type of T-lymphocyte), which are acti- tem. Natural (innate) immunity is or who have widespread cancer, or those
vated by helper cells and destroy cells present from birth and is passively taking oral corticosteroid drugs should not
that have been invaded. acquired from the mother through the receive vaccines containing live organ-
placenta. Acquired (adaptive) immunity isms. Those who have previously had a
immune system disorders develops either through exposure to severe reaction to a vaccine should not be
Disorders of the immune system in- invading microorganisms or through immunized. Some vaccines should not be
clude immunodeficiency disorders and immunization and can be active or pas- given to young children, during preg-
allergy, in which the immune system sive. Active immunity occurs through nancy, or to HIV positive individuals.
has an inappropriate response to usu- vaccination with killed or weakened
ally innocuous antigens such as pollen. microorganisms, which primes the immunoassay
In certain circumstances, such as body to produce antibodies as a defence A group of laboratory techniques,
following tissue transplants, immuno- against future invaders of this type; pas- which include radioimmunoassay and
suppressant drugs are used to suppress sive immunity involves the admin- ELISA (enzyme-linked immunosorbent
the immune system and thus prevent istration of specific antibodies to fight assay), that are used in the diagnosis of
the body rejecting the donor tissue as the infection, for example, following infectious diseases, to confirm immun-
a foreign organism. exposure to chickenpox. ity, and also to investigate allergies. The

413
 IMMUNOCOMPROMISED

due to autoimmune diseases or after

TYPICAL CHILDHOOD IMMUNIZATION SCHEDULE organ transplantation, or as a side effect
Age Disease of treatment for another condition.
Severe malnutrition and many cancers
2 months Diphtheria/tetanus/pertussis/poliomyelitis/haemophilus can also cause immunodeficiency. Mild
influenzae b (Hib)*; meningococcus c immunodeficiency arises through a natu-
ral decline in immune defences with age.
3 months Diphtheria/tetanus/pertussis/poliomyelitis/haemophilus
influenzae b (Hib)*; meningococcus c immunoglobulin
Also known as an antibody, a type of pro-
4 months Diphtheria/tetanus/pertussis/poliomyelitis/haemophilus tein found in blood and tissue fluids.
influenzae b (Hib)*; meningococcus c Such proteins are produced by B-lym-
phocytes (a type of white blood cell).
12–15 months Measles/mumps/rubella (MMR)* Their function is to bind to substances
in the body that are recognized as for-
3–5 years Diphtheria/tetanus/pertussis/poliomyelitis*†; measles/mumps/
eign antigens, such as proteins on the
rubella*† surfaces of bacteria and viruses. This
binding is crucial for the destruction of
10–14 years (tuberculin- Bacillus Calmette Guerin (BCG) against tuberculosis
antigen-bearing microorganisms. Im-
negative children) munoglobulins also play a key role in
I allergies and hypersensitivity reactions.
There are five main classes of im-
13–18 years Diphtheria/tetanus/poliomyelitis*†; in addition, meningococcus c
can be given up to age 24 if not had already munoglobulin in the blood (IgA, IgD,
IgE, IgG, and IgM). IgA is mainly found
†Booster
in secretions of the respiratory tract,
*Combined injection
intestine, and urinary tract. Only low
levels of IgD are present in the body and
its function is not known. IgE is involved
tests are performed to determine tunistic infections), and an undue sus- in the immune response to worm infes-
the presence or absence of particular ceptibility to certain forms of cancer. tations; high levels are also produced to
antigens (proteins that are present on Opportunistic infections include pneu- fight atopic (allergic) conditions. IgG is
the surface of microorganisms or aller- mocystic pneumonia, fungal infections, and the major class of immunoglobulin,
gens) or antibodies (proteins that are widespread herpes simplex infections. with four subclasses; its molecule con-
formed by the immune system to INHERITED IMMUNODEFICIENCY sists of two parts, one of which binds to
combat a particular microorganism or Congenital or inherited deficiencies can an antigen and the other to other cells
allergen). Immunoassay procedures may occur in either of the two prongs of the of the immune system, which then
also be used to measure blood levels of adaptive immune system – humoral or engulf the microorganisms bearing the
hormones (which are also proteins). cellular immunity – or in both. antigen.The most important function of
Deficiencies of the humoral system IgG is to mount a response to bacterial
immunocompromised include hypogammaglobulinaemia and infections. IgM is produced promptly in
A term used to describe a person whose agammaglobulinaemia. The former may response to infection and then levels
immune system activity has been cause few or no symptoms, depending fall; IgM present in an infant at birth is
reduced by disease (such as AIDS or can- on the severity of the deficiency, but an indicator of intrauterine infection.
cer) or by certain medical treatments agammaglobulinaemia can be fatal if Immunoglobulins can be extracted
(such as treatment with immunosuppres- not treated with immunoglobulin. from the blood of people who have rec-
sant drugs). An immunocompromised Congenital deficiencies of T-lympho- overed from certain infectious diseases
person is at a greater than normal risk cytes may lead to problems such as and used for passive immunization.
of contracting infections, particularly persistent and widespread candidiasis
so-called opportunistic infections (diseases (thrush). A combined deficiency of immunoglobulin injection
caused by organisms that rarely pose a both humoral and cellular components The administration of immunoglobulin
threat to healthy people). of the immune system, called severe preparations (antibodies) to prevent or
combined immunodeficiency (SCID), is treat infectious diseases. Such prepara-
immunodeficiency disorders usually fatal in the first year of life tions, also known as immune globulin
Disorders in which the defences of the unless treatment can be given by bone or gamma-globulin injections, work by
immune system fail to fight infection and marrow transplant. passing on antibodies obtained from
tumours. Immunodeficiency disorders ACQUIRED IMMUNODEFICIENCY the blood of people who have prev-
may be due to an inherited or a congeni- Acquired immunodeficiency may be iously been exposed to these diseases.
tal defect or may be the result of due to disease processes (such as infec- The main use of these injections is
acquired disease. The result is persistent tion with HIV, which leads to AIDS). It to prevent infectious diseases, such as
or recurrent infection, including infec- may also be caused by damage to the chickenpox, in those people exposed
tions with organisms that would not immune system as a result of its sup- to infection who are not already
ordinarily cause disease (see oppor- pression by drugs, either intentionally immune, or in those who are at special

414
 IMPETIGO

risk (during cancer treatment, for The drugs work by suppressing the pro- tooth and the gum, causing pain and
example). They are also given intra- duction and activity of white blood inflammation in the gum tissues (see
venously on a regular basis for immuno- cells called lymphocytes. Side effects vary, gingivitis). If the problem persists, the
deficiency disorders. Side effects of such but all of these drugs increase the risk affected teeth need to be removed.
injections include rash and fever, and of infection and of the development of
pain and tenderness at the injection certain cancers. impaction, faecal
site if injected into a muscle. See faecal impaction.
immunotherapy
immunology Stimulation of the immune system as a impedance audiometry
The discipline that is concerned with the treatment for cancer. The term is also A hearing test used to investigate the
immune system. Immunologists study used to describe hyposensitization treat- performance of the middle ear in cases
the immune system’s functioning and ment for allergy. of conductive deafness.
investigate and treat immune system dis- One type of immunotherapy that is
orders, including autoimmune disorders, employed in the treatment of cancer imperforate
allergies, and immunodeficiency disorders uses immunostimulant drugs. For exam- A term meaning “without an opening”.
such as AIDS. ple, treatment of bladder cancer may The term is used to describe a body
Immunologists are also concerned involve the introduction of BCG into structure, such as the hymen or the anus
with finding ways in which the the bladder. More recently, genetic engi- (see anus, imperforate), which should
immune system can be stimulated to neering has been used to manufacture have an opening but does not.
provide immunity. In addition, they monoclonal antibodies (see antibody,
play a role in transplant surgery. Before monoclonal) to be directed against impetigo I
operations, they look for a good match tumours. Interferon or chemical poisons A highly contagious skin infection,
between recipient and donor organ; can be linked to these antibodies in common in children, that most com-
after transplantation they use drugs to order to increase their ability to monly occurs around the nose and
suppress the recipient’s immune sys- destroy tumour cells without damag- mouth, but can affect the skin anywhere
tem, in order to minimize the chances ing normal cells. on the body.
of organ rejection. CAUSE AND SYMPTOMS
Imodium Impetigo is caused by bacteria (usually
immunostimulant drugs A brand name for loperamide, an staphylococci) entering areas of bro-
COMMON DRUGS antidiarrhoeal drug. ken skin. The skin reddens and small,
• Aldesleukin • BCG • Interferon alfa fluid-filled blisters appear. The blisters
• Interferon beta • Peginterferon alfa impaction, dental tend to burst, leaving moist, weeping
Failure of a tooth to emerge completely
A group of drugs that increase the effi- from the gum. It may occur because of
ciency of the body’s immune system. overcrowding or when a tooth grows in
Immunostimulant drugs include vac- the wrong direction.
cines, interferon, and aldesleukin (inter- Impacted wisdom teeth are common
leukin-2). Interferon alfa is used to treat when the teeth come through in early
persistent viral infections, such as adulthood. If they cause no symptoms,
hepatitis C. Interferon beta is used to they do not need to be removed. In
treat some types of multiple sclerosis. some cases, however, impacted wis-
Aldesleukin is used in the treatment of dom teeth partially penetrate the gum,
kidney cancer. leaving a flap of tissue over most of the
crown. Plaque, bacteria, and food
immunosuppressant drugs debris may then collect between the
COMMON DRUGS The appearance of impetigo
Fluid-filled blisters appear on the skin (in this case,
ANTICANCER DRUGS • Azathioprine on a young child’s mouth and chin). The blisters
• Chlorambucil • Cyclophosphamide often burst, releasing fluid that dries to leave pale
• Methotrexate • Mycophenolate mofetil brown crusts on the skin.
CORTICOSTEROID DRUGS • Prednisolone
ANTIBODIES • Anti-lymphocyte globulin areas that dry to leave honey-coloured
• Basiliximab • Daclizumab or golden crusts. In severe cases, there
OTHER DRUGS • Ciclosporin • Tacrolimus may be swelling of the lymph nodes in
the face or neck and fever.
A group of drugs that are used to TREATMENT AND PREVENTION
reduce the activity of the immune system. Treatment is with topical (locally ad-
Immunosuppressants are given to pre- ministered) antibiotic drugs unless the
vent rejection of donor tissue after condition is widespread, in which case
Impacted wisdom teeth
transplant surgery. They are also given to This X-ray shows impacted upper and lower wisdom oral antibiotics are usually given.
slow the progress of autoimmune dis- teeth. The teeth are wedged against an adjacent As the condition is highly contagious,
orders such as rheumatoid arthritis and molar and are unable to erupt normally; the tooth to prevent the spread of the infection,
systemic lupus erythematosus. in the lower jaw is lying horizontally. towels, flannels, and pillowcases should

415
 IMPLANT

not be shared. Children should not go mellitus, damage to the spinal cord, or an a simultaneous stimulus on the other
to school or mix with others until alcohol-related disorder. Impotence may side. Visual inattention (failure to
they have been treated and the condi- be caused by taking various drugs, respond to local visual stimuli) may
tion has cleared up. such as antidepressant drugs and antihy- also be present. The condition is most
pertensive drugs. Impotence is found to commonly the result of a stroke.
implant be more common in older men, which
Any material, either natural or artificial, is possibly due to altered circulation or inborn errors of metabolism
that is inserted into the body for medical reduced levels of the male sex hor- See metabolism, inborn errors of.
or cosmetic purposes. mone testosterone.
TREATMENT incest
implantation, egg Tests may be performed to eliminate Sexual intercourse between close rela-
Attachment of a fertilized ovum (egg) to the possibility of a physical disorder. A tives, such as with a parent, a son or
the wall of the uterus. Implantation change in current medication may also daughter, a brother or sister, an uncle or
occurs about six days after fertilization, be advised to see if the condition of aunt, a nephew or niece, or a grandpar-
when the blastocyst (early embryo) impotence is affected. ent or grandchild. Incest is illegal or
comes into contact with the uterus wall. If the cause of impotence is psycho- taboo in most societies and is against
As the cells of the developing embryo logical, counselling or sex therapy may the teaching of many religions.
continue to divide, the outer cell layer be recommended and is often found to
penetrates the lining of the uterus to be a successful treatment. incidence
obtain oxygen and nutrients from the Treatment of a physical cause may be One of the two principal measures (the
I mother’s blood; later, this layer develops
into the placenta. The embryo usually
possible, for example, with the drug
sildenafil (Viagra). However, due to the
other is prevalence) of how common a
disease is in a defined population. The
implants in the upper part of the uterus; drug’s effects on the vascular system, it incidence of a disease is the number of
if it implants low down near the cervix, should be used with caution in men new cases that occur during a given
placenta praevia may develop. Rarely, with certain disorders, such as angina period (for example, 17 new cases per
implantation occurs outside the uterus, pectoris; it should not be used after a 100,000 people per year).
possibly in a fallopian tube, resulting in recent stroke or myocardial infarction
an ectopic pregnancy. (heart attack). Sildenafil should never incision
be taken without medical advice. Other A cut made into the tissues of the body
implant, dental treatments include self-administered by a scalpel (surgical knife). Most inci-
A post that is surgically embedded in the injections into the penis and a surgical sions are made to gain access to tissue
jaw for the attachment of a dental pros- implant, which can produce a sus- inside the body, usually to repair or
thesis (an artificial tooth). Titanium or tained erection. remove a diseased organ. An incision
synthetic materials may be used. A den- may also be made to allow pus to drain
tal implant is fitted under either a local impression, dental from an abscess or boil.
or general anaesthetic (see anaesthesia, A mould taken of the teeth, gums, and
dental). A hole is drilled in the jaw and palate. A quick-setting material, such as incisional hernia
the post inserted. Several months later, alginate, is placed in a mould over the A type of hernia in which the intestine
an attachment that protrudes from the teeth. The mould is then removed, and bulges through a scarred area of the
gum is screwed into the post; a few plaster of Paris poured into it to obtain abdominal wall because the surround-
weeks after that, the prosthesis is fitted. a model of the area. This model is then ing muscle has been weakened by a
used as a base on which to build a den- previous surgical incision.
implosive therapy ture, bridge, or dental inlay.
A form of behaviour therapy, also known Dental impressions are also used in incisor
as flooding, used for desensitizing a per- orthodontics to study the position of the One of the eight front teeth (four in
son to the cause of a phobia. teeth, and to make orthodontic appli- the upper jaw and four in the lower)
ances to correct irregularities. used for cutting through solid food
impotence (see teeth).
The inability to achieve or maintain an impulse
erection. Impotence, known medically as A sudden, spontaneous force or action. incompatible blood transfusion
erectile dysfunction, is the most com- In biology and medicine, the term A blood transfusion in which the
mon male sexual disorder, affecting “impulse” is usually used to refer to patient’s immune system reacts against
most men at some time in their lives. the electrical activity that travels along the donor blood as a foreign invader
CAUSES a nerve which may result, for example, (see blood transfusion, incompatible).
Impotence is usually caused by psycho- in a muscle contraction.
logical factors, be they temporary (for incompetence
example, due to stress) or longstanding inattention, sensory A medical term applied to a structure
(such as due to anxiety and guilt origi- In neurology (the study of diseases of that should close tightly but does not.
nating in childhood). Impotence may the nervous system), a term meaning For example, valve incompetence (see
be a symptom of depression. the inability to recognize a tactile stim- aortic incompetence; mitral incompetence)
Some cases of impotence are caused ulus (such as a pinprick) on one side causes leakage of blood; cervical incompe-
by a physical disorder, such as diabetes of the body, while reacting normally to tence may result in a miscarriage.

416
 INDERAL

incomplete abortion not full) is accompanied by inability to incubation period

The retention in the uterus of placental control the bladder as it contracts. Once The time during which an infectious dis-
or fetal tissue after a miscarriage or a urination starts, it cannot be stopped, ease develops, from the point when the
medical abortion (see abortion, induced). leading to the loss of large volumes of infectious organism enters the body
If this tissue is not promptly removed, it urine. Urge incontinence is often caused until symptoms appear. Different infec-
may become infected, resulting in a by irritability of the bladder lining. The tions have characteristic incubation
dangerous condition called septic abor- problem may be caused by infection or periods; for example, 14–21 days for
tion and haemorrhage (bleeding). inflammation (see cystitis). It may also chickenpox and 7–14 days for measles.
result from the presence of stones (see The incubation period for cholera may
incontinence, faecal calculus, urinary tract) or bladder tumours; be as short as several hours.
Inability to retain faeces in the rectum, disorders affecting the nerves that sup-
leading to involuntary defaecation. ply the bladder (such as stroke or multiple incubator
CAUSES sclerosis); or anxiety. In some cases the A transparent plastic cot that provides
A common cause of faecal incontinence bladder muscles are too sensitive to premature or sick infants with ideal
is faecal impaction, which often results increasing pressure within the bladder, conditions for survival. In an incubator,
from long-standing constipation. In this inappropriately triggering emptying. oxygen, temperature, and humidity lev-
condition the rectum becomes overfull, Total incontinence is a complete lack els are controlled. Incubators have
causing faecal fluid and small pieces of of bladder control due to loss of func- portholes to allow handling of the baby,
faeces to be passed involuntarily around tion in the urethral sphincter. It may be and smaller ones through which mon-
the impacted mass of faeces. Temporary associated with spinal cord damage, due itoring cables and intravenous and
loss of continence may also occur in
severe diarrhoea. Other causes include
to disease or injury, that affects the
nerves supplying the bladder.
respiratory tubing can pass. I
injury to the anal muscles (as may occur Overflow incontinence occurs in
during childbirth), paraplegia (damage long-term urinary retention, often because
to the nerves in the lower trunk, includ- of an obstruction such as an enlarged
ing those supplying the intestines), and prostate gland. The bladder is always full,
dementia (loss of normal brain functions, leading to constant dribbling of urine.
such as control of the bowels). Incontinence due to lack of control by
TREATMENT the brain commonly occurs in young
Faecal incontinence can usually be suc- children (see enuresis) or elderly people,
cessfully treated. If the underlying cause and in those with learning difficulties.
of faecal impaction is constipation, TREATMENT
recurrence may be prevented by eating a A wide range of treatments for urinary
high-fibre diet. Suppositories contain- incontinence are available, and most
ing glycerol or laxative drugs may be affected people achieve significant
recommended. Pelvic floor and anal improvement. If weak pelvic muscles
Premature infant in an incubator
sphincter damage can often be surgical- are causing stress incontinence, pelvic Portholes make it possible for medical staff or
ly repaired. Faecal incontinence in people floor exercises may be helpful. Some- parents to handle the infant without disturbing
with dementia or a nerve disorder may times, surgery may be needed to tighten the special conditions in the incubator.
be avoided by regular use of enemas or the pelvic muscles or correct a prolapse.
suppositories to empty the rectum. Anticholinergic drugs may be used to incus
relax the bladder muscle if irritable One of the three tiny, linked bones
incontinence, urinary bladder is the cause. Collagen injections (ossicles) in the middle ear that convey
Involuntary passing of urine, often due into the urethral wall, performed under sound vibrations. The incus (the Latin
to injury or disease of the urinary tract. anaesthetic, may also be effective. name for an anvil) is so called because
There are several types. If normal bladder function cannot be it is said to resemble an anvil.
TYPES AND SYMPTOMS restored, incontinence pants can be
Stress incontinence refers to the invol- worn; men, alternatively, can wear a indapamide
untary escape of urine when a person penile sheath leading into a tube con- A diuretic drug used in the treatment of
coughs, laughs, picks up a heavy object, nected to a urine bag. Some people hypertension (high blood pressure). Pos-
runs, or jumps. It develops when the can avoid incontinence by means of sible side effects include headaches,
urethral sphincter muscles (which nor- self-catheterization (see catheterization, fatigue, and muscle cramps. Less com-
mally keep the bladder outlet closed) urinary). Permanent catheterization is mon adverse effects include dizzi-
have been stretched and weakened. Stress necessary in some cases. ness, fainting, “pins and needles”, sore
incontinence is common in women, par- throat, rash, and jaundice; these prob-
ticularly after childbirth or in patients incoordination lems need prompt medical attention.
with prolapse of the uterus or vagina. Loss of the ability to produce smooth,
This condition results in the loss of muscular movements, leading to clum- Inderal
small amounts of urine. siness and unsteady balance. The term A brand name for propranolol, a beta-
In urge incontinence, also known as “incoordination” can also mean the blocker drug used to treat heart and
irritable bladder, an urgent desire to failure of a group of organs to work circulatory disorders as well as some
pass urine (even though the bladder is together successfully. (See also ataxia.) mental problems.

417
 INDIAN MEDICINE

Indian medicine such as rheumatoid arthritis, osteoarthri- blood vessel walls) or an organ (such
A system of medicine originally based tis, and tendinitis. It is also prescribed to as the lung or liver) due to inflamma-
largely on herbal treatment, although relieve the pain that is caused by injury tion or disease. (See also sclerosis.)
simple surgical techniques were also to soft tissues, such as muscles and lig-
used. Indian medicine, also known as aments. Side effects of indometacin industrial diseases
ayurvedism, later developed into a scien- include abdominal pain, nausea, heart- See occupational disease and injury.
tifically based system with a wide range burn, headache, dizziness, and an
of surgical techniques (such as opera- increased risk of peptic ulcer. industrial psychology
tions for cataracts and kidney stones) A field of psychology in which human
alongside emphasis on purifying tech- indoramin behaviour is studied in relation to the
niques, diet, yoga, breathing exercises, An alpha-blocker drug used to treat hyper- effects and influences of the workplace.
and the herbal tradition. Indian medicine tension (high blood pressure). It acts by The principles of industrial psychology
has been used effectively to treat a variety relaxing the muscles in the blood vessel are applied to such issues as leadership,
of conditions, including digestive prob- walls, thus allowing the vessels to communications, motivation, job analy-
lems, rheumatoid arthritis, allergies, viral widen and easing the flow of blood. In sis, and selection of employees.
infections, and anxiety-related disorders lower doses, indoramin is also pre-
such as insomnia. scribed to relieve the symptoms of an indwelling catheter
enlarged prostate gland (see prostate, A catheter (flexible tube) that remains
indigenous enlarged); it relaxes the muscle of the in place for a prolonged period. The
Native to a particular place or country. prostate and thereby enables urine to be term usually refers to a urinary catheter
I In medicine, this concept is important
when investigating the effect of envi-
passed more easily.
When first taken, indoramin can
that is used to drain the contents of the
bladder via the urethra; it is held in place
ronmental factors on disease patterns. cause a rapid fall in blood pressure. For with a balloon (see balloon catheter).
this reason, the first dose is usually
indigestion small and is taken lying down. Indo- in extremis
A common term (known medically as ramin may also cause drowsiness at the The Latin term for “at the point of death”.
dyspepsia) covering a variety of symp- start of treatment and whenever the
toms brought on by eating, including dosage is increased. Infacol
heartburn, abdominal pain, nausea, and A brand name for dimeticone (an anti-
flatulence (excessive wind in the stom- induction of labour foaming agent used to relieve colic).
ach or intestine, that causes belching Use of artificial means to begin labour if
and discomfort). the health of the mother or baby would infant
Discomfort in the upper abdomen is be at risk if the pregnancy was allowed A term usually applied to a baby up to
often caused by eating too much, too to continue for longer. the age of 12 months.
quickly, or by eating very rich, spicy, or WHY IT IS DONE
fatty foods. Persistent or recurrent indi- The most common reason for inducing infantile autism
gestion may be due to a peptic ulcer, labour is that the pregnancy has con- An alternative term for autism, a disor-
gallstones, oesophagitis (inflammation of tinued past the estimated delivery date, der that usually develops in early
the oesophagus), or, rarely, stomach cancer. which increases the chance of compli- childhood and causes severe impairment
Antacid drugs help to relieve the symp- cations during childbirth. Other reasons of language and communication skills.
toms, but they may mask an underlying for induction are pre-eclampsia (a seri-
cause that needs medical attention. They ous condition involving high blood infantile cataract
should not be taken for longer than two pressure and fluid accumulation), Rhe- A congenital disorder (one present from
weeks without medical advice. sus incompatibility (a difference between birth) in which a baby’s sight is seriously
the blood groups of mother and fetus), impaired by opacity of the lens of the
indole or intrauterine growth retardation (poor eye (see cataract). Causes include infec-
A substance produced by the break- growth of the developing fetus). tions, such as rubella (German measles)
down of the amino acid tryptophan in HOW IT IS DONE and toxoplasmosis, passed from mother
the intestine. Indole is excreted in Different methods of induction are to baby before birth. Surgical removal
urine. An indole compound (5-hydroxy- used, depending on the stage of labour of the cataract may be beneficial.
indole acetic acid) is measured in the and cervical condition. A prostaglandin
urine in the investigation of possible pessary may be inserted high into the infantile colic
carcinoid tumours. vagina to encourage the cervix to soften See colic, infantile.
and open. The hormone oxytocin may
indolent ulcer also be given as a continuous intra- infantile eczema
A term describing an ulcer that is slow venous infusion in order to stimulate An alternative term for atopic eczema
to heal but usually causes little pain. uterine contractions. that first develops in early childhood.
indometacin induration infantile spasms
A nonsteroidal anti-inflammatory drug A specific medical term meaning the A rare type of recurrent seizure, also
(NSAID) used to relieve pain, stiffness, hardening or thickening of areas of called progressive myoclonic enceph-
and inflammation caused by disorders soft tissue (for example, the skin or alopathy or salaam attacks, that affects

418
 INFECTIOUS DISEASE

babies. The condition is a form of antibacterials or antivirals. For further infections. Conditions that may be acqu-
epilepsy and first occurs around four to information about different infectious ired during delivery include herpes,
nine months of age. diseases, see the accompanying tables. chlamydial infections, and gonorrhoea.
Spasms may occur hundreds of times TREATMENT
a day, each lasting a few seconds. Dur- infection, congenital Treatment of the baby depends on the
ing a seizure, the baby’s head suddenly Infection that is acquired by a baby in type of infection. Some birth defects
falls forwards, the body stiffens, and the the uterus or during birth. caused by infection (such as certain
limbs bend, then the arms and hands INFECTIONS ACQUIRED IN THE UTERUS types of heart defect) can be treated;
extend and move outwards. These Many microorganisms can pass from others (such as congenital deafness) are
seizures are usually a sign of brain dam- the mother, by way of the placenta, into usually not treatable.
age; affected babies usually have severe the circulation of the growing fetus.
developmental delay. Particularly serious infections that may infectious disease
be acquired in the uterus are rubella, Any illness that is caused by a specific
infant mortality syphilis, toxoplasmosis, and cytomegalo- microorganism. The most important
The number of infants who die during virus. All these infections may cause disease-causing organisms are viruses,
the first year of life per 1,000 live births intrauterine growth retardation. Rubella bacteria, including rickettsiae, chlamyd-
(usually expressed as per year). The that occurs in early pregnancy may iae, mycoplasmas, and fungi. Others are
majority of infant deaths occur during cause deafness, congenital heart disease, protozoa and worms.
the neonatal period (the first month of and eye disorders. INCIDENCE
life). Most of those who die are very Some diseases in later pregnancy In affluent countries, infectious diseases
premature and of low birth weight, or
have severe congenital abnormalities.
may also damage the fetus severely.
One such condition is infection with a
are generally less of a threat than in the
past because of better methods to con-
I
herpes virus. A woman infected with trol the spread of disease organisms
infarction HIV risks passing it on to her baby dur- (such as improved sanitation and water
Death of an area of tissue due to ing pregnancy, but the risk can be purification); effective drugs; immuniza-
ischaemia (lack of blood supply). One reduced by use of antiretroviral drugs tion; and better general health and
common example is myocardial infarc- during the pregnancy. nutrition. In poorer countries, such dis-
tion, commonly called a heart attack. INFECTIONS ACQUIRED DURING BIRTH eases still pose a threat, both to people
Another is pulmonary infarction, which Infections acquired during birth are who live in these countries and to trav-
is lung damage caused by a pulmonary almost always the result of microorgan- ellers who visit them.
embolism – a blood clot that has moved isms in the mother’s vaginal secretions or INCUBATION PERIOD
into a vessel in the lung and is obstruct- uterine fluid. Premature rupture of the For most infectious diseases, there is a
ing the flow of blood. (See also necrosis). membranes is associated with increased time gap between the entry of the micro-
risk of disease, particularly streptococcal organisms into the body and the first
infection
The establishment in the body of dis-
ease-causing microorganisms (such as HOW INFECTIOUS DISEASES ARE TRANSMITTED
bacteria, viruses, or fungi). The organisms
In affluent countries, infections are usually spread by sexual transmission, airborne
reproduce and cause disease by direct transmission, blood-borne transmission, or direct skin contact. In poorer countries,
damage to cells or by releasing toxins. insects, food, and water are other important mechanisms of transmission. Certain
This activity normally provokes the im- infectious diseases can also pass from a pregnant woman’s blood across the
mune system into responding, which placenta into the blood of the fetus.
accounts for many common symptoms.
Infection can be localized within a Body of Flagella (propels
nta Wate
particular area or tissue, as in a boil, or bacterium bacterium) lace r-bo
sp rne
cros
be systemic (spread throughout the A
body), as in influenza. Localized infec-
ion
iss

tion may result from the spread of

Fo
sm

od -

organisms through wounds, or during

ran

b
orne

surgery. This form of infection is gener-

Sexual t

ally associated with pain, redness,

swelling, and formation of a pus-filled
abscess at the site of infection, and a
rise in temperature. Weakness, aching
ne
Airb

-bor

joints, and fever are expressions of sys-

o

ect

temic infectious disease.

rne

Salmonella bacterium
Ins

Many minor infections are dealt with This image shows the bacterium
by the immune system and need no Salmonella enteritidis, which can
Blo t
specific treatment. A localized infection cause food poisoning. These od- tac
bacteria may be found in meat, born con
that has produced pus may be drained e Sk in
eggs, and milk.
surgically. Severe systemic infections may
need treatment with drugs such as

419
 INFECTIOUS DISEASE

appearance of symptoms. This incubation bacterial infection. For viral infection, such as sexually transmitted infections is
period, during which an infected person however, drug treatment is restricted to difficult to control and, for many infec-
is likely to pass the microorganism to severe infections and often relies on tions, no effective vaccine exists.
others, may vary from a few hours or supportive measures alone. Some bacteria have developed resis-
days to, in some cases, several months. OUTLOOK tance to the drugs available; this could
TREATMENT Progress has been made in the fight lead to a rise in potentially fatal
and other antimicrobial
Antibiotic drugs against infectious diseases, but many bacterial infections similar to those
drugs are the mainstay of treatment for problems remain. The spread of diseases common before the development of

INFECTIOUS DISEASES: VIRAL INFECTIONS

Disease Infective agent Transmission Incubation Symptoms Treatment
period

AIDS/HIV Human Sexual contact; sharing 6–8 weeks Flulike illness; fever; fatigue; Treatment given for
infection immunodeficiency hypodermic needles; sore throat; muscle aches; complicating infections;
virus (HIV) mother to fetus or to swollen lymph nodes; skin antiviral drugs can
breast-fed baby; disorders; fungal, viral, or prolong life expectancy
unscreened blood bacterial infections
transfusions

I Chickenpox Varicella-zoster Airborne droplets; direct 7–21 days Slight fever; malaise; crops of Relief of symptoms;
virus (herpes contact itchy blisters aciclovir beneficial
zoster virus) in adults

Common cold Numerous Airborne droplets; hand-to- 1–3 days Sneezing; chills; muscle aches; Relief of symptoms
rhino- and hand contact runny nose; cough
adenoviruses;
coronaviruses

Hepatitis, viral Hepatitis virus A, E: infected food or water A, E: 3–6 Flulike illness; jaundice; many Relief of symptoms;
types A, B, C, D, weeks people are asymptomatic interferon may be
or E B, C, D: sexual contact; B, C, D: a few beneficial in some cases
infected blood; sharing weeks to
needles several months

Influenza Influenza virus Airborne droplets 1–3 days Fever; chills; aches; headache; Relief of symptoms;
types A, B, or C sore throat; cough; runny nose fluids

Measles Measles virus Airborne droplets 7–14 days Fever; coldlike symptoms; Relief of symptoms
(a paramyxovirus) mottled red rash that fades to
leave staining; conjunctivitis

Meningitis, Various viruses Various methods, including Variable Fever; headache; drowsiness; Relief of symptoms
viral via rodents confusion

Mononucleosis, Epstein–Barr virus Possibly via saliva 1–6 weeks Swollen glands; fever; sore Relief of symptoms; rest;
infectious throat; headache; malaise; fluids
(glandular lethargy
fever)

Poliomyelitis 3 polioviruses From faeces to mouth via 3–21 days Minor illness: headache; sore Relief of symptoms
hands; airborne droplets throat; vomiting
Major illness: fever; stiff neck and
back; muscle aches; paralysis

Rabies Rabies virus Bite, or lick on broken skin, Usually 2–8 Fever; malaise; irrationality; No effective treatment
(a rhabdovirus) from infected animal weeks, but may throat spasms; hydrophobia
be over 1 year

Rubella Rubella virus Airborne droplets; mother 14–21 days Low fever; characteristic rash; Relief of symptoms
to fetus congenital abnormalities in
fetus, including ear, eye, and
heart defects

420
 INFECTIOUS DISEASE

INFECTIOUS DISEASES: BACTERIAL INFECTIONS

Disease Infective agent Transmission Incubation period Symptoms Treatment

Gonorrhoea NEISSERIA Sexual contact; 2–6 days Pain on passing urine; Penicillin; ampicillin;
GONORRHOEAE mother to baby at discharge; pain in abdomen other antibiotics for
delivery resistant forms

Meningitis, NEISSERIA Airborne droplets Less than 3 weeks; High fever; stiff neck; nausea; Immediate treatment
bacterial MENINGITIDIS may be less than confusion; purple rash that with antibiotics
(meningococcus); 48 hours does not fade (in
STREPTOCOCCUS meningococcus)
PNEUMONIAE ;
others

Pertussis BORDETELLA Airborne droplets 1–2 weeks Runny nose and moderate Erythromycin to prevent
(whooping PERTUSSIS fever; slight cough leading to spread of infection; small
cough) characteristic cough spasms children may require
and vomiting hospital admission

Pneumonia STREPTOCOCCUS Airborne droplets 1–3 weeks Cough; fever; chest pain; Antibiotics
PNEUMONIAE ;
MYCOPLASMA
shortness of breath I
PNEUMONIAE ;
others

Tuberculosis MYCOBACTERIUM Airborne 4–12 weeks for Fever; malaise; weight loss; Multiple antituberculous
TUBERCULOSIS transmission; primary infection; cough; shortness of breath; drugs for several months
unpasteurized disease may be chest pain
cows’ milk reactivated later in life

Typhoid fever SALMONELLA TYPHI Food or water 1–2 weeks, Headache; lethargy; Antibiotics
contaminated with sometimes longer constipation; very high,
infected faeces prolonged fever; dry cough

INFECTIOUS DISEASES: CHLAMYDIAL INFECTIONS

Disease Infective agent Transmission Incubation period Symptoms Treatment

Nongonococcal CHLAMYDIA Sexual contact 1–4 weeks Nongonococcal urethritis: pain Antibiotics
urethritis TRACHOMATIS on passing urine; watery
(in men) / mucous discharge
Chlamydia Nonspecific genital infection:
(in women) often no symptoms

Psittacosis CHLAMYDIA Inhalation of dust 1–3 weeks Flulike and feverish symptoms; Antibiotics
PSITTACI containing faeces shortness of breath
from infected birds

INFECTIOUS DISEASES: RICKETTSIAL INFECTIONS

Disease Infective agent Transmission Incubation period Symptoms Treatment

Q fever COXIELLA Inhalation of 2–4 weeks Sudden onset of fever and Antibiotics
BURNETTI infected dust sweating; cough; chest pains;
headache

Epidemic RICKETTSIA Bite from infected About 7 days Severe headache; high fever; Antibiotics
typhus PROWAZEKII body louse muscle aches; weakness; rash

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 INFECTIOUS MONONUCLEOSIS

INFECTIOUS DISEASES: FUNGAL INFECTIONS

Disease Infective agent Transmission Incubation period Symptoms Treatment

Tinea TRICHOPHYTON Direct contact with Variable Itchy skin patches; patchy hair Topical or systemic
(ringworm) RUBRUM ; infected humans or loss; cracking skin between antifungal drugs
MICROSPORUM animals toes
CANIS ; others

Meningitis, CRYPTOCOCCUS Inhalation of fungus Unknown Headache; stiff neck; Antifungal drugs
fungal NEOFORMANS from pigeon photophobia
droppings

INFECTIOUS DISEASES: PROTOZOAL INFECTIONS

Disease Infective agent Transmission Incubation period Symptoms Treatment

I Amoebiasis ENTAMOEBA
HISTOLYTICA
Food or water
contaminated by
A few weeks to
many years
Severe, sometimes bloody
diarrhoea
Antiprotozoal drugs
(such as metronidazole)
faeces

Giardiasis GIARDIA LAMBLIA Food or water 7–40 days Diarrhoea; abdominal Antiprotozoal drugs
contaminated by discomfort; bloating (such as metronidazole)
faeces; sexual
contact

Malaria PLASMODIUM Bite from infected 10–40 days Chills; high fever; sweating; Various drugs (such as
FALCIPARUM ; mosquito headache; fatigue chloroquine)
PLASMODIUM
VIVAX ; others

antibiotics. The majority of viral infec- from a conflict between the positive due to an endocrine disorder (see hypog-
tions cannot be combated with drugs. wish to be recognized as someone onadism) or damage to the testes by
The widespread incidence of HIV, worthwhile and the haunting fear of orchitis may also cause defective sperm.
particularly in developing countries, frustration and failure. Smoking, toxins, or various drugs can
poses a great threat to world health; Attempts to compensate for the sense lower the sperm count (the number of
HIV infection also increases the risk of of worthlessness may take the form of sperm cells in a sample of semen). Other
a surge in less common infections in aggression and violence, or an over- causes are disorders affecting ejaculation
those people whose immune systems zealous involvement in activities. (See (see ejaculation, disorders of). Rarely, male
are compromised. also superiority complex.) infertility is due to a chromosomal abnor-
mality, such as Klinefelter’s syndrome, or a
infectious mononucleosis infertility genetic disease, such as cystic fibrosis.
See mononucleosis, infectious. The inability to produce offspring, FEMALE INFERTILITY
which may result from a problem in The most common cause of female
infective arthritis either the male or the female reproduc- infertility is failure to ovulate. Other
An alternative term for septic arthritis. tive system, or, in many cases, from a causes are blocked, damaged or absent
combination of problems in both. fallopian tubes; disorders of the uterus,
infective endocarditis MALE INFERTILITY such as fibroids and endometriosis; prob-
See endocarditis. The main cause of male infertility is a lems with fertilization; or difficulties
lack of healthy sperm. In azoospermia, with implantation in the uterus (see
inferior no sperm are produced; in oligospermia implantation, egg). Infertility also occurs
An anatomical term that is used to only a few sperm are produced. In some if the woman’s cervical mucus contains
describe the lower of two body struc- cases, sperm are produced but are mal- antibodies that kill or immobilize her
tures, surfaces, or organs. formed or short-lived. partner’s sperm. Rarely, a chromosomal
The underlying cause of these prob- abnormality, such as Turner’s syndrome, is
inferiority complex lems may be blockage of the spermatic the cause of a woman’s infertility.
A neurotic state of mind that develops tubes or damage to the spermatic ducts, INVESTIGATION
because of repeated hurts or failures usually due to a sexually transmitted infec- The initial investigation performed for
in the past. Inferiority complex arises tion. Abnormal development of the testes male infertility is semen analysis, which

422
 INFERTILITY

INVESTIGATING INFERTILITY

First, a general check-up and/or a personal interview regarding It is important that both partners are tested for infertility,
sexual behaviour are carried out. If no cause for infertility is because infertility can be attributed to one person, to both
found at this stage, more specialized tests may be performed. people, or to mutual incompatibility.

CAUSES OF INFERTILITY

Conception is a complicated Vas deferens Fallopian tubes

process; the reproductive organs Blockage or structural abnormality Blockage may prevent
may impede the passage sperm from reaching
can be affected in numerous ways, of sperm. an egg; one or both
resulting in infertility. Some of the tubes may be absent
principal underlying causes of or damaged.
infertility in men and in women
are illustrated on the right.
Ovaries
Eggs may fail to
Penis mature or may not be
There may be failure to achieve released.
or maintain an erection, or
abnormality of ejaculation.
Uterus
Abnormality or
disorder may prevent
I
implantation of a
fertilized egg.
Testes
Too few sperm may be produced;
sperm could be abnormally Cervix
shaped, too short-lived, or have Cervical mucus may damage
impaired motility. or destroy sperm.

FEMALE INFERTILITY Hysterosalpingography MALE INFERTILITY

This is an X-ray technique
Investigations to discover the that is used to show the The first test for investigating male
cause of a woman’s infertility may uterus and/or fallopian infertility is semen analysis (below).
include taking a menstrual history tubes. Here, the right- If it reveals a low sperm count, more
and a study of the woman’s body hand tube (on the left tests may be needed to investigate
temperature during her menstrual of the image) is totally the underlying cause.
cycle (below). There may also be blocked, and the left-hand
blood and urine tests to discover tube appears enlarged.
whether ovulation is normal,
hysterosalpingography (right),
and/or laparoscopy (below right).
Uterus Ovarian cyst
°C

37

36.5 Semen analysis

Semen produced by masturbation is examined
as soon as possible, and the number, shape,
and degree of motility (movement) of the sperm
36 are determined. A postcoital semen test may
also be performed.
10 11 12 13 14 15 16 17 18

Day of cycle
Abnormal sperm
Body temperature and ovulation If a man’s semen
Charting the changes in a woman’s body Laparoscopy contains large
temperature during her menstrual cycle In this technique, a laparoscope (a type of viewing numbers of
can reveal abnormalities of ovulation. tube) is inserted through the abdominal wall to abnormally shaped
The chart above shows typical daily examine the woman’s reproductive organs and sperm, such as the
temperature fluctuations during a determine whether an abnormality or disorder, two-headed one at
normal menstrual cycle (blue line) and such as blocked fallopian tubes or endometriosis, the top of this
temperature changes associated with is present. The laparoscopic view above shows image, his fertility
failure to ovulate (grey line). an ovarian cyst. may be reduced.

423
 INFESTATION

includes a sperm count. Investigations infirmity nity against type C for life. Infection
to discover the cause of a woman’s A term meaning frailty, weakness or with a strain of type A or B virus pro-
infertility may include blood and urine lack of strength. It is most commonly duces immunity only to that particular
tests to check that ovulation is occur- used in relation to illness or old age. strain. Type A and B viruses, however,
ring, ultrasound scanning or X-ray are capable of altering to produce new
examinations to assess whether the fal- inflammation strains; type A has been the cause of
lopian tubes are blocked, and laparoscopy Redness, swelling, heat, and pain in a pandemics (disease outbreaks affecting
to determine if a condition, such as tissue due to injury or infection. When millions of people) in the last century.
endometriosis, is present. body tissues are damaged, mast cells SYMPTOMS AND COMPLICATIONS
TREATMENT release the chemical histamine and other Types A and B produce classic flu symp-
Treatment of male infertility is limited. substances. Histamine increases the toms: fever, headache, muscle aches, and
The only option for men with azoosper- flow of blood to the damaged tissue and weakness. Type C causes a mild illness
mia is adoption of children or artificial also makes the blood capillaries more indistinguishable from a common cold.
insemination by a donor. If the sperm leaky; fluid then oozes out and into the Flu usually clears up completely
count is low, artificial insemination by tissues, causing localized swelling. The within 7–10 days. Rarely, however, it
the male partner or, alternatively, in vitro inflammatory chemicals stimulate the takes a severe form, causing acute pneu-
fertilization (IVF) with intracytoplasmic nerve endings, causing pain. Inflamma- monia that may be fatal within a day or
sperm injection may be tried. In some tion is usually accompanied by a local two, even in healthy young adults.
cases of male infertility, gonadotrophin increase in the number of white blood Type B infections in children some-
hormone therapy may prove useful. cells. These cells help to destroy invading times mimic appendicitis, and they have
I Failure of the woman to ovulate re-
quires ovarian stimulation with a drug
microorganisms and are involved in
repairing the damaged tissue.
been implicated in Reye’s syndrome. In
elderly people and those with lung or
such as clomifene, given either with or Inflammation may be suppressed by heart disease, influenza may be fol-
without a gonadotrophin hormone. corticosteroid drugs or by nonsteroidal lowed by a bacterial infection such as
Microsurgery can sometimes repair dam- anti-inflammatory drugs. bronchitis or pneumonia.
age to the fallopian tubes. If surgery is TREATMENT
unsuccessful, IVF is an option. Uterine inflammatory bowel disease Analgesics (painkillers) help to relieve
abnormalities or disorders, such as A collective term for chronic disorders aches and pains and reduce fever. Anti-
fibroids, may require treatment. In some that affect the small and/or the large viral drugs such as zanamivir may be
cases, provided the woman has normal intestine and cause abdominal pain, used to treat at-risk people who develop
fallopian tubes, either gamete intra- bleeding, and diarrhoea. Crohn’s disease flu; to be effective, treatment must be
fallopian transfer (GIFT) or zygote intrafal- and ulcerative colitis are the most common started within 48 hours of symptoms
lopian transfer (ZIFT) may be carried out. types of inflammatory bowel disease. appearing. Amantadine may be used in
specific cases for prevention during an
infestation inflammatory oedema outbreak of flu. Antibiotics may be used
The presence of animal parasites (such A term sometimes used to describe the to combat secondary bacterial infection.
as mites, ticks, or lice) in the skin or swelling associated with inflammation, PREVENTION
hair, or of worms (such as tapeworms) such as the swelling that develops Flu vaccines, containing killed strains of
inside the body. around a cut as it heals. the types A and B virus in circulation, are
available, but have only a 60–70 per cent
infibulation infliximab success rate.The immunity that they pro-
A form of female circumcision in A drug that inhibits the activity of vide is only short-lived and vaccination
which the labia majora (the outer lips tumour necrosis factor (TNF), a chemi- (recommended for older people, anyone
surrounding the vagina) are removed cal released by lymphocytes causing tissue suffering from respiratory or circulatory
and the entrance to the vagina narrowed damage and pain. Such drugs are known problems, chronic renal failure or dia-
(see circumcision, female). as TNF blockers or anti-TNF drugs. betes mellitus as well as key health
Infliximab is used to treat severe rheuma- workers) must be repeated annually.
infiltrate toid arthritis and Crohn’s disease that have
The term used for a build-up of sub- not responded to other drug treatment. informed consent
stances or cells within a tissue that are See consent.
either not normally found in it or are influenza
usually present only in smaller amounts. Popularly known as “flu”, a viral in- infra-
The word “infiltrate” may also refer to fection of the respiratory tract (air A prefix meaning “below”, commonly
a drug (such as a local anaesthetic) that passages). Influenza is spread by infec- used in medical terminology.
has been injected into a tissue, or to the ted droplets from coughs or sneezes. It
build-up of a substance within an organ usually occurs in small outbreaks or infrapatellar bursitis
(for example, fat in the liver caused by every few years in epidemics. Inflammation of the bursa (fluid-filled
excessive alcohol consumption). In addi- CAUSES sac) that lies below the patella (kneecap)
tion, radiologists use the term to refer to There are three main types of influenza and over the top of the tibia (shinbone)
the presence of abnormalities, most virus: A, B, and C. A person who has acting as a cushion against friction. The
commonly on a chest X-ray, due to con- had an attack caused by the type C virus condition is usually the result of pro-
ditions such as infection. acquires antibodies that provide immu- longed kneeling in an upright position

424
 INHERITANCE

(which it is why it is sometimes called direct or indirect. In a direct inguinal are the units of DNA (deoxyribonucleic
“clergyman’s knee”). Infrapatellar bursi- hernia, there is a localized weakness in acid) that are contained in a person’s
tis is similar to prepatellar bursitis, or the abdominal wall through which the cells; DNA controls all aspects of the
housemaid’s knee; however, this second intestine pushes. In an indirect inguinal body’s growth and functioning. Half of
condition often results from prolonged hernia the intestine protrudes through a person’s genes come from the mother
kneeling while leaning forwards, which the inguinal canal (in males the passage and half from the father.
puts excessive pressure on the bursa through which the testes descend into GENES AND CHROMOSOMES
that lies in front of the kneecap. the scrotum). An indirect inguinal her- Genes are organized into chromosomes
Infrapatellar bursitis causes swelling nia may also occur in females. (long, thread-like structures) in the cell
and pain. Knee movement may also be nucleus. Genes controlling most charac-
restricted. The swelling usually reduces inhalation teristics come in pairs, one from each
with rest; nonsteroidal anti-inflammatory The act of taking in breath (see breath- parent. Every individual has 22 pairs of
drugs may help to relieve the discom- ing). Aninhalation is also a medication chromosomes (called autosomes), with
fort. For persistent symptoms, a doctor designed to be breathed in and pre- each chromosome in a pair bearing one
may drain the fluid from the bursa and pared in the form of a gas, vapour, of the paired genes. In addition, there
inject a corticosteroid drug into the sac. powder, or aerosol. are two sex chromosomes: females have
Frequent changes in position and use of two X chromosomes, and males have an
foam padding is recommended. inhaler X and a Y chromosome.
A device used for administering a drug MECHANISMS OF INHERITANCE
infra-red in powder or vapour form. Inhalers are Most physical characteristics, many
A term denoting the part of the electro-
magnetic spectrum that is immediately
used mainly in the treatment of various
respiratory disorders, including asthma
disorders, and some mental abilities
and aspects of personality are inheri-
I
beyond the red end of the visible light and chronic bronchitis. Metered-dose ted. The inheritance of normal traits
spectrum (see colour vision). inhalers deliver a precise dose when the and disorders can be divided into three
Infra-red radiation is directed on to inhaler is pressed. Drugs taken by groups: those that are controlled by a
the skin and heats the skin and the tis- inhalation include bronchodilators and single pair of genes on the autosomal
sues immediately below it. An infra-red corticosteroids. See the illustrated box for chromosomes (unifactorial inheritance);
lamp is one means of giving heat treat- information on using an inhaler. those that are controlled by genes on the
ment to promote healing from injuries sex chromosomes (sex-linked inheri-
and inflammatory conditions. inheritance tance, such as haemophilia); and those
The transmission of characteristics and that are controlled by the combination
infundibulum disorders from parents to their children of many genes (multifactorial inheri-
The medical term for a funnel-shaped through the influence of genes. Genes tance, such as height).
passage or structure. Specifically, infun-
dibulum refers to the short stalk carrying
nerve fibres connecting the hypothala- HOW TO USE A METERED-DOSE INHALER
mus in the brain to the pituitary gland.
The user puts the mouthpiece of the Aerosol inhaler
inhaler in the mouth, presses the end, This type of
infusion, intravenous inhaler delivers a
and simultaneously breathes in through
See intravenous infusion. dose of the drug
the mouth. If the device is used correctly, as an aerosol
the drug is dispersed to the bronchi.
ingestion Young children, or people who find it
spray when the
user presses the
The act of taking any substance (for difficult to use an inhaler, can use a top of the inhaler.
example, food, drink, or medications) spacer. A nebulizer is a device that
into the body through the mouth. The delivers the drug directly as a fine mist,
term “ingestion” also refers to the through a face-mask or mouthpiece,
Top of inhaler is pressed
process by which certain cells (for over several minutes.
example, some white blood cells) sur- Canister of liquid drug
round and then engulf small particles.
Spacer
ingrowing toenail The inhaler fits on to the spacer and the drug
dose is released into it. The user inhales
See toenail, ingrowing. normally from the spacer’s mouthpiece.
inguinal
A word relating to the groin (the area
between the abdomen and thigh), as in
inguinal hernia.

inguinal hernia
Inhaler fits on to
A type of hernia in which part of the Mouthpiece Spacer end of spacer
intestine protrudes through the abdom-
inal wall in the groin. It can be either

425
 INHIBITION

UNIFACTORIAL INHERITANCE Any faults in a male’s genes on the they are given into a vein); intramus-
Either of the pair of genes controlling a X chromosome tend to be evident cular (into a muscle); intradermal
trait may take any of several forms, because there is no second, normal X (into the skin); subcutaneous (into the
known as alleles. chromosome that would mask the tissue layer under the skin); or intra-
For example, the genes controlling faults (as there is in females). Faults in articular (into a joint).
eye colour exist as two main alleles, the genes of the X chromosome include
coding for blue and brown eye colour. those responsible for colour vision defi- injury
The brown allele is dominant over blue ciency, haemophilia, and other sex- Physical harm to any part of the body.
in that it “masks” the blue allele, linked inherited disorders, which Injury may have many possible causes,
which is described as “recessive” to almost exclusively affect males. including environmental influences (for
the brown allele. Only one of the pair MULTIFACTORIAL INHERITANCE example, force, heat, cold, electricity,
of genes controlling a trait is passed to Multifactorial inheritance, along with vibration, and radiation), chemical
a child from each parent. For example, the effects of environment (such as causes (such as poisons), bites, or oxy-
someone with the brown/blue combi- diet and exposure to diseases or tox- gen deprivation.
nation for eye colour has a 50 per cent ins), may play a part in causing certain
chance of passing on the blue gene, disorders, such as diabetes mellitus and ink-blot test
and a 50 per cent chance of passing on neural tube defects. An outdated psychological test in which
the brown gene, to any child. This fac- the subject was asked to interpret the
tor is combined with the gene coming inhibition appearance of a number of ink blots;
from the other parent, according to The process of preventing any mental or the person’s responses were thought to
I dominant or recessive relationships, to
determine the child’s eye colour. Cer-
physical activity. Inhibition in the brain
and spinal cord is carried out by certain
reveal aspects of mental function such
as emotions and psychological conflicts.
tain genetic disorders are also inherited neurons (nerve cells), which damp down The most widely used example was the
in a unifactorial manner (for example, the action of other nerve cells in order to Rorschach test.
cystic fibrosis and achondroplasia). keep the brain’s activity in balance.
SEX-LINKED INHERITANCE In psychoanalysis, the term “inhibi- inlay, dental
Sex-linked inheritance depends on the tion” refers to the unconscious restraint A filling of porcelain or gold used to
two sex chromosomes, X and Y. The of instinctual impulses. restore a badly decayed tooth where the
most obvious example of this type of cavity is too big to receive amalgam. An
inheritance is gender of an individual. injection inlay may be needed for the back teeth
Male gender is determined by genes Introduction of a substance into the or to protect a weakened tooth.
on the Y chromosome, which is pre- body from a syringe via a needle. In-
sent only in males. jections may be intravenous (where innate
A term to describe a condition or trait
that is present from birth (see congenital).
INHERITANCE OF EYE COLOUR
inner ear
Eye colour is determined by two main alleles (forms of a gene), one coding for
brown eyes and the other for blue eyes. The brown allele is dominant to the blue
The deepest part of the ear, lying closest
one (which is therefore recessive). to the brain, that contains the organs of
hearing and balance. The inner ear reg-
Parents Children Parents Children isters air vibrations and other sensory
stimuli, such as head movement; cells
convert the information into electrical
impulses, which pass along nerves to
the brain. The other parts of the ear are
the outer and middle ear.
innervation
A term meaning the supply of nerves to
an organ or other part of the body.
innocent murmur
A murmur (a sound made by blood flow
Eye colour of offspring through the heart, as heard through a
Key Two brown-eyed parents, each with the stethoscope) that is not due to any dis-
Allele for Brown eyes brown/blue combination of alleles, have a one- ease of the heart or its valves. Innocent
brown eyes in-four chance of producing a blue-eyed child
or heart murmurs are commonly found in
(above left). However, when one parent is
brown-eyed (with brown/blue alleles) and the children and may be more noticeable
Allele for Blue eyes other is blue-eyed (with blue alleles), there is a after exercise or during a fever. If there
blue eyes one-in-two chance that they will have a blue- is any doubt about the significance of a
eyed child (above). murmur, tests such as echocardiography
or ECG may be requested.

426
 INSECT STINGS

inoculation insanity PREVENTION

The act of introducing a small quantity A term commonly used for serious The avoidance of insect-borne disease is
of a foreign substance into the body, mental disorder. Although used legally, largely a matter of keeping flies off
usually by injection, for the purpose of the term has no real technical meaning. food, discouraging insect bites by the
stimulating the immune system to pro- use of suitable clothing and insect
duce antibodies (protective proteins) insect bites repellents, and, in parts of the world
against the substance, a process known Puncture wounds inflicted by bloodsuck- where malaria is present, the use of
as active immunity. Inoculation is usually ing insects such as gnats, mosquitoes, mosquito nets and screens, pesticides,
done to protect individuals against fleas, and lice. Most bites cause only tem- and antimalarial tablets.
future infection by particular bacteria or porary pain or itching, but some people
viruses (see immunization). have severe skin reactions. In the tropics insect stings
and subtropics, insect bites are poten- Reactions that are produced by the
inoperable tially more serious because certain biting stings of insects such as bees and wasps.
A term applied to any condition that species are capable of transmitting dis- Venom injected by the insect contains
cannot be alleviated or cured by ease (see insects and disease). inflammatory substances that cause
surgery, particularly cancers. All insect bites provoke a skin reac- local pain, redness, and swelling for
tion to substances in the insect’s saliva about 48 hours.
inorganic or faeces, which may be deposited at or A sting in the mouth or throat is dan-
A term used to refer to any of the large near the site of the bite. Reactions vary gerous because the swelling may ob-
group of substances that do not contain from red pimples to painful swellings struct breathing. A severe allergic reaction
carbon. Some examples of inorganic
substances include table salt (sodium
or an intensely itching rash. Some
insects, such as bees and wasps, have
can occur in response to insect venom,
leading to anaphylactic shock. A procedure
I
chloride) and bicarbonate of soda stings (see insect stings) that can pro- known as hyposensitization is sometimes
(sodium bicarbonate). The term “inor- duce fatal allergic reactions. (See also recommended for such individuals.
ganic” is also applied to a few of the lice; spider bites; mites and disease; ticks If the symptoms of anaphylactic
most simple carbon compounds, such and disease.) shock develop, it is essential to seek
as carbon dioxide and carbon monoxide. emergency medical treatment. Anyone
insecticides
inotropic See pesticides.
A term used to refer to anything that INSECT-BORNE DISEASES
affects the force or energy of muscular insects and disease
Malaria is by far the most prevalent
contractions, either positively (strength- Relatively few insect species cause dis- of the insect-borne diseases, causing
ening the contractions) or negatively ease directly in humans. Some parasitize about 300 million acute illnesses
(weakening the contractions). humans, living under the skin or on the and 1 million deaths each year.
Inotropic drugs are drugs that stim- body surface (see lice; chigoe; myiasis).
ulate, and increase the force of, heart The most troublesome insects are flies
muscle contractions. Inotropic drugs and biting insects. Flies can carry infec-
are sometimes needed immediately tious microorganisms from human or
after a myocardial infarction (heart attack) animal excrement via their feet or legs
to maintain blood pressure and tissue and contaminate food or wounds.
circulation. In such cases, drugs such A number of serious diseases are
as dopamine and dobutamine are given spread by biting insects. These disor-
by intravenous infusion. In cases of ders include malaria and filariasis
chronic heart failure, digitalis drugs, and (transmitted by mosquitoes), sleeping
especially digoxin, may be used for the sickness (from tsetse flies), leishmaniasis
same purpose. (sandflies), epidemic typhus (lice), and
plague (rat fleas). Mosquitoes, sand- Skin
inpatient treatment flies, and ticks can also spread illnesses Infected
saliva
Care or therapy in hospital following such as yellow fever, dengue, Lyme
Malaria
patient admission. disease, and some types of viral protozoan
encephalitis. Organisms picked up when
inquest an insect ingests blood from an in-
Blood
sucked
An official inquiry by a coroner into a fected animal or person are able to Mosquito’s
death that is of unknown cause or is survive or multiply in the insect. Later, mouthparts
suspected of being unnatural. the organisms are either injected into a Blood vessel
new human host via the insect’s saliva
INR or deposited in the faeces at or near the Transmission of malaria
When an infected Anopheles mosquito feeds
The abbreviation for International Nor- site of the bite. on a person’s blood, it injects saliva through
malized Ratio,a measure used in the Most insect-borne diseases are con- its mouthparts to stop the blood from
management of anticoagulant drugs. It fined to the tropics and subtropics, clotting; the protozoa that cause malaria
enter the blood via the insect’s saliva.
allows for uniform measurement of although tick-borne Lyme disease occurs
the anticoagulation status of patients. in some parts of the UK.

427
 INSECURITY

who is known to be hypersensitive to Sleeping drugs should be used only on affects the legs, the blood does not
bee or wasp venom should obtain and medical advice. Possible complemen- drain adequately through the veins;
carry an emergency kit for the self- tary therapies for insomnia include this condition can sometimes lead to
injection of adrenaline (epinephrine). acupuncture and aromatherapy using swelling and leg ulcers.
lavender oil. (See also nightmares; night
insecurity terrors; sleepwalking.) insufflation
Lack of self-confidence and uncertainty A technique in which air, another type
about one’s abilities, aims, and rela- inspiratory capacity of gas, or powder is blown into a body
tionships with others. A feeling of The volume of air that can be drawn cavity. Insufflation may be used during
insecurity may be a feature of anxiety into the lungs in a maximum inhalation medical investigations in order to
and other neurotic mental disorders. following a normal expiration. make the viewing of organs easier or
to identify blockages. In laparoscopy,
insemination inspiratory reserve volume for example, the abdomen is insufflat-
The term used for the introduction of a The volume of air that can be drawn ed using carbon dioxide.
man’s semen into a woman’s uterus. into the lungs beyond the end of a nor-
Insemination may occur through sexual mal inhalation. insulin
intercourse or by the use of instruments A hormone produced by clusters of
as part of infertility treatment (see artifi- inspiratory stridor cells in the pancreas, known as the Islets
cial insemination). A harsh, high-pitched sound heard on of Langerhans, that regulates the level of
inhaling. Inspiratory stridor is associat- glucose in the blood. It is produced con-
I insight ed with damage to or a disorder of the tinuously, but the amount increases in
Being aware of one’s own mental state. respiratory tract, particularly in the area response to a raised glucose level after a
In a general sense, “insight” means of the larynx (voice-box). (See also expi- meal. Insulin is essential if glucose is to
knowing one’s own strengths, weak- ratory stridor; stridor.) be absorbed into cells where it is con-
nesses, and abilities. verted into energy. Insulin thus prevents
The term also has the specific psychi- inspissation a buildup of glucose in the blood and
atric meaning of knowing that one’s Thickening or drying up of secretions ensures that tissues have sufficient
symptoms are an illness. Loss of insight as a result of dehydration or evapor- amounts of glucose.
may be a feature of psychotic disorders ation. Inspissated secretions in the Failure of insulin production results
(see psychosis). airways, for example, can lead to block- in diabetes mellitus. An insulinoma is a
age and collapse of areas of lung tissue. rare tumour that causes excessive pro-
in situ duction of insulin and consequent
A Latin term meaning “in place”. The instep attacks of hypoglycaemia (an abnormally
phrase “carcinoma in situ” is used to The arched area of the foot between the low blood glucose level).
describe tissue (particularly of the skin heel and ball of the foot. INSULIN THERAPY
or cervix) that is cancerous only in its Insulin replacement, self-administered
surface cells. instinct by injection or through an infusion
An innate primitive urge. The need for pump (see pump, insulin), is used in the
insomnia warmth, food, love, and sex are all treatment of diabetes mellitus. Insulin
A regular inability to fall asleep or stay forms of instinct, but the instinct for cannot be taken orally because it is
asleep, leading to excessive tiredness. survival is probably the most powerful. destroyed by stomach acid. This treat-
CAUSES An instinct is different from a reflex, ment prevents hyperglycaemia (high
The most common cause of insomnia is which is an involuntary response to a blood glucose) and ketosis (a buildup of
stress, but other causes include physical stimulus (such as withdrawing quickly acids in the blood), which, in severe
symptoms such as a cough, itching, or from a source of pain). cases, may cause coma. Human insulin
conditions such as restless legs. Environ- preparations are produced by genetic
mental and lifestyle factors or misuse of institutionalization engineering, although older beef or pork
sleeping drugs are also common causes. Loss of personal independence that insulins are still available.
Insomnia can be a symptom of a psy- stems from living for long periods Too high a dose of insulin will cause
chiatric illness, such as anxiety and/or under a rigid regime, such as in a hypoglycaemia, which can be reversed
depression. Withdrawal symptoms from prison or other large institution. Apathy, by consuming food or a sugary drink.
antidepressants, antianxiety drugs, sleep- obeying orders unquestioningly, accept- Severe hypoglycaemia may cause coma,
ing drugs, and some illicit drugs (see ing a standard routine, and loss of for which emergency treatment with an
drug abuse) may also cause insomnia. interests are the main features. intravenous injection of glucose, or
PREVENTION AND TREATMENT glucagon (a hormone that opposes the
People with insomnia should ensure insufficiency effects of insulin) given into a muscle,
that they get sufficient exercise during The inability of an organ or body part vein, or subcutaneously is necessary.
the day and moderate their alcohol and to perform its intended function. In
caffeine intake. They should also avoid hepatic insufficiency, for example, the insulinoma
eating late at night and should establish liver cannot carry out its normal work A rare noncancerous tumour of the
regular routines and times for going to (see liver failure). In another example, insulin-producing cells of the pancreas.
bed and waking. venous insufficiency, which usually The tumour causes abnormal quantities

428
 INTERCOURSE, PAINFUL

of insulin to be produced, with the Examples of extremes of intelligence

result that the amount of glucose in occur in people with learning difficulties
the blood can fall to dangerously low (as defined by a low IQ) and gifted peo-
levels (hypoglycaemia). Unless sugar is ple (as defined by IQ scores over 130).
given immediately, this situation can
cause coma and death. Once the con- intelligence quotient (IQ)
dition has been diagnosed, a drug See intelligence tests; IQ.
(diazoxide) is given to prevent hypo-
glycaemia from occurring until the intelligence tests
tumour is removed. Tests designed to provide an estimate of
a person’s mental abilities. The most
insulin resistance widely used are Wechsler tests.There are
An impaired response of body cells to two basic types: the Wechsler Adult Intel-
the effects of insulin, a hormone pro- ligence Scale (WAIS) and the Wechsler
duced by the pancreas to regulate blood Intelligence Scale for Children (WISC).
sugar levels. The most common cause of Each is divided into verbal (language
mild insulin resistance is obesity; and skills) and performance sections including
sensitivity is regained with weight loss. measures of visual–spatial and percep-
In type 2 diabetes mellitus, raised blood tual ability (interpretation of shapes)
glucose levels are partly due to insulin and constructional ability. Other tests
resistance, but also to a reduced capacity
to produce insulin.
include the Stanford–Binet test, used
mainly as a measure of scholastic ability.
Intensive care unit
An intensive care unit has sophisticated equipment
I
for constant monitoring of a seriously ill patient. He
Insulin resistance is also a feature of In most intelligence tests, scoring is or she is usually sedated and connected to a
other conditions, such as polycystic ovary based on mental age (MA) in relation to ventilator to maintain breathing.
syndrome and acanthosis nigricans. Peo- chronological age (CA). The intelligence
ple with unstable diabetes occasionally quotient (IQ) is MA divided by CA, An ICU contains a high ratio of special-
require massive doses of insulin to multiplied by 100. The tests are devised ly trained nursing and medical staff to
achieve a reduction in blood sugar. In to ensure that 3 in 4 people have an IQ patients, enabling treatment to be tai-
such cases, the cause of the insulin between 80 and 120. They are standard- lored to a patient’s condition as it
resistance is often not known. ized so that the score indicates the same changes. (See also coronary care unit.)
relative ability at different age levels.
insulin shock Intelligence tests may be used to intention tremor
An uncommon term for hypoglycaemia assess school or job aptitude. They have, A form of tremor (involuntary, rhythmic
(abnormally low blood glucose levels). however, been criticized for their shaking of the muscles) occurring only
alleged bias regarding gender and race. when a person tries to carry out a con-
Intal scious movement, such as touching or
A brand name for inhaled sodium cro- intensive care unit picking up an object. The tremor wors-
moglicate,an antiallergy drug commonly A medical facility in which critically ill ens as the object is approached. The
used to prevent asthma. patients are given intensive care (con- condition is usually due to disease or
stant close monitoring and treatment). damage affecting the cerebellum (the
intelligence Intensive care units (ICUs), some- area at the back of the brain responsible
The ability to understand concepts and times called intensive treatment/ therapy for coordinating movement).
to reason them out. Intelligence can units (ITUs), contain electronic equip-
also be considered as having three sep- ment to monitor vital functions such as inter-
arate forms: abstract (understanding blood pressure and heart rate. Blood A prefix that means between, as in inter-
ideas and symbols); practical (aptitude pressure is monitored by an automatic costal (between the ribs). (See also intra-.)
in dealing with practical problems sphygmomanometer, and heart rate and
such as repairing machinery); and rhythm by an ECG machine. Frequently, intercostal
social (coping reasonably and wisely patients in ICUs require mechanical ven- A term meaning “between the ribs”, as
with human relationships). tilation, in which a machine takes over in the intercostal muscles, thin sheets of
Intelligence has been shown to be or assists with breathing. Urine is col- muscle between each rib.
partly inherited, although the environ- lected via a catheter. Urine output, fluid
ment (including early nutrition) also balance, and blood chemistry are intercourse, painful
plays a major part, as does physical recorded regularly and fluids are given Pain during sexual intercourse, known
health and personality. Intelligence intravenously. If nutrients are needed, medically as dyspareunia, which can
increases up to the age of about six they are supplied directly to the stom- affect both men and women. Pain may
years and then stabilizes. Intelligence ach through a tube or are administered be superficial (around the external gen-
quotient (IQ), as measured by intelli- intravenously. Body fluids and blood itals) or deep (within the pelvis).
gence tests, continues to increase to sugar levels are maintained by intra- CAUSES
about the age of 26, stays the same venous infusion of salts and glucose. In men, superficial pain may be due to
until about the age of 40, and then Monitors are fitted with alarms to alert anatomical abnormalities such as chor-
gradually declines. the staff to any dangerous fluctuations. dee (bowed erection) or phimosis (tight

429
 INTERCURRENT

foreskin). Prostatitis (inflammation of in the treatment of a rare condition internal fixation

the prostate gland) may cause a wide- called chronic granulomatous disease. A procedure for treating fractured
spread pelvic ache, a burning sensation Adverse reactions to interferons are bones (see fracture) by surgically insert-
in the penis, or pain on ejaculation. common including fever, headaches, ing metal plates, pins, rods, or wires to
In women, one possible cause of pain lethargy, depression, and dizziness. hold the broken bone ends together.
is scarring (after childbirth, for exam- The procedure is used to treat severe
ple) and lack of vaginal lubrication, interleukin fractures that cannot be stabilized by
especially after the menopause. Psycho- One of a group of proteins that occur other means. Once the bone has healed,
sexual dysfunction may also cause pain naturally in the body. Interleukins are the devices used for internal fixation are
during intercourse. Vaginismus, a condi- involved in the production of different often left in place if they are not causing
tion in which the muscles of the vagina types of blood cells and also help to reg- any problems. In some cases, however,
go into spasm, is usually psychological ulate the immune system. At least 18 it is necessary to remove them in anoth-
in origin. Deep pain is frequently different interleukins have been identi- er operation.
caused by pelvic disorders (such as fied. One form of interleukin, known
fibroids, endometriosis, ectopic pregnancy, as interleukin-2 or aldesleukin, is be- internal haemorrhoids
or pelvic inflammatory disease due to sex- lieved to slow the progress of kidney Swollen veins that develop within the
ually transmitted infections), disorders cancer. However, it often has very severe rectum (see haemorrhoids).
of the ovary (such as ovarian cysts), and side effects, including damage to the
disorders of the cervix. Other causes of brain and bone marrow and leakage of International Normalized Ratio
deep and superficial dyspareunia are fluid into the lungs. (INR)
I cystitis and urinary tract infections.
intermenstrual bleeding
A measure introduced by the World
Health Organization to standardize the
TREATMENT
Treatment of painful intercourse is Bleeding from the vagina between men- control of anticoagulant drug therapy
directed at the underlying cause of the strual periods (see menstrual cycle). The internationally. The ratio is based on
pain. If the discomfort is psychological condition may be due to a disorder of comparing the prothrombin time (see
in origin, special counselling may be the uterus, but is also a common side blood-clotting tests) of a patient’s blood
needed (see sex therapy). effect of oral contraception (see break- with a control time.
through bleeding).
intercurrent intersex
A term used to describe a condition, intermenstrual pain A group of abnormalities in which the
usually an infection, that develops in a Pelvic pain occurring between men- affected person has ambiguous genitalia
person who is already suffering from strual periods, which may be due to a (abnormal external sex organs) or exter-
another disorder. variety of causes. In one type, pain nal genitalia that have the opposite
occurs in the middle of the menstrual appearance to the chromosomal sex of
interdigital cycle, around the time of ovulation (see the individual (see sex determination).
A term meaning between two fingers or mittelschmerz).
toes. Interdigital is used to refer to the interstitial
skin in such an area. intermittent claudication A word used medically to refer to gaps
Cramping pain in the legs due to inade- (interstices) between cells, tissues, or
interferon quate blood supply (see claudication). other body structures. For example, tis-
One of a group of proteins produced sue fluid between the body cells is
naturally by body cells in response to intermittent positive pressure called interstitial fluid. (See also inter-
viral infections and other stimuli. ventilation (IPPV) stitial radiotherapy.)
Interferon inhibits viral multiplication A form of mechanical ventilation in
and increases the activity of natural which air is delivered into a person’s interstitial cystitis
killer cells (a type of lymphocyte that is lungs under pressure and in short A chronic inflammation of the bladder
part of the immune system). The sub- bursts, to simulate intakes of breath. lining that causes pain and a frequent
stance may also be produced artificially IPPV can be administered through a urge to pass urine. An ulcer usually
for use as a drug in the treatment of tube into a lung, which may be carried develops in the bladder wall and, even-
various disorders. Interferon has to be out in an intensive care unit. A similar tually, the bladder muscles thicken and
given by injection. procedure of continuous positive air- contract (shorten).
There are three main types: interfer- way pressure (CPAP) can be delivered Interstitial cystitis is most likely to
on alfa, beta, and gamma. Interferon by mask to treat sleep apnoea. occur in women. Unlike most other
alfa is used in the treatment of certain bladder inflammation (see cystitis) the
lymphomas, a type of leukaemia, and internal cardiac massage disorder is not due to bacterial infec-
chronic hepatitis B and C. Peginterfer- A procedure carried out during surgery tion and the cause is unknown.
on, a modified form of interferon alfa, on the chest to maintain circulation if The disorder is difficult to treat. In a
remains in the circulation longer and the heart has stopped beating (see car- procedure carried out under general
is used particularly in the treatment of diac massage). In internal cardiac anaesthesia, the bladder may be
hepatitis C. Interferon beta is used to massage, the surgeon reaches into the stretched by being filled with water or
treat some patients with relapsing mul- open rib cage and squeezes the heart other liquids. Anti-inflammatory drugs
tiple sclerosis. Interferon gamma is used directly with his or her hands. may also be given as a treatment.

430
 INTERVERTEBRAL FORAMEN

Transplantation of a single lung (see

HOW INTERFERON FIGHTS VIRAL INFECTIONS transplant surgery)may be considered.
The outlook of occupational dust dis-
Interferon is part of the body’s immune system, providing a defence against many
different types of virally infected cells or tumour cells. It is produced naturally in
ease depends on the type of dust
the body during viral infections, but can also be administered as a drug to enhance involved and the level of exposure. If
its natural actions. IPF is due to an allergy, however, the
condition can more easily be treated
VIRAL MULTIPLICATION HOW INTERFERON WORKS and the outlook is better.
Virus Cell Nucleus Interferon Natural
killer cell
interstitial radiotherapy
Treatment of a cancerous tumour by
inserting radioactive material into the
cancerous growth or into neighbour-
ing tissue. Using this method, which is
a type of brachytherapy, radiation can
be targeted at the diseased area.

1 A virus can multiply

only by first invading
1cellsInterferon attaches to
the membrane of host
and primes them
1attackInterferon also causes
natural killer cells to
virally infected cells
Radioactive material (usually artifi-
cial radioisotopes) contained in wires,
one of its host’s cells. against viral attack. or tumour cells. small tubes, or seeds is implanted into
or near to the diseased tissue under
general anaesthesia (see anaesthesia,
general). The material is left in place
I
Antiviral
enzymes for variable amounts of time depend-
ing on the radioactive substance and
the tumour that is being treated. In
some cases, such as in prostate cancer,
If a virus invades a cell
2cell’sThe genetic material of
the virus takes over the
chemical machinery to
2enzymes
primed by interferon,
are produced
2hostAattaches
natural killer cell
to the abnormal
cell and makes the cell
the material is left in place perm-
anently as the radiation decays after a
make copies of the virus. that impair viral copying. disintegrate. relatively short period of time. (See
also radiotherapy.)
intertrigo
Inflammation of the skin due to two
surfaces rubbing together. Intertrigo is
most common in obese people. The
affected skin is red and moist and may
Being unable to copy itself, The effect of this process have an unpleasant odour, and is often
3 The copies of the virus
escape, killing the host
3the infection
the virus is nullified, and
is either stopped
3 is to help limit a viral
infection or to slow down
accompanied by a fungal infection
such as candidiasis; there may also be
cell, and invade more cells. altogether or shortened. the growth of a tumour.
scales or blisters. The condition wors-
ens with sweating.
Treatment consists of weight reduc-
interstitial pulmonary fibrosis The diagnosis of IPF is based on the tion and keeping the affected areas
Scarring of lung tissue mainly affecting symptoms and a physical examination; clean and dry. A cream containing
the alveoli (the tiny air sacs in the it is confirmed by chest X-ray and a antifungal drugs, with or without a
lungs; see alveolus, pulmonary). Intersti- biopsy (removal of a sample of lung corticosteroid, is used if candidiasis is
tial pulmonary fibrosis (IPF) may have tissue for microscopic examination). found to be present.
various causes, including occupational TREATMENT AND OUTLOOK
exposure to mineral dusts; fibrosing Treatment for interstitial pulmonary intervertebral cartilage
alveolitis (an autoimmune disorder in fibrosis depends on the cause. Treat- The strong tissue, also called fibro-
which the immune system attacks the ment for fibrosing alveolitis often cartilage, that makes up the platelike,
lung tissue); and an allergic reaction includes use of immunosuppressant shock-absorbing discs between the
(see allergy) that causes inflammation drugs and corticosteroid drugs, which bones of the spine (see cartilage; disc,
of the alveoli. suppress the activity of the immune intervertebral).
SYMPTOMS AND DIAGNOSIS system. However, there is no known
Symptoms of interstitial pulmonary treatment for localized fibrosis due to intervertebral disc
fibrosis include progressive shortness of radiotherapy. In other cases, treatment See disc, intervertebral.
breath, coughing, chest pain, and club- is directed at the underlying cause.
bing (abnormal thickening and broad- For people with fibrosing alveolitis, intervertebral foramen
ening) of the fingertips. There may also the outlook is poor: the lungs become A natural opening between adjacent
be additional symptoms caused by any progressively stiffer and heart failure vertebrae (the spinal bones) in the
underlying disease. and bronchopneumonia may develop. spine formed by the space between

431
 INTESTINAL IMAGING

small notches in each side of the verte- rectum, cancer of). Both the small and SYMPTOMS
brae. Such gaps are the exit points for large intestine may develop carcinoid A blockage in the small intestine usually
the peripheral nerves branching from tumours (causing carcinoid syndrome) causes intermittent cramplike pain in
the spinal cord. and lymphomas. the centre of the abdomen with increas-
ingly frequent bouts of vomiting and
intestinal imaging intestine, obstruction of failure to pass wind or faeces. An
See barium X-ray examinations. A partial or complete blockage of the obstruction in the large intestine causes
small or large intestine. pain, distension of the abdomen, and
intestinal lipodystrophy CAUSES failure to pass wind or faeces.
See Whipple’s disease. Possible causes include a strangulated TREATMENT
hernia (protrusion of the intestines Treatments involve emptying the stom-
intestine through the abdominal wall); stenosis ach via a nasogastric tube and replacing
The major part of the digestive tract (see (narrowing) of the intestine, often due lost fluids through an intravenous drip in
digestive system), extending from the to cancer in the intestine; intestinal some instances, this measure will be suf-
exit of the stomach to the anus. It forms atresia (congenital closure); adhesions ficient to correct the problem. In many
a long tube divided into two main sec- (scar tissue); volvulus (twisting of cases, however, surgery to deal with the
tions: the small and large intestines. loops of bowel); and intussusception (in cause of the blockage is necessary.
SMALL INTESTINE which the intestine telescopes inside
The small intestine is about 6.5 m in itself). Intestinal obstruction can also intestine, tumours of
length and has three sections: the duode- occur in diseases that affect the intesti- Cancerous or noncancerous growths in
I num, the jejunum and the ileum. Partially
digested food from the stomach is forced
nal wall, such as Crohn’s disease or
paralysis of the muscles in the intesti-
the intestine. Cancerous tumours com-
monly affect the large intestine (see
along the intestine by peristalsis. nal wall (see ileus, paralytic). colon, cancer of; rectum, cancer of); the
The small intestine is concerned Less commonly, an internal blockage small intestine is only rarely affected.
with the digestion and absorption of of the intestine is caused by impacted Lymphomas and carcinoid tumours (lead-
food. Digestive enzymes and bile, food, faecal impaction, gallstones, or by ing to carcinoid syndrome) may sometimes
which break down food to release an object of some kind that has been develop in the intestine. Noncancerous
nutrients, are added to the partly accidentally swallowed. tumours include polyps in the colon,
digested food in the duodenum via the
bile and pancreatic ducts (see biliary
system). Glands within the walls of each DISORDERS OF THE INTESTINE
section of the small intestine produce
mucus and other enzymes, which also The intestine is subject to the effects of Structural abnormalities
help to break down the food. Blood many infective organisms and parasites. Structural defects may be congenital
vessels in the intestinal walls absorb It may also be affected by tumours, (present from birth) or may develop
nutrients and carry them to the liver for structural defects, and other disorders. later.They include atresia (congenital
distribution to the rest of the body. closure), stenosis (narrowing), and
Infection and inflammation volvulus (twisting of loops of bowel).
LARGE INTESTINE
The large intestine is approximately 1.5 m Generalized inflammation of the intestine These abnormalities can cause blockage
long. The main section, the colon, is may be caused by viral or bacterial of the intestine (see intestine, blockage
divided into an ascending, a transverse, infections such as food poisoning, traveller’s of). In newborn babies with cystic
diarrhoea, cholera, typhoid fever, amoebiasis, fibrosis, meconium (fetal intestinal
a descending, and a pelvic portion (the
sigmoid colon). The appendix hangs from or giardiasis, or to infestation with contents) is much thicker than normal
roundworms or tapeworms. It may also have and may block the intestine.
a pouch (the caecum) between the small
intestine and the colon. The final section noninfectious causes, as in ulcerative colitis
before the anus is the rectum. and Crohn’s disease. Gastroenteritis is the Obstruction
Unabsorbed material leaves the term commonly applied to inflammation Impaired blood supply (ischaemia) to
small intestine as liquid and fibre. As of the stomach and intestines. Sometimes, the intestine may result from partial or
this material passes through the large inflammation is localized, as in appendicitis complete obstruction of the arteries in
intestine, water and mineral salts are and diverticular disease. the abdominal wall (from diseases such
absorbed into the bloodstream, leaving as atherosclerosis) or from the blood
faeces that are made up of undigested Tumours vessels being compressed or trapped, as
food residue, fat, various secretions, and Tumours of the small intestine are rare, in intussusception or hernias. Loss of
bacteria. The faeces are compressed and but noncancerous growths, lymphomas, blood supply may cause gangrene.
pass into the rectum for evacuation. and carcinoid tumours (causing carcinoid
syndrome) may occur. Tumours of the Other disorders
intestine, cancer of large intestine are common (see colon, Other disorders that affect the intestine
cancer of; rectum, cancer of). Some forms include peptic ulcers, diverticulosis,
A malignant tumour occurring in the
small or the large intestine. Cancer of of familial polyposis, a condition causing malabsorption, coeliac disease, and
the small intestine is rare; cancer of the the development of noncancerous irritable bowel syndrome.
large intestine is one of the most com- growths, may progress to cancer.
mon cancers (see colon, cancer of;

432
 INTRADERMAL

uterus, cancer of; cervix, cancer of). ly enlarge or rupture, causing subarach-
LOCATION OF THE INTESTINE Implants of radioactive material (usual- noid haemorrhage or stroke, which are
ly in the form of artificial radioisotopes potentially fatal. (See also aneurysm;
Situated below the
stomach and the liver,
in small tubes) are placed near the berry aneurysm.)
the intestine occupies tumour and left there for a period of
a large proportion of the time. This varies from hours to days intracranial hypertension,
central and lower part depending on the type of radioactive benign
of the abdomen. substance used and the type of tumour A condition in which intracranial pres-
being treated. sure is substantially raised. The cause of
Small Intracavitary chemotherapy may be the condition is unknown, but it often
Liver intestine Stomach
used to treat a malignant effusion (a occurs in obese young women with
collection of fluid that contains cancer- menstrual irregularities. Rarely it is
ous cells) that has developed in the caused by drugs, including cortico-
chest or abdomen. Treatment slows the steroid drugs. Symptoms may include
rate at which the fluid returns after it headache, vomiting, and visual distur-
has been drained. Intracavitary chemo- bance. The condition is not fatal but
therapy is also used to treat cancers of can damage the optic nerves, leading to
the bladder. The drugs are introduced permanent visual loss. Treatment is
into the cavity through a catheter (flex- with diuretic drugs; occasionally, excess
ible tube) and may either be left in cerebrospinal fluid may be diverted by
place or drained off after a certain
period of time.
way of a surgically inserted shunt (arti-
ficial passage).
I
intracerebral haemorrhage intracranial pressure (ICP)
Bleeding into the tissue of the brain Pressure exerted by cerebrospinal fluid
Caecum Colon from a ruptured blood vessel. Intrac- (fluid that cushions and nourishes the
(large
intestine) erebral haemorrhage is one of the brain and spinal cord) around the
three principal mechanisms by which brain. ICP can be assessed during a
Appendix Rectum Anus a stroke can occur. lumbar puncture. Following serious head
CAUSES injury or some types of neurosurgery,
This disorder mainly affects middle- ICP may be monitored continuously
and adenomas, leiomyomas, lipomas, and aged or elderly people and is usually using a transducer that is inserted
angiomas in the small intestine. due to atherosclerosis (accumulation of through the skull.
fatty deposits in the walls of the arter- Raised ICP may be due to a brain
intoxication ies). Untreated hypertension (high blood tumour, head injury, meningitis, or benign
A general term for a condition resulting pressure) increases the risk of intracere- intracranial hypertension. Untreated, it can
from poisoning. It customarily refers to bral haemorrhage. result in permanent neurological dam-
the effects of excessive drinking (see SYMPTOMS age and may be serious and, in some
alcohol intoxication). The term may also The ruptured artery is usually in the cases, life-threatening.
be used of drug poisoning; poisoning cerebrum (the main mass of the brain).
from the accumulation of the by-prod- The escaped blood seeps out, damaging intracranial tumour
ucts of metabolism in the body; or the brain tissue. The symptoms are sudden Any tumour that develops within the
effects of industrial poisons. headache, weakness, and confusion, and skull.
often loss of consciousness. Speech loss,
intra- facial paralysis, or one-sided muscle intractable
A prefix that means “within”, as in the weakness may develop, depending on A term used to describe any condition
term “intramuscular” (within a mus- the area affected. that does not respond to treatment.
cle). (See also inter-.) TREATMENT AND OUTLOOK
Surgery is usually impossible; treatment intracytoplasmic sperm
intra-articular cartilage is aimed at life-support and the reduc- injection (ICSI)
See hyaline cartilage. tion of blood pressure. Large haemorr- A treatment for male infertility in which
hages are usually fatal. For the survivor a single sperm is collected from a sam-
intracavitary therapy of an intracerebral haemorrhage, reha- ple of semen and injected into an ovum
Treatment of a cancerous tumour in a bilitation and outlook are the same as (egg). The ovum is then placed in the
hollow organ by placing a radioactive for any type of stroke. woman’s uterus (see in vitro fertilization).
implant or anticancer drugs within the
cavity of the organ. intracranial aneurysm intradermal
Intracavitary radiotherapy is a type of The abnormal dilation of an artery A medical term meaning “into or with-
brachytherapy (the practice of implant- occurring anywhere inside the area in the skin”. For example, an intradermal
ing radioactive wires or grains close to enclosed by the cranium (skull bones). injection is made into the skin, whereas
the tumour) that is mainly used to treat Intracranial aneurysms may cause no a subcutaneous injection is made into the
cancers of the uterus and cervix (see symptoms. However, they can sudden- layer of fat under the skin.

433
 INTRADERMAL NAEVUS

intradermal naevus section may be necessary. Most babies the baby’s skull) is used to check for
A type of pigmented naevus (skin blem- whose growth was retarded in the bleeding. Intraventricular haemorrhage
ish) formed by groups of melanocytes uterus gain weight rapidly after deliv- may cause no long-term problems. In
(pigment-producing cells) within the ery. If an intrauterine infection or some cases, however, it may lead to
dermis (the thick inner layer of the genetic disorder was the cause, howev- disability or hydrocephalus (a buildup
skin). An intradermal naevus is usually er, poor growth may continue after birth. of fluid around the brain). In the most
raised and may range in colour from severe cases, it may be life-threatening.
dark brown to pink. They are noncancer- intravenous
ous and may disappear spontaneously. A term meaning “within a vein”, as in intrinsic asthma
(See also junctional naevus.) intravenous infusion (slow introduction The name sometimes given to a type of
of a substance into a vein) and intra- asthma that is not associated with an
intramuscular venous injection (rapid introduction of identifiable allergic trigger, such as
A medical term meaning “within a a substance into a vein). pollen. (See also allergy; hypersensitivity.)
muscle”, as in an intramuscular injec-
tion, in which a drug is injected deep intravenous infusion intrinsic factor
within a muscle. The slow introduction of fluid into the A chemical produced by the stomach
bloodstream through a cannula (thin lining that is necessary for the absorp-
intraocular pressure plastic tube) inserted into a vein. An tion of vitamin B12. A lack of intrinsic
The pressure within the eye that helps intravenous injection is given over sev- factor leads to a deficiency in vitamin
to maintain the shape of the eyeball. eral hours or days and is commonly B12; this problem, in turn, results in per-
I Normal intraocular pressure is pro-
duced by a balance between the rate of
known as a drip. The procedure is used
to give blood (see blood transfusion) or,
nicious anaemia.

production and removal of aqueous more commonly, fluids or essential introitus

humour, the watery fluid that fills the salts. Other uses of intravenous infu- A general term for the entrance to a
front of the eyeball. Aqueous humour is sion include providing nutrients to body cavity or space. The word is most
continually produced from the ciliary people who are unable to digest food commonly used for the vagina.
body and exits from the drainage angle (see feeding, artificial) as well as the
(a network of tissue between the iris administration of certain drugs. A introspection
and cornea). If drainage is impeded, machine known as an infusion pump The contemplation or analysis of one’s
intraocular pressure builds up; this may be used to control the amount of own thoughts, feelings, and other men-
condition is called glaucoma. If the cil- the drug or fluid being infused. tal processes. (See also insight.)
iary body is damaged (as a result of
prolonged inflammation), insufficient intravenous urography introvert
aqueous fluid may be produced and An X-ray procedure, commonly abbre- A person who is more concerned with
the eyeball may become soft. viated to IVU, that is used to give a clear his or her inner world than the external
image of the urinary tract. or social environment. Introverts prefer
intrauterine contraceptive The procedure involves intravenous to work alone, are shy and quiet, and
device injection of a contrast medium (a sub- become withdrawn when under stress.
See IUD. stance that is opaque to X-rays) into the (See also extrovert; personality.)
arm. The medium is carried in the
intrauterine growth retardation blood to the urinary system, where it intubation
Poor growth in a fetus (an unborn passes through the kidneys, ureters, A term most commonly used to refer to
baby within the uterus). Intrauterine and bladder to be excreted in the urine. the process of passing an endotracheal
growth retardation usually results from X-rays taken at intervals show outlines (breathing) tube into the trachea (wind-
a failure of the placenta to provide ade- of the urinary system.
quate nutrients (which is often related IVU reveals abnormalities such as Endotracheal Laryngoscope Balloon on
tube end of
to pre-eclampsia) or sometimes from a tumours and obstructions, and signs of endotracheal
fetal defect. Severe maternal disease, kidney disease. tube
such as chronic kidney failure, can
reduce fetal growth. If the mother intraventricular haemorrhage
smokes during pregnancy, this may Bleeding into the ventricles (the fluid- Trachea
also reduce the growth and birth filled cavities of the brain). Premature
weight. Problems in the fetus, such as babies are at greater risk because the
an intrauterine infection or genetic dis- nearby blood vessels are underdevel- Tongue
order, can also impair growth. oped and fragile, but the bleeding may
Intrauterine growth retardation may occur in babies carried to full term.
be suspected on antenatal examination; There may be no obvious signs that a
ultrasound scanning may be performed haemorrhage has occurred; alternative-
to assess the problem. ly, the baby may be pale and limp.
Endotracheal intubation
The underlying cause is treated, if Seizures may also occur. Guided by an anaesthetist, the endotracheal tube
possible. If the baby’s growth is slow- Ultrasound scanning of the baby’s is passed through the patient’s mouth and down
ing, induction of labour or a caesarean brain through the fontanelle (a gap in the throat into the trachea.

434
 IN VITRO FERTILIZATION (IVF)

pipe). Endotracheal intubation is carried TREATMENT inverted nipple

out if mechanical ventilation is needed In some cases, an enema can be used to An indrawing of the nipple. The condi-
to deliver oxygen into the lungs. force the abnormal area of intestine tion can be longstanding or may develop
The anaesthetist looks down the pati- back into a normal position. In other in later life as a result of changes in the
ent’s throat with a laryngoscope (viewing cases, surgery may be necessary to repo- breast tissue. Possible causes include nor-
instrument) to identify the vocal cords. sition the intestine. mal changes associated with aging or, in
The tube is then passed through the some cases, an underlying cancer.
mouth or nose and down the throat invasive
between the vocal cords and trachea. A term used to describe anything that in vitro
The term “intubation” is also used to forcibly enters or spreads through the The performance of biological processes
refer to the placement of a gastric or body. The word “invasive” is usually in a laboratory rather than within the
intestinal tube in the stomach for pur- applied to cancerous tumours or harm- body.The term literally means “in glass”.
poses of suction or the giving of ful microorganisms that tend to spread
nutrients (see feeding, artificial). throughout body tissues. It can also be in vitro fertilization (IVF)
used to refer to surgery. In an “inva- A technique used to treat infertility when
intussusception sive” medical procedure, the body its cause cannot be determined or treat-
A condition in which part of the intes- tissues are penetrated by an instrument ed or if there is a blockage in a fallopian
tine telescopes in on itself, forming a during surgery. (See also minimally inva- tube. IVF is also used to treat couples
tube within a tube, usually resulting sive surgery; noninvasive.) affected by a genetic disorder because the
in intestinal obstruction (see intestine,
obstruction of). The condition usually
affects the last part of the small intes- PROCEDURE FOR IN VITRO FERTILIZATION
I
tine, where it joins the large intestine.
CAUSES
Fertilization of eggs outside a woman’s body can be performed to treat some types
of infertility. One such technique used is in vitro fertilization; the main stages
In some cases there is an association
involved in this procedure are illustrated below.
with a recent infection. In other cases, it
may start at the site of a polyp or Meck-
el’s diverticulum (a pouch-like projection
from the ileum).
SYMPTOMS AND COMPLICATIONS
Intussusception occurs most common-
ly in children under the age of two. An
affected child usually develops severe
abdominal colic; vomiting is common,
and blood and mucus are often found
in the faeces.
In severe cases of intusseption, the
blood supply to the intestine becomes 3 4 5 6
2 7
blocked. Gangrene (tissue death), fol- Days 1 to 8 1 8 Days 9 to 13
lowed by peritonitis (inflammation of 28 9
During the first eight days of During these five days, the
27
the abdominal lining) or perforation a woman’s menstrual cycle, 10 woman undergoes a series of
(rupture), may result. she is given fertility drugs to 26 11 ultrasound scans to monitor
stimulate the ripening of 25 12 the ripening of the eggs in
several eggs. 24 her ovaries.
13
23 14
22 15
21
20 19 18 17 16

Caecum

Ileum Days 14 to 15
Days 16 to 17
About two days later, the eggs are examined Immediately before ovulation (which may be
to see if they have been fertilized and have induced with drugs), ripe eggs are removed by
Appendix started to develop into embryos. If they have, laparoscopy (above) or by ultrasound-guided
two or three of the best embryos are needle aspiration through the vagina or the
Intussusception introduced into the woman’s uterus through abdomen. The eggs are mixed with the man’s
This disorder is characterized by part of the intestine the vagina. Further embryos may be frozen sperm in a dish (above, centre), which is then
telescoping in on itself. The problem usually occurs and stored. put in an incubator.
at the junction between the ileum and the caecum.

435
 IN VIVO

embryo can be tested for abnormalities iodine ion

before implantation. IVF involves the A trace element essential for formation A particle that carries an electrical
surgical removal of an ovum (egg) from of the thyroid hormones, triiodothyro- charge; positive ions are called cations
the ovary and its fertilization outside nine (T3) and thyroxine (T4), which and negative ions anions. Many vital
the body. control the rate of metabolism (internal body processes, such as the transmis-
HOW IT IS DONE chemistry) as well as growth and sion of nerve impulses, depend on the
The woman is given a course of fertility development of the body. movement of ions across cell mem-
drugs to stimulate the release of mature Iodine must be obtained from the branes. Sodium is the principal cation
ova, followed by ultrasound scanning to diet; it is found in seafood and dairy in the fluid that bathes all cells (extra-
check the ova. The ova are collected products, as well as in vegetables grown cellular fluid), affecting the flow of
immediately before ovulation using in soil containing iodides. Dietary short- water into and out of cells (see
the guidance of ultrasound, either by age may lead to enlargement of the osmosis), thereby influencing the con-
laparoscopy or via the vagina under thyroid gland known as goitre or centration of body fluids.
sedation. They are then mixed with hypothyroidism. A deficiency in newborn The acidity of the blood and other
sperm – usually from the partner, but babies can, if left untreated, lead to body fluids is dependent on the level
sometimes from a donor – in the labo- mental deficiency and incomplete phys- of hydrogen cations, which are pro-
ratory and are incubated at body ical development known as cretinism. duced by metabolic processes. To
temperature for about 48 hours to Shortages are very rare in developed prevent the fluids from becoming too
allow fertilization to take place. Two, or countries due to bread and table salt acidic, hydrogen cations are neutral-
sometimes more, fertilized ova are being fortified with iodide or iodate. ized by bicarbonate anions in the
I introduced into the woman’s uterus
through a thin tube fed through the
Radioactive iodine is sometimes used
to reduce thyroid gland activity in cases
extracellular fluid and the blood, and
by phosphate anions inside cells (see
cervix. If they become safely implanted of thyrotoxicosis and in the treatment acid–base balance).
in the uterine wall, the pregnancy usu- of thyroid cancer. Iodine compounds
ally continues normally. are used as antiseptics, in radiopaque ionizer
Many attempts at IVF may be needed contrast media in some X-ray proce- A device that produces ions. Some peo-
before a successful pregnancy is ach- dures (see imaging techniques), and in ple believe that use of an ionizer,
ieved. Modifications of the technique, some cough remedies. which produces negative ions, reduces
such as gamete intrafallopian transfer
(GIFT), are technically simpler than
the original method. (See also intracyto- IMPORTANT IONS AND THEIR ROLES
plasmic sperm injection.)
Types of ion Name Major roles in body
in vivo
Literally “in the living organism”; bio- Cations Ammonium (NH4+) Acid–base balance; produced by protein
logical processes occurring within the (positively metabolism
charged ions)
body. (See also in vitro.)
Calcium (Ca2+) Nerve conduction; muscle contraction; blood
involuntary movements clotting; bone and tooth formation; heart muscle
contraction
Uncontrolled movements of the body.
These movements occur spontaneously
and may be slow and writhing (see Hydrogen (H+) Acid–base balance; component of stomach acid
athetosis); rapid, jerky, and random
(see chorea); or predictable, stereo- Magnesium (Mg2+) Nerve conduction; muscle contraction; bone and
typed, and affecting one part of the tooth formation; enzyme activation; protein
body, usually the face (see tic). They metabolism
may be a feature of a disease (for
example, Huntington’s disease) or a side Potassium (K+) Nerve conduction; muscle contraction; water
effect of certain drugs used to treat balance; acid–base balance; heart rhythm
psychiatric conditions.
Sodium (Na+) Nerve conduction; muscle contraction; water
involuntary muscle balance; acid–base balance
An alternative name for smooth muscle,
which lines the walls of internal body Anions Bicarbonate (HCO3-) Acid–base balance; neutralizes stomach acid
structures such as the blood vessels, air- (negatively
ways, and digestive tract. charged ions)
Chloride (Cl-) Acid–base balance; water balance; component of
stomach acid
involution
A term meaning a return to normal Phosphate (PO43-) Acid–base balance; bone and tooth formation;
size; it is most commonly used to refer protein metabolism; energy metabolism; structure
to the shrinkage of the enlarged uterus of cell membranes
following childbirth.

436
 IRRITABLE BLADDER

symptoms, such as headaches and from a peptic ulcer or particularly heavy

fatigue that may result from a buildup LOCATION OF THE IRIS periods but may also be due to diet.
of the positive ions generated by elec- Iron supplements may cause nausea,
The iris lies behind the cornea and in
trical machines. abdominal pain, constipation, or diar-
front of the lens. The outer edge is
connected to a ring of muscle called
rhoea and may colour the faeces black.
ionizing radiation the ciliary body (not shown). At the Excessive iron in the tissues is a feature
A type of radiation. centre is an aperture called the pupil. of haemochromatosis, which commonly
results in cirrhosis, or other forms of
ipecacuanha Lens Iris organ damage.
A drug (also called ipecac) previously
used to induce vomiting in the treatment iron-deficiency anaemia
of types of poisoning. See anaemia, iron-deficiency.
ipratropium bromide iron lung
A bronchodilator drug used in the treat- A large machine formerly used to main-
ment of breathing difficulties. tain breathing, especially in people
paralysed by poliomyelitis. An iron lung
IQ consisted of a chamber that enclosed
The abbreviation for intelligence quoti- the patient’s chest. The air pressure in
ent, which is an age-related measure of the chamber could then be controlled
intelligence (see intelligence tests). in order to force air into and out of the
lungs. The iron lung has been replaced
I
iridectomy Pupil Cornea by more efficient means of maintaining
A procedure performed on the eye to breathing (see ventilation).
remove part of the iris. The most com-
mon type of iridectomy, known as a of melanin (dark pigment) in its tissues. irradiation
“peripheral iridectomy”, is usually per- Brown eyes contain a high level of See radiation hazards; radiotherapy.
formed to treat acute glaucoma. A small melanin. Blue and grey eyes contain
opening is made, surgically or with a very little melanin, their colour comes irradiation of food
laser, near the outer edge of the iris to instead from the collagen tissues them- Treatment of food with ionizing radia-
form a channel through which aqueous selves. Hazel and green eyes contain tion in order to kill bacteria, moulds,
humour can drain. moderate levels of melanin; their insects, and other parasites. Irradiation
colour comes partly from the pigment improves the keeping qualities of food
iridocyclitis and partly from the collagen tissues. and is a means of controlling some
Inflammation of the iris and ciliary body. Flecks of colour in the iris are due to types of food poisoning. It does not,
Iridocyclitis is more usually known as scattered light reflected off blood ves- however, destroy bacterial toxins and
“anterior uveitis”. (See eye, disorders of). sels and muscle tissue. It is possible may destroy vitamins. Irradiation does
for people to have eyes of different not render food radioactive, and there
iridotomy colours (a fairly rare condition called is no evidence that it poses a risk to
A surgical procedure performed on the heterochromia iridium). People with human health.
eye, in which an incision is made in albinism have no melanin in their bod-
the iris using a knife or a laser. (See ies and therefore the colour is governed irrigation, antral
also iridectomy). by the tissues. Such people have light See antral irrigation.
blue or even pink eyes.
iris irrigation, wound
The coloured part of the eye. The iris iritis Cleansing of a dirty or contaminated
is made up of a loose framework of An inflammation of the iris, now often wound by washing it out repeatedly
transparent collagen and two sets of termed an “anterior uveitis”. with a medicated solution or sterile
muscle fibres (one radial and one cir- saline solution.
cular) that lies behind the cornea and iron
in front of the lens. It is connected at A mineral that is essential for the for- irritable bladder
its outer edge to the ciliary body and mation of certain enzymes, haemoglobin Intermittent, uncontrolled contractions
has a central aperture, the pupil, (the oxygen-carrying pigment in red of the muscles in the bladder wall that
through which light enters the eye blood cells), and myoglobin (the oxy- may cause urge incontinence (see
and falls on the retina. The iris con- gen-carrying pigment in muscle cells). incontinence, urinary).
stantly contracts and dilates to alter Iron is found in foods such as liver, Irritable bladder can occur if there is
the size of the pupil, in order to control cereals, fish, green leafy vegetables, a urinary tract infection (see cystitis); a
the amount of light that passes through nuts, and beans. During pregnancy, catheter present within the bladder;
it and so falls on the retina. iron supplements may be required. a bladder stone (see calculus, urinary
The colour of the iris is inherited Iron deficiency leading to anaemia tract); or an obstruction to the outflow
from the parents (see inheritance) and is (see anaemia, iron deficiency) is usually of urine by an enlarged prostate gland,
determined principally by the amount caused by abnormal blood loss, such as however often the cause of discomfort

437
 IRRITABLE BOWEL SYNDROME (IBS)

is not known. In some cases, symp- 50 years old. People with diseases affect-
toms may be relieved by antispasmodic ing blood vessels elsewhere in the body,
drugs; other treatment is directed at such as stroke or peripheral vascular disease,
any underlying cause. Bladder training are more likely to be affected. Other risk
may also be used. factors include a history of congestive
heart failure or diabetes mellitus; surgery
irritable bowel syndrome (IBS) Heart that has resulted in damage to the colon’s
A combination of intermittent abdom- blood supply; and treatment of the
inal pain and constipation, diarrhoea, abdomen with radiotherapy.
or bouts of each, that occurs in the SYMPTOMS AND COMPLICATIONS
absence of other diagnosed disease. Like other forms of colitis, ischaemic
CAUSE AND INCIDENCE colitis may cause abdominal pain,
The precise cause of IBS is unknown, diarrhoea (which may contain blood),
but anxiety and stress tend to exacer- Kidney fever, and vomiting. A longstanding
bate the condition. IBS affects about reduction in the blood supply may
one in five people at some time in life lead to the formation of a stricture
and accounts for more referrals to (narrowed area) in the affected part of
gastroenterologists than any other the colon. Sudden total loss of blood
disorder. It is twice as common in supply, due to thrombosis or to an
women as in men and the disorder is embolism, can cause gangrene (tissue
I generally found to begin in early or
middle adulthood.
Legs death) of the colon.
DIAGNOSIS AND TREATMENT
SYMPTOMS AND SIGNS Symptoms of ischaemia
The condition may be diagnosed by
Symptoms of IBS include intermittent, Ischaemia (insufficient blood supply) of the heart viewing the colon (see colonoscopy; sig-
cramplike pain in the abdomen; causes the chest pain of angina pectoris. Ischaemia moidoscopy) and by taking a biopsy
abdominal distension, often on the left of blood vessels in the legs may cause a cramplike (sample of colon tissue). Angiography
side; transient relief of pain by bowel pain during exercise. The condition may also affect
the kidneys, causing kidney failure, or the brain (not
may also be performed to locate any
movement or passing wind; a sense of shown), resulting in a stroke. blocked blood vessels.
incomplete evacuation of the bowels; In mild ischaemia, treatment with
excessive wind; passage of mucus; drugs used to treat heart failure and
diarrhoea; constipation; and nausea. may be given for persistent diarrhoea. hypertension in combination with lipid-
Some people also have symptoms Antispasmodic drugs may be prescribed lowering drugs and, in some cases,
unrelated to the digestive tract, such as to relax the contractions of the diges- antiplatelet or anticoagulant drugs is
headache, back pain, and tiredness. tive tract and relieve abdominal pain. often sufficient, but acute ischaemia
Symptoms are typically intermittent, Hypnosis, psychotherapy, and counselling may require surgery in order to remove
and usually recur throughout life, have proved effective in some cases. any blockages in the blood vessels.
though they may become less frequent Areas of colon that have been irrepara-
and severe with time. The condition is ischaemia bly damaged must be removed before
unlikely to lead to complications. Insufficient blood supply to a specific peritonitis and gangrene (tissue death)
DIAGNOSIS AND TREATMENT organ or tissue. It is usually caused by develop (see colectomy).
There is no single test to diagnose IBS a disease of the blood vessels, such as
as opposed to another disorder of the atherosclerosis, but may also result from ischaemic necrosis
digestive tract. In order for a diagnosis injury, constriction of a blood vessel The death of tissue as a result of an
of IBS to be made, a patient must have due to spasm of the muscles in the ves- inadequate blood supply (see necrosis).
had continuous or recurrent abdominal sel wall, or an inadequate blood flow
pain or discomfort for at least 12 weeks due to inefficient pumping of the ischaemic optic atrophy
accompanied by at least two of the heart. Symptoms displayed depend on See optic atrophy.
following features: relief of pain on the area affected.
defaecation; onset of pain associated Treatment may include vasodilator ischium
with a change in stool frequency; and drugs to widen the blood vessels or, One of the bones that form the lower
onset of pain associated with a change in more severe cases, an angioplasty part of the pelvis.
in stool consistency. or bypass operation.
IBS can sometimes be controlled islets of Langerhans
through a change in diet and use of ischaemic attack Clusters of endocrine (hormone-pro-
relaxation techniques. An individual See transient ischaemic attack. ducing) cells within the pancreas. The
may need to experiment to find the islets of Langerhans contain at least
approach that works best. ischaemic colitis four different types of cells, which
If constipation is the main problem, A form of colitis (inflammation of the secrete hormones that control the level
a high-fibre diet or bulk-forming colon, the main part of the large intes- of glucose in the body. One type of cell
agents (see laxative drugs), such as bran tine) caused by an interruption of the secretes insulin, which lowers the
or methylcellulose, may be helpful. blood supply to the colon. Ischaemic col- blood glucose level; another secretes
Short courses of antidiarrhoeal drugs itis most commonly affects people over glucagon, which raises the blood glu-

438
 ISTIN

cose level; a third secretes a hormone isoniazid netic radiation. This radiation release
called somatostatin, which inhibits An antibacterial drug that is used in the means that such isotopes may be used
the secretion of insulin; and a fourth, treatment of tuberculosis. Isoniazid is in some medical procedures, such as
about which relatively little is known, given in combination with other anti- radiotherapy for cancer and imaging tests
secretes a pancreatic polypepetide (a tuberculous drugs, usually for a such as radionuclide scanning.
protein molecule). minimum of six months.
One common disorder affecting the isotope scanning
islets of Langerhans is type 1 diabetes isoprenaline See radionuclide scanning.
mellitus, in which the insulin-secreting A drug that is used on rare occasions as
cells are destroyed. Other, less com- an emergency treatment of heart block isotretinoin
mon disorders include the growth of or severe bradycardia (an abnormally A drug derived from vitamin A used in
tumours in particular groups of cells, slow heart rate). Isoprenaline was pre- the treatment of acne. Isotretinoin
leading to an excess of the hormone viously used to treat asthma, but it has works by reducing the formation of
produced by those cells (see glucagono- now been replaced by drugs with sebum (natural skin oils) and keratin (a
ma; insulinoma). fewer side effects. tough protein that is the major compo-
nent of the outer layer of skin).
Isogel isosorbide Isotretinoin can be used as a topical
A brand name for ispaghula husk, a A long-acting nitrate drug that acts as a gel to treat mild to moderate cases of
bulk-forming agent used as a laxative vasodilator drug (by widening blood acne, or it may be taken orally in the
drug. Isogel is also used to control vessels). Isosorbide is used to reduce treatment of severe, scarring acne that is
some types of diarrhoea. the severity and frequency of angina
pectoris (chest pain caused by an
unresponsive to other treatments. Side
effects of topical treatment include
I
isoimmunization, Rhesus impaired blood supply to the heart inflammation and peeling of the skin;
See Rhesus isoimmunization. muscle). Isosorbide is also given to sunlight should be avoided. Isotretinoin
treat severe heart failure. There are two should only be taken orally under med-
isolation forms of isosorbide: mononitrate and ical supervision. In this form, it may
Nursing procedures (also called barrier dinitrate. Isosorbide dinitrate is con- cause drying of the skin and the
nursing) designed to prevent a patient verted by the body into isosorbide mucous membranes, nosebleeds, sore
from infecting others or from being mononitrate, which is the active form eyes, and disorders of the blood.
infected. The patient is usually isolated of the drug. Isotretinoin may damage a develop-
in a single room. Side effects of isosorbide include ing fetus; pregnancy must be avoided
Complete isolation is used if a patient headache, hot flushes, and dizziness. In during treatment and for at least one
has a contagious disease, such as Lassa addition, tolerance to the drug may month after taking the drug. Regular
fever, that can be transmitted to others develop especially in patients who are blood tests are recommended to check
by direct contact and airborne germs. In using long-acting preparations or for complications.
this case, all bedding, equipment, and patches; a change in the dosage, fre-
clothing are either sterilized or inciner- quency, or timing, or changing to a ispaghula
ated after use. Partial isolation is carried different drug, may be required. A bulk-forming laxative drug that is
out if the disease is transmitted in a used to treat constipation, diverticular
more limited way (by droplet spread, as isotonic disease, and irritable bowel syndrome. As
in tuberculosis, for example). Having the same tension. It is used to ispaghula travels through the intestine,
Reverse isolation, also called reverse define a system of exercise, such as it absorbs water, thereby softening and
barrier nursing, is used to protect a weight lifting, in which muscle ten- increasing the volume of the faeces.
patient whose resistance to infection is sion is kept constant as the body works Ispaghula is also used in people who
severely lowered by a disease or treat- against its own, or an external, weight. have chronic, watery diarrhoea and in
ment such as chemotherapy. The air The term “isotonic” also describes flu- those patients who have had a colos-
supply to the room is filtered and all ids, such as intravenous fluids or tomy or an ileostomy to control the
staff and visitors must wear caps, drinks, with the same osmotic pressure consistency of faeces.
gowns, masks, and gloves. Occasionally, (see osmosis) as the blood. (See also Adverse effects include flatulence,
long-term reverse isolation may be isometric; hypotonic solutions.) abdominal distension, and discomfort.
required for patients who have severe
combined immunodeficiency (see im- isotope isthmus
munodeficiency disorders). Any one of the different atoms of a A narrow connecting structure or tissue
chemical element. Different isotopes of between two larger body parts, such as
isometric an element have the same number of the portion of tissue connecting the two
A term used for a system of exercise that protons (positively charged particles) lobes of the thyroid gland.
involves no body movement, and in but different numbers of neutrons
which muscles build up strength by (neutral particles) in their nucleus, and Istin
working against resistance. The resis- therefore a different atomic weight. A brand name for amlodipine, a calcium
tance is provided by either a fixed Radioactive isotopes are unstable channel blocker drug used in the treat-
object or an opposing set of muscles. and break down into more stable ment of disorders such as angina pectoris
(See also isotonic). forms, with the release of electromag- (chest pain due to insufficient blood

439
 ITCHING

into the uterus for contraception. Most

THE IUD (INTRAUTERINE CONTRACEPTIVE DEVICE) IUDs are plastic devices that have copper
incorporated to improve their effective-
The IUD, also known as the IUCD, is
a small plastic contraceptive device
ness. One type of IUD releases small
inserted into the uterus through the amounts of progestogen hormone and is
cervix. IUDs are thought to work by sometimes known as an IUS.
preventing the implantation of IUDs are believed to inhibit the im-
fertilized eggs in the uterus. All types plantation of a fertilized egg in the wall
of IUD can be fitted, by specially of the uterus (see implantation, egg).
trained healthcare personnel, in family HOW IUDS ARE USED
planning clinics, hospitals, or general An IUD is inserted through the vagina
practitioners’ surgeries. and cervix into the uterine cavity. Once in
position, it provides immediate protec-
tion. Most IUDs have one or two plastic
strings attached to make removal easier
and to indicate their presence. IUDs
usually need to be replaced every three
IUD
to eight years depending on the type.
Uterus WHO SHOULD USE IUDS
Cervix
Plastic threads
Women who have been pregnant are less
I likely to have complications than women
who have never been pregnant. For
Vagina
example, they may feel less pain on
insertion and have lighter menstrual flow
Site of an IUD and lower expulsion rates. IUDs are usu-
An IUD is inserted into the uterus. Most types that extend through the cervix to the vagina. ally not recommended for women with
have two arms that hold them in position. The The threads enable the user to check that the fibroids or an irregular uterine cavity. If
base of the IUD has one or two plastic threads device is in place.
menstrual flow is heavy, an IUS may be
recommended instead of an IUD.
RISKS AND COMPLICATIONS
supply to the heart muscle) and hyper- TREATMENT A rare complication of the use of IUDs
tension (high blood pressure). Specific treatment for itching depends is perforation of the uterus, which most
on the underlying cause. Cooling and commonly occurs at the time of inser-
itching soothing lotions, such as calamine, may tion. Rarely, pregnancy can occur with
Known medically as pruritus, an intense help to relieve irritation; emollients an IUD in place; however, an IUD sel-
irritation or tickling feeling in the skin. (substances that moisten and soften the dom causes problems and it can be
TYPES AND CAUSES skin) may reduce dryness. removed early in pregnancy. IUDs
Generalized itching may result from increase the risk of PID, which can lead
excessive bathing, which removes the -itis to permanent infertility.
natural oils from the skin and may A suffix meaning “inflammation of”.
leave the skin excessively dry. Some Virtually every organ or tissue in the IUS
people experience general itching after body can suffer inflammation, so “itis” is An abbreviation for intrauterine system.
taking certain drugs. Many elderly a very common word ending in medi- The IUS is a contraceptive device that fits
people suffer from dry, itchy skin, cine. Examples of its use are bronchitis inside the uterus, like an IUD. It contains
especially on their backs. Itching com- (inflammation of the bronchi) and the progestogen hormone levonorgestrel,
monly occurs during pregnancy. hepatitis (inflammation of the liver). which is released continuously over three
Conditions, including chickenpox, to five years.The IUS acts by thinning the
urticaria (nettle rash), and eczema, pro- ITP uterine lining and thickening cervical
duce itching. Generalized skin itchiness An abbreviation for idiopathic thrombocy- mucus. It also makes menstrual periods
can be a result of diabetes mellitus, kidney topenic purpura. lighter, so may be used for women with
failure, jaundice, and thyroid disorders. heavy periods (see menorrhagia). One
Pruritus ani (itching around the anal itraconazole widely used brand of IUS is the Mirena.
region) occurs with haemorrhoids and A type of antifungal drug.
anal fissure. Threadworm infestation is the IVF
most likely cause of anal itching in IUCD See in vitro fertilization.
children. Pruritus vulvae (itching of An abbreviation for intrauterine contra-
the external genitalia in women) may ceptive device (see IUD). IVU
be due to the condition candidiasis, The abbreviation for intravenous urogra-
hormonal changes, or to use of sper- IUD phy (an X-ray imaging technique for
micides or vaginal ointments and An abbreviation for intrauterine contra- visualizing the urinary tract).
deodorants. Insect bites, lice, and scabies ceptive device. An IUD, also known as
infestations cause intense itching. an IUCD or coil, is a device inserted

440
 JAW, DISLOCATED

jaundice

J
In rare cases, severe or persistent neo-
Yellowing of the skin and whites of the natal jaundice can be caused by the
eyes, caused by an accumulation of blood disorder haemolytic disease of the
the yellow-brown pigment bilirubin in newborn; the genetic condition G6PD
blood and tissues. Jaundice is the chief deficiency; hepatitis (inflammation of the
sign of many disorders of the liver and liver); hypothyroidism (underactivity of
biliary system. Many otherwise healthy the thyroid gland); biliary atresia
babies are affected briefly by jaundice (abnormal formation or absence of the
soon after birth (see jaundice, neonatal). bile ducts); or infection.
TYPES AND CAUSES Jaundiced babies usually require extra
Bilirubin is formed from haemoglobin fluids and may be treated with photo-
Jaccoud’s arthropathy (the oxygen-carrying pigment in red therapy (light therapy) or, in severe cases,
Also called Jaccoud’s arthritis or Jac- blood cells) when old red cells are bro- exchange transfusion (see blood transfu-
coud’s syndrome, a rare form of chronic ken down, mainly by the spleen. It is sion). If severe neonatal jaundice is not
arthritis associated with systemic lupus absorbed by the liver, where it is made treated promptly, kernicterus (a form of
erythematosus. The disorder causes fib- soluble in water and excreted in bile. brain damage) may occur.
rous changes in the joint capsules and There are three main types of jaun-
tendons at the base of the fingers, lead- dice: haemolytic, hepatocellular, and jaw
ing to pain and swelling. obstructive. In haemolytic jaundice, too The mobile bone of the face, also called
much bilirubin is produced for the liver the mandible (or lower jaw). The term
Jacksonian seizures to process. This condition results from sometimes includes the maxilla (upper
A temporary brain disturbance in which excessive haemolysis (breakdown of red jaw), the bone that extends from the
seizures begin in one part of the body,
such as a limb or the face, and then
blood cells), which can have many
causes (see anaemia, haemolytic).
inner rims of the eyes to the mouth.
The mandible bears the lower teeth on
J
spread to other areas or even the whole In hepatocellular jaundice, bilirubin its upper surface, and is connected to the
body (a progression called the march of accumulates because it is prevented base of the skull at the temporomandibular
the seizure). The person usually retains from passing from liver cells into the joints. Muscles attached to the jaw move
consciousness but may have amnesia bile. This form of jaundice is usually the bone to enable chewing, biting, and
(memory loss). (See also epilepsy.) due to acute hepatitis (inflammation of side-to-side and downward motions.
the liver) caused by taking certain drugs
Jahnke’s syndrome or by liver failure.
A form of Sturge–Weber syndrome in In obstructive jaundice, also called ANATOMY OF THE JAW
which there is malformation of blood cholestatic jaundice, bile cannot leave
The U-shaped jaw bone (mandible)
vessels in the face and brain but without the liver because of bile duct obstruction, joins the skull in front of the ears, at
the glaucoma (increased fluid pressure which may be caused by gallstones or the temporomandibular joint. The
in the eye) that is usually associated due to a tumour anywhere in the duct. jaw can move in several directions
with the syndrome. Obstructive jaundice can also occur if to enable biting and chewing.
the bile ducts are underdeveloped (as in
Jakob–Creutzfeldt disease biliary atresia) or have been destroyed by Maxilla Temporomandibular joint
See Creutzfeldt–Jakob disease. disease. Cholestasis (stagnation of bile in
the liver) then occurs and bilirubin
Japanese B encephalitis overflows into the blood.
An epidemic, mosquito-borne form of DIAGNOSIS AND TREATMENT
encephalitis (brain inflammation) occur- Blood tests, andpossibly also a liver biopsy
ring in Japan, India, and parts of (removal of a sample of tissue for analy-
southeast Asia. In most cases the infec- sis), may be performed to identify the
tion causes no symptoms; however, cause of the jaundice. Investigation of the
some people develop severe encephalitis bile duct may be carried out using such
leading to paralysis, seizures, coma, and imaging techniques as ERCP and MRI.
death. Immunization is available for Treatment is for the underlying cause.
those travelling to high-risk areas.
jaundice, neonatal
jargon aphasia Yellowing of the skin and whites of the
Teeth Mandible Muscles
A form of aphasia (loss of language eyes in newborn babies, due to accu-
skills) in which the affected person can- mulation of the yellow-brown bile
not form grammatical sentences but pigment bilirubin in the blood. Neonatal
utters meaningless phrases composed of jaundice usually results from the liver jaw, dislocated
jumbled words or neologisms (made- being too immature to excrete bilirubin Displacement of the lower jaw from one
up words). Jargon aphasia may be due efficiently. The condition, which tends or both temporomandibular joints (which
to a lesion in the dominant temporal to be more common in breast-fed connect the jaw to the base of the
lobe of the brain, or, rarely, may be a babies, is usually harmless and disap- skull), usually due either to a blow or to
sign of schizophrenia. pears within a week. yawning. There is usually pain in front

441
 JAW, FRACTURED

of the ear on the affected side, and the ning. Covering the nipple with a ban-
jaw projects forwards. The mouth can- ANATOMY OF THE JEJUNUM dage or a layer of petroleum jelly
not be fully closed, which makes eating reduces rubbing.
This section of the
and speaking difficult. Surgery may be small intestine joins
performed to stabilize the joint, but dis- the duodenum (first
joint
location tends to recur. section) to the ileum The junction between two or more
(final section). It is bones. Many joints are highly mobile,
jaw, fractured wider than the ileum while others are fixed or allow only a
A fracture of the jaw bone, most often and has a thicker wall. small amount of movement (see Types of
caused by a direct blow. A minor frac- joint box opposite).
Duodenum
ture may cause tenderness and pain on Stomach STRUCTURE
biting. In severe injuries, jaw movement In all types of joint, the bones are held
may be limited, and there may be loss together by soft tissues. In fixed joints,
of feeling in the lower lip. such as those in the skull, the bones are
Minor fractures are normally left to firmly secured by fibrous tissue. In
heal on their own. Severe fractures with semi-mobile joints (such as those in the
bone displacement, however, require spine), the bones are connected by car-
surgery and immobilization of the jaw tilage, which allows limited movement.
(see wiring of the jaws). Mobile joints (such as those in the
limbs) are supported by strong liga-
JC virus ments. They are moved by muscles,
A type of virus called a polyomavirus. which are attached to the bones by ten-
J JC virus does not usually cause symp-
toms in healthy adults but can be
dons. Each mobile joint is also sealed
within a tough, fibrous capsule.
dangerous in people with a depressed TYPES
immune system due to diseases such as There are several types of mobile joint,
leukaemia, lymphoma, or AIDS. In such each allowing a specific form of move-
cases, JC virus causes a brain disease ment. Hinge joints, such as those in the
Colon Ileum Jejunum
called progressive multifocal leucoen- fingers, knees, and elbows, principally
cephalopathy, which leads to dementia. allow bending and straightening. Pivot
joints, such as the joint between the
jealousy, morbid jellyfish stings first and second vertebrae (see vertebra),
Preoccupation with the potential sexual Injections of venom from the stinging allow rotation only. Ellipsoidal joints,
infidelity of one’s partner. The sufferer, cells of jellyfish, which belong to a such as the wrist, allow all types of
most often a man, becomes convinced group of marine animals called cnidari- movement except pivotal. Ball-and-
that his partner is having an affair. Mor- ans. In most instances of jellyfish stings, socket joints, such as the shoulder and
bid jealousy is usually caused by a there is only mild pain or itching, but hip, allow movement in all directions.
personality disorder, depression, or para- some jellyfish venom causes vomiting, DISORDERS
noia, but may also result from alcohol breathing difficulties, and collapse. Dan- Common joint injuries include sprains
dependence or organic brain syndrome gerous species live mainly in tropical (minor tears) or rupture of ligaments;
(see brain syndrome, organic). waters. Antivenoms may be used to treat damage to cartilage; and tearing of joint
severe cases. capsules. Such injuries may be caused by
jejunal biopsy sudden twisting or wrenching move-
A diagnostic test in which a small piece jerky nystagmus ments, often during sport or vigorous
of tissue is removed from the lining of A form of nystagmus (involuntary eye exercise, or in a fall. Separation of the
the jejunum (middle section of the small movement) in which the eyes move bone ends (see dislocation, joint), and
intestine) for microscopic examination. slowly in one direction, then dart back. partial displacement (see subluxation),
It is especially useful in the diagnosis of are also usually caused by injury, but are
coeliac disease, intestinal lymphoma, and jet-lag occasionally present from birth. Rarely,
other causes of malabsorption. The biop- Fatigue and disruption of the sleep– the bone ends are fractured, which may
sy is taken through an endoscope wake cycle, caused by disturbance of cause bleeding into a joint (haemarthro-
introduced via the mouth, or with a normal body biorhythms as a result of sis). Joint effusion (build-up of fluid in a
device called a Crosby capsule, which is flying across different time zones. joint) is usually due to synovitis (inflam-
attached to a thread and swallowed. mation of the joint lining).
jigger One of the main diseases of the joints
jejunum An alternative name for a chigoe, which is arthritis, which causes pain, stiffness,
The middle, coiled section of the small is also sometimes known as a sand flea. inflammation, and degeneration of the
intestine, joining the duodenum to the joints. Other joint disorders include bur-
ileum. The main functions of the jeju- jogger’s nipple sitis (inflammation of a fluid-filled
num are to digest food and absorb Soreness of the nipple caused by fric- cushion around a joint); distortion or
nutrients. It may be affected by coeliac tion from clothing, usually during such rupture of an intervertebral disc (see
disease, Crohn’s disease, and lymphoma. sports as jogging or long-distance run- disc, slipped); gout; and bunions.

442
 JOINT

TYPES OF JOINT

There are several types of joint. Some are fixed (such as the ball-and-socket have the widest range of movement. Pivot
skull joints), some allow only a little movement (the vertebral joints allow rotation only. Ellipsoidal joints allow movement
joints, for example), and some are mobile. Of the mobile joints, in most directions. Hinge joints mainly allow bending.

Ball-and-socket joint Pivot joint

A ball-and-socket joint is formed by the ball- In a pivot joint, movement is limited to rotation,
shaped end of one bone fitting into a hollow either by means of a bony projection pivoting
in another. It allows movement backwards or within a ring or by a ring pivoting around an axis.
forwards, movement sideways, and rotation.
Examples are the hip and shoulder joints.
An example of a moving ring is the joint between
the first and second vertebrae, in the neck. J

Ellipsoidal joint Hinge joint

In an ellipsoidal joint, the oval-shaped end of This is the simplest joint; the cylindrical end of one
one bone fits into an elliptical cavity in another, bone fits into a groove in another to allow bending and
allowing all types of movement except pivoting. straightening, as in the fingers. The knee and elbow are
An example is the wrist joint. modified hinge joints that allow some rotation as well.

STRUCTURE OF A FIXED JOINT STRUCTURE OF A MOBILE JOINT

Fixed joints are firmly secured by The surfaces of the bone ends are Fluid-filled cavity
fibrous tissue. The joints between coated with very smooth cartilage to Smooth
the bones of the skull (known as reduce friction as they move against each cartilage
sutures) are an example. other. The ends are sealed within a tough
Bone
fibrous capsule; this is lined with synovial
membrane, which produces a sticky
lubricating fluid. The joint is surrounded
by strong ligaments that support it
and prevent excessive movement. Its
movement is controlled by muscles that
are attached to bone by tendons on either
side of the joint. Most mobile joints have Ligament
at least one bursa (fluid-filled sac) nearby,
Sutures
which cushions a pressure point. Synovial membrane

443
 JOINT REPLACEMENT

joint replacement jugular venous pressure brane around the heart), and enlarge-
See arthroplasty. An assessment of the pressure within ment of the liver and spleen. Uveitis
the internal jugular vein, one of the three (inflammation of parts of the eye) may
Joubert’s syndrome major veins on each side of the neck develop. Rarely, amyloidosis (in which an
An autosomal recessive genetic disorder, that carry deoxygenated blood to the abnormal protein is deposited in body
present from birth, in which part of the right atrium of the heart. Heart failure can organs) or kidney failure may develop.
cerebellum, an area located at the back cause raised jugular venous pressure. DIAGNOSIS
of the brain, fails to develop properly. Diagnosis is based on the symptoms,
Affected children have impaired balance junctional naevus together with the results of X-rays and
and coordination; abnormal breathing A pigmented naevus formed by a cluster blood tests; it is made only if the condi-
patterns; hypotonia (decreased muscle of melanocytes (pigment-producing tion lasts for longer than three months.
tone); and, sometimes, seizures. cells) in the skin, at the junction TREATMENT AND OUTLOOK
between the epidermis (outer layer) Treatment may include antirheumatic
joule and the dermis (inner layer). The nae- drugs, corticosteroid drugs, nonsteroidal
The international unit of energy, work, vus looks like a flat, non-hairy, brown anti-inflammatory drugs, or aspirin. Splints
and heat. Approximately 4,200 joules mole. (See also intradermal naevus.) may be worn to rest inflamed joints and
(symbol J) or 4.2 kilojoules (kJ) equal to reduce the risk of deformities. Physio-
1 kilocalorie (kcal); 1 kJ is equal to Jungian theory therapy reduces the risk of muscle
about 0.24 kcal. (See also calorie.) The Swiss psychiatrist Carl Gustav Jung wasting and deformities. The arthritis
(1875–1961) theorized that certain usually clears up after several years, but in
jugular vein ideas called archetypes, inherited from some children it persists into adult life.
One of three veins on each side of the experiences in humanity’s distant past,
juvenile muscular atrophy
J neck (the internal, external, and anterior
jugular veins) that return deoxygenated
existed in the unconscious and con-
trolled the way a person viewed the A form of muscle atrophy (wasting and
blood from the head to the heart. The world. Jung called these shared ideas weakness) that occurs in children and
internal jugular vein, the largest of the the “collective unconscious”. Jungian adolescents, and is caused by an autoso-
three, arises at the base of the skull and therapy was aimed at putting people in mal recessive genetic disorder. Muscle
travels down the neck alongside the touch with this source of ideas, part- atrophy is most obvious in the legs, and
carotid arteries, before passing behind icularly through the interpretation of later the arms. Respiratory muscles may
the clavicle (collarbone), where it joins dreams. Jung also postulated two basic also be involved. Most affected children
the subclavian vein (the large vein that types of personality: the extrovert and eventually become wheelchair bound.
drains blood from the arms). the introvert.
juvenile-onset diabetes
ANATOMY OF THE juvenile arthritis A form of type 1 (insulin-dependent)
JUGULAR VEINS See juvenile chronic arthritis. diabetes mellitus that develops suddenly
in childhood or adolescence.
There are three jugular veins on each juvenile chronic arthritis
side of the neck that return blood A rare form of arthritis (joint inflamma- juvenile osteoporosis,
from the head to the heart. tion) affecting children. Juvenile chronic idiopathic
External Internal jugular vein
arthritis occurs more often in girls, and A rare form of osteoporosis (loss of
jugular vein usually develops between two and four bone density) that occurs in children
years of age or around puberty. of eight to 14 years. Idiopathic juvenile
TYPES osteoporosis causes leg and back pain;
There are three main types, all of which kyphosis (curvature of the upper spine);
cause joint pain, swelling, and stiffness. walking difficulty; and an increased sus-
The most common form is pauciarticu- ceptibility to fractures. The disorder
lar juvenile arthritis, which affects four usually begins suddenly and often dis-
joints or fewer and usually occurs in appears spontaneously after two to four
very young girls. Polyarticular juvenile years. Treatment is aimed at preventing
arthritis affects five or more joints, and fractures and maintaining mobility.
is more common in girls. Still’s disease
(systemic onset juvenile arthritis) affects
both boys and girls. It starts with fever,
rash, enlarged lymph nodes, abdominal
pain, and weight loss. These symptoms
last for several weeks. The joint prob-
lems may not develop for some months.
COMPLICATIONS
Possible complications include short
Subclavian Anterior stature, anaemia, pleurisy (inflammation
vein jugular vein
of the membranes around the lungs),
pericarditis (inflammation of the mem-

444
 KERATOACANTHOMA

Kaposi’s varicelliform eruption

K
ally after a skin injury. Keloids can develop
A generalized, serious skin eruption, anywhere on the body, but the breastbone
consisting of pus-filled blisters, caused and shoulder are common sites. Black
by a viral infection in areas of pre-exist- people are affected more commonly
ing atopic dermatitis.The disorder is also than white people. After several months,
known as eczema herpeticum. The most keloids flatten and cease to itch.
viruses usually responsible are herpes Injection of corticosteroid drugs into
simplex virus (HSV-1 and HSV-2) and the keloid may reduce itchiness more
coxsackievirus. quickly and cause some shrinkage.
Kartegener’s syndrome
kala-azar An inherited disorder in which the heart
A form of the parasitic disease leishma- is situated on the right instead of the left
niasis, which is spread by sandflies. side of the chest (a condition known as
Kala-azar occurs in parts of Africa, India, dextrocardia). This is associated with
the Mediterranean, and South America. abnormal functioning of the cilia (hair-
like projections) lining the airways,
Kallmann’s syndrome which impairs clearance of mucus and
An inherited condition in which there results in bronchiectasis and sinusitis.
is a deficiency of gonadotrophin-releas-
ing hormone (GnRH). This hormone, karyotype
which is produced in the hypothala- The characteristics of chromosomes, in
mus, is responsible for regulating the terms of number, size, and structure, in
release of other hormones in the pitu- an individual or a species. The term
Keloid on the earlobe
itary gland that in turn stimulate the “karyotype” is also applied to a diagram
testes. The deficiency of GnRH delays of chromosome pairs arranged in their
This large overgrowth of scar tissue has formed on
the earlobe after the ear was pierced. Black people K
or sometimes prevents normal sexual assigned numerical order. are particularly susceptible to keloids.
development at puberty. The condition
is also associated with colourblindness Kawasaki disease keratin
and a lack of sense of smell. Kallmann’s A rare, acute illness of unknown cause A fibrous protein that is the main con-
syndrome is treated with hormones that that most commonly affects children stituent of the tough outermost layer of
replace GnRH. under two years of age. The disease is the skin, nails, and hair.
characterized by fever lasting one to
kaolin two weeks; conjunctivitis; dryness and keratitis
An aluminium compound used as an cracking of the lips; swollen lymph nodes Inflammation of the cornea (the transpar-
ingredient in some antidiarrhoeal drugs. in the neck; reddening of the palms and ent front part of the eyeball). It often
Kaolin is an adsorbent and is taken by soles; and a generalized rash. By the end takes the form of a corneal ulcer and may
mouth to treat the diarrhoea and vomit- of the second week of illness, the skin at result from injury, contact with chemicals,
ing caused by food poisoning and other the tips of the fingers and toes peels and or an infection. Symptoms of keratitis
digestive disorders. other symptoms subside. The heart include pain and excessive watering of
muscle and coronary arteries are affected the eye, blurring of vision, and photopho-
Kaposi’s sarcoma in some cases. bia (abnormal sensitivity to bright light).
A cancerous tumour arising from blood High doses of gamma-globulin (see Noninfective keratitis is treated by
vessels in the skin or, less commonly, in immunoglobulin injections) and aspirin keeping the affected eye covered until
internal organs. Almost all cases of may be given in order to prevent asso- is has healed. Drugs such as antibiotics
Kaposi’s sarcoma occur in people who ciated heart complications. The majority may be given to treat infective keratitis.
have AIDS. Several tumours are often of children recover completely. (See also disciformis keratitis.)
present, appearing as pinkish-purple,
raised areas of skin. The tumours can Keller’s operation keratoacanthoma
spread rapidly over the body; they usu- A type of surgery sometimes used to A type of harmless skin nodule that
ally develop first on the feet and the treat hallux valgus (a deformity of the commonly occurs in elderly people,
ankles, spread up the legs, then occur big toe). The operation involves cutting most often on the face or arm. The
on the hands and the arms. Internal away a piece of bone from the base of cause is unknown, but many years of
tumours, such as those affecting the the first joint of the toe. Fibrous tissue exposure to strong sunlight or long-
gastrointestinal and respiratory tracts, forms in the gap, although the toe is left term use of immunosuppressant drugs
may cause severe bleeding. shorter. (See also bunion.) may be contributory factors. Initially,
Skin tumours may be treated with the nodule resembles a small wart, but
radiotherapy. Anticancer drugs may be keloid it grows to 1–2 cm across in about
used if the skin is widely affected, or A raised, hard, irregularly shaped, itchy eight weeks. Although the nodule usual-
for internal tumours. Antiretroviral drugs scar on the skin due to a defective healing ly disappears gradually after this time,
often control the cancerous growths process in which too much collagen (a surgical removal is often recommended
and may shrink them. tough, fibrous protein) is produced, usu- to prevent scarring.

445
 KERATOCONJUNCTIVITIS

keratoconjunctivitis common, often leading to loss of the eye thighs, and buttocks. The openings of
Inflammation of the cornea (the trans- through infection. The disorder usually the hair follicles become enlarged by
parent front part of the eyeball) that is occurs only in severely malnourished plugs of keratin (a tough, fibrous pro-
associated with conjunctivitis (inflamma- children and is a common cause of tein), and hair growth may be distorted.
tion of the conjunctiva, the membrane blindness in developing countries. The condition is not serious and usu-
covering the eyeball). The most com- In the early stages, the damage can be ally clears up on its own. In severe
mon form of the disorder, epidemic reversed by treatment with large doses cases, applying a mixture of salicylic
keratoconjunctivitis, is caused by a virus of vitamin A but, if the condition is left acid and soft paraffin and scrubbing
and is highly infectious. The inflamma- untreated, blindness is usually inevitable. with a loofah may help.
tion is often severe and in some cases
may destroy the surface of the conjunc- keratopathy keratotomy, radial
tiva. Tiny, opaque spots develop in the A general term used to describe a vari- An uncommon procedure in which radi-
cornea that may interfere with vision ety of disorders of the cornea (the ating incisions are made in the cornea
and persist for some months. transparent front part of the eyeball). (the transparent front part of the eyeball)
There is no specific treatment, but TYPES up to, but not through, its innermost
corneal spots may be minimized by using Actinic keratopathy is a painful condi- layer, in order to reduce myopia (short-
eye-drops containing corticosteroid drugs. tion in which the outer layer of the sightedness). Radial keratotomy has been
cornea is damaged by ultraviolet light largely replaced by laser procedures,
keratoconjunctivitis sicca emitted from the sun, reflected from such as LASIK, which carry less risk of
Persistent dryness of the cornea (the surfaces such as snow (in which case permanent damage to the eye.
transparent front part of the eyeball) the problem is called snow-blindness),
and the conjunctiva (the membrane cov- or given off by artificial sources such as kerion
ering the eyeball) caused by deficiency sunbeds or arc-welding torches. A red, painful swelling, oozing fluid, that
in tear production. The condition is Exposure keratopathy is corneal dam- appears on the scalp due to infection
associated with autoimmune disorders age due to loss of the protection with scalp ringworm (see tinea). Treat-
K such as rheumatoid arthritis, Sjögren’s syn- afforded by the tear film and blink ment with oral antifungal drugs needs to
drome, and systemic lupus erythematosus, reflex. It may occur in conditions in be continued for several weeks before the
all of which can damage the tear glands. which the eyelids inadequately cover scalp heals. The disorder may leave scar-
Prolonged dryness may lead to blurred the cornea, including severe exophthal- ring and an area of permanent hair loss.
vision, itching, grittiness, and, in severe mos, facial palsy, and ectropion.
cases, the formation of a corneal ulcer. kernicterus
The most effective treatment is frequent keratoplasty The abnormal accumulation of the
use of artificial tears (see tears, artificial). See corneal graft. pigment bilirubin in the brain of a new-
born baby, as a result of severe jaundice.
keratoconus keratosis Kernicterus causes permanent brain
An inherited disorder of the eye, in which A skin growth that is caused by an damage, but the effective treatment of
the cornea (the transparent front part of overproduction of the tough, fibrous jaundice in newborn babies has made
the eyeball) becomes gradually thinned protein keratin. Keratoses occur mainly the condition rare.
and conical. The condition affects both in elderly people.
eyes and usually develops around puberty, TYPES ketamine
giving rise to increasing myopia (short- Seborrhoeic keratoses are harmless A general anaesthetic administered by
sightedness) and progressive distortion of growths that occur mainly on the trunk. injection. It is mainly given to children
vision that cannot be fully corrected by They range in appearance from flat, undergoing painful procedures, such as
glasses. Hard contact lenses improve vision dark-brown patches to small, wartlike bone marrow biopsy. Ketamine may be
in the early stages, but later it is generally protrusions. The growths do not need abused for its stimulant effect.
necessary to perform a corneal graft to treating unless they are unsightly.
restore normal vision permanently. Solar keratoses are small, wartlike red ketoacidosis
or flesh-coloured growths that appear A combination of acidosis and ketosis.
keratolytic drugs on exposed parts of the body as a result (See also diabetic ketoacidosis.)
Drugs that loosen and remove the of overexposure to the sun over many
tough outer layer of skin. Keratolytic years. Rarely, they may develop into skin ketoconazole
drugs, which include urea and salicylic cancer, usually squamous cell carcinoma. An antifungal drug used to treat fungal
acid preparations, are used to treat skin TREATMENT infections of the gut, skin, and finger
and scalp disorders, such as warts, acne, Seborrhoeic keratoses can be removed nails, and candidiasis (thrush) of the
dandruff, and psoriasis. by curettage (scraping away). Surgery is mouth or vagina. It is also used as a
required for solar keratoses that have shampoo to treat dandruff. Adverse
keratomalacia become cancerous, however. effects include nausea and rash.
A progressive disease of the eye, caused
by severe vitamin A deficiency, in which keratosis pilaris ketone
the cornea (the transparent front part of A common condition, usually occur- Any of a group of chemicals related to
the eyeball) becomes opaque and ulcer- ring in adolescents, in which patches of acetone (which is found in solvents
ated. Perforation of the cornea is also rough skin appear on the upper arms, such as nail polish remover). Certain

446
 KIDNEY CANCER

ketones are produced during the meta-

bolism of fats; if excessive amounts build
LOCATION OF THE KIDNEYS
up in the body, they cause ketosis.
The kidneys are situated at the is connected to the bladder by a
ketoprofen back of the abdominal cavity, ureter. The renal arteries, which
just above the waist, on either supply the kidneys, arise directly
A type of nonsteroidal anti-inflammatory side of the spine. The right from the aorta, and the renal
drug (NSAID) that is prescribed as an anal- kidney lies below the liver (not veins join on to the inferior vena
gesic drug (painkiller) for injuries to soft shown), and the left kidney lies cava. The two adrenal glands sit
tissues, such as muscles and ligaments. below the spleen. Each kidney on top of each kidney.
Ketoprofen also reduces joint pain and
stiffness in arthritic conditions. It may
Spleen
cause abdominal pain, nausea, indiges-
Adrenal
tion, and an increased risk of peptic ulcer. gland
Rib cage
ketosis
A potentially serious condition in which Right Left kidney
excessive amounts of chemicals called kidney
ketones accumulate in the body. Ketones
are normal products of fat metabolism, Renal vein Renal artery
but are produced in excess when body
cells cannot use glucose as an energy Vena cava Aorta
source. This occurs in starvation, in
prolonged vomiting, and in untreated
diabetes mellitus (see diabetic ketoacidosis)
when a lack of insulin prevents glucose Ureters
from entering cells. Symptoms include K
sweet, acetone-smelling breath, loss of
appetite, nausea, and abdominal pain.
Ketosis may eventually result in con-
fusion, unconsciousness, and death.
Treatment is of the underlying cause. The kidneys also regulate the body’s TYPES
fluid balance. To do this, they excrete There are three main types of cancer
keyhole surgery excess water, and when water is lost that affect the kidney: renal cell carcin-
Another name for minimally invasive from the body (for example, as a result oma, nephroblastoma, and transitional
surgery. of sweating), they conserve it (see ADH). cell carcinoma.
In addition, they control the body’s Renal cell carcinoma
kidney acid–base balance by adjusting urine Also known as hypernephroma or ade-
Either of the two organs that filter the acidity. Lastly, the kidneys produce hor- nocarcinoma, this is the most common
blood and excrete waste products and mones involved in the regulation of red type of kidney cancer. It usually occurs
excess water as urine. The kidneys are blood cell production and blood pressure. in people over the age of 40 and affects
situated at the back of the abdominal twice as many men as women. A com-
cavity, on either side of the spine. kidney biopsy mon symptom is blood in the urine.
STRUCTURE A procedure in which a small sample of There may also be pain in the back, a
Each kidney is surrounded by a fibrous kidney tissue is removed and examined lump in the abdomen, fever, or weight
capsule and is made up of an outer layer under a microscope. Kidney biopsy is loss. The cancer often spreads to the
(cortex) and an inner layer (medulla).The performed to investigate and diagnose lungs, bones, liver, and brain.
cortex contains specialized capillaries serious disorders such as glomerulo- Nephroblastoma
(tiny blood vessels) called glomeruli; nephritis, proteinuria, nephrotic syndrome, Nephroblastoma (also called Wilms’
these vessels, together with a series of and acute kidney failure, or to assess the tumour) is a fast-growing tumour that
tubules, make up the nephrons, the filter- kidneys’ response to treatment. mainly affects children under five years
ing units of the kidney. Urine, the waste There are two basic techniques: per- old. Nephroblastoma sometimes runs in
product from filtering, passes through cutaneous needle biopsy, in which a families, but its cause is unknown.
tubules to the medulla, collects in an area hollow needle is passed through the Symptoms may include swelling of the
called the renal pelvis, then travels through skin into the kidney under local anaes- abdomen, abdominal pain or discom-
tubes called ureters to the bladder. thesia; and open surgery under general fort, and, occasionally, blood in the
FUNCTIONS anaesthesia. urine. Nephroblastoma may spread to
The nephrons filter blood under pres- the lungs, liver, and brain.
sure and then selectively reabsorb water kidney cancer Transitional cell carcinoma
and certain other substances into the A cancerous tumour of the kidney. Most This type of kidney cancer arises from
blood. Urine is formed from substances kidney cancers originate in the kidney cells lining the renal pelvis (the urine-
that are not reabsorbed (see illustrated itself, but in rare cases cancer spreads to collecting system within the kidney); it
box: the function of the kidney). the kidney from another organ. is most common in smokers or in people

447
 KIDNEY CYST

DISORDERS OF THE KIDNEY

The kidneys are susceptible to a wide blood flow. Such conditions include hyperuricaemia, may cause kidney stones
range of disorders. Only one normal shock, haemolytic–uraemic syndrome, poly- to form (see calculus, urinary tract).
kidney is needed for good health, arteritis nodosa, diabetes mellitus, and
however, so disease is rarely life- systemic lupus erythematosus. Impaired Infection
threatening unless it affects both kidneys blood flow through the kidneys can lead Infection of the kidney is called pyelo-
and is at an advanced stage. Hypertension to tissue damage, hypertension, and nephritis and can be a complication of
(high blood pressure) can be both a kidney failure. cystitis. A predisposing factor to infection
cause and an effect of kidney damage. is obstruction of urine flow through the
Other effects of serious damage include Autoimmune disorders urinary tract due to a kidney or ureteral
nephrotic syndrome and kidney failure. Glomerulonephritis includes a group of stone, tumour, or congenital defect.
autoimmune disorders (in which the
Congenital and genetic disorders immune system attacks the body’s own Other disorders
Congenital abnormalities, such as duplex tissues) that cause the filtering units of Hydronephrosis (a kidney swollen with
kidney (in which a kidney is partially the kidneys to become inflamed and urine) is caused by obstruction of the
duplicated) and horseshoe kidney (in unable to function normally. urinary tract. Crush syndrome is a
which the two kidneys are joined at their condition in which kidney function is
base), are fairly common and usually Drugs disrupted by proteins released into the
harmless. Serious inherited disorders Allergic reactions to drugs, prolonged blood from damaged muscle.
include polycystic kidney disease (see treatment with analgesic drugs (pain-
kidney, polycystic), in which multiple cysts killers), and some antibiotics can damage
develop on both kidneys; and Fanconi’s kidney tubules. INVESTIGATION
syndrome and renal tubular acidosis, in
Kidney disorders are investigated by
K which the kidney tubules function
abnormally so that certain substances
Tumours
Noncancerous kidney tumours are rare;
kidney imaging techniques such as
ultrasound scanning, urography,
are inappropriately lost in the urine. kidney cancer is uncommon. angiography, and CT scanning or MRI;
by kidney biopsy (removal of a small
Impaired blood supply Metabolic disorders amount of tissue for analysis; by blood
Various conditions may cause damage Diabetes mellitus is the commonest cause tests; and by kidney function tests such
to, or lead to blockage of, the blood of kidney failure in developed countries. as urinalysis.
vessels within the kidneys, impairing Other metabolic disorders, such as

who have taken certain analgesic drugs kidney cyst to accumulate in the body, and also pro-
for a long time. Blood in the urine is a A fluid-filled sac in the kidney. Cysts duces other chemical imbalances in the
common symptom; hydronephrosis (dis- commonly develop in people over 50, blood and body tissues.
tension of the kidney with urine) may and can occur either singly or multiply TYPES
occur due to blockage of the ureter. in one or both kidneys. Most cysts occur Kidney failure can be acute or chronic.
DIAGNOSIS, TREATMENT, AND OUTLOOK for no known reason, are noncancerous, In the acute form, kidney function often
The doctor will conduct a physical and do not usually produce symptoms returns to normal once the underlying
examination and test a urine sample for unless they become large enough to cause has been discovered and treated.
the presence of blood. Diagnosis can be cause lower back pain due to pressure In chronic kidney failure, however, kid-
confirmed by ultrasound scanning, CT on surrounding tissues. Large numbers ney tissue is progressively damaged over
scanning, MRI, or intravenous urography. of kidney cysts, however, may be associ- several months or years. This condition
All types of kidney cancer require ated with polycystic kidney disease (see may develop into end-stage kidney
surgical removal of the affected kidney kidney, polycystic), which often leads to failure, a life-threatening condition in
and sometimes also of the ureter. Any kidney failure. which kidney function is usually
remaining cancerous cells are destroyed Simple cysts do not usually require irreversibly lost.
using radiotherapy and/or treatment with treatment. For cases in which the cysts CAUSES
anticancer drugs (for example, interleukin are painful or recurrent, however, aspi- Causes of acute kidney failure include a
or medroxyprogesterone are given to treat ration (withdrawal of fluid) or surgical severe reduction in blood flow to the
some cases of renal cell carcinoma). removal may be carried out. kidneys, as occurs in shock; an obstruc-
Survival rates vary, depending on the tion to urine flow, for example due to a
type of cancer and how early treatment kidney, duplex bladder tumour; or certain rapidly
is commenced. In the case of nephro- See duplex kidney. developing types of kidney disease,
blastoma, about four in every five such as glomerulonephritis.
affected children survive; cure rates for kidney failure Chronic kidney failure can be the
this form of kidney cancer are relatively A reduction in the function of the result of a disease that causes progres-
high even if it has spread by the time kidneys. Kidney failure causes waste sive damage to the kidneys, such as
diagnosis is made. products such as urea and excess fluid polycystic kidney disease (see kidney,

448
 KIDNEY IMAGING

(examination of a tissue sample) and

THE FUNCTION OF THE KIDNEYS intravenous urography (taking X-rays of
the urinary tract), may be carried out
The kidneys’ main function is
to filter the blood. This activity RENAL FUNCTION AND AGE to identify the cause of the kidney fail-
is essential in regulating the ure if this is not already obvious.
body’s fluid balance and acid- The efficiency of the kidneys diminishes If acute kidney failure is due to a sudden
base balance. Each kidney with age as the number of functional reduction in blood flow, blood volume
has about 1 million nephrons, nephrons is reduced. and pressure can be normalized by saline
where the filtering takes place. intravenous infusion or blood transfusion. If
1,000,000
A nephron consists of a knot there is an obstruction in the urinary
of capillaries, which is called 750,000
tract, surgery may be needed. Acute kid-
a glomerulus, and a tubule, 500,000 ney disease may be treated with
where urine is formed. Urine 250,000 Nephrons corticosteroid drugs. Treatment may also
drains out of the kidney via per kidney
involve diuretic drugs and temporary dialy-
the ureter; the normal daily sis (artificial purification of the blood).
output is 1 to 2 litres. Age 10 20 30 40 50 60 70 80 90
A high-carbohydrate, low-protein diet
with controlled fluid and salt intake is
Fibrous capsule
important in the treatment of acute and
Cortex Arterioles chronic kidney failure, because this
Arterioles are tiny blood vessels reduces the workload on the kidneys.
that carry blood to and from
Nephron each glomerulus and surround
For end-stage kidney failure, long-
each tubule. term dialysis or a kidney transplant is the
only effective treatment.
Medulla

kidney function tests

Renal artery
Tubule
Tests that are performed to investigate K
About 140 litres of filtered kidney disorders. Urinalysis is a simple
salt and water solution pass test in which a urine sample is exam-
from the glomeruli into the ined under a microscope for blood
tubules each day; 99 per
cent of it is reabsorbed into cells, pus cells, and casts (cells and
the surrounding capillaries. mucous material that accumulate in the
Renal vein The capillaries also reclaim
other essential substances, tubules of the kidneys and pass into the
such as amino acids, urine). Urinalysis is used to test for
Renal pelvis glucose, bicarbonate,
calcium, and phosphorus substances, such as proteins, that leak
and, when necessary, add into the urine when the kidneys are
potassium and hydrogen
Calyces ions to the tubular fluid. damaged. Kidney function can be asses-
sed by measuring the concentration in
the blood of substances that the kidneys
normally excrete, such as urea and crea-
tinine; by creatinine clearance, in which
Renal pyramid levels of creatinine in the blood are
Ureter These structures, which
Urine from the form the medulla of the compared with creatinine excreted in
urine-collecting kidney, contain thousands urine over 24 hours; and by kidney
ducts passes into of urine-collecting ducts.
the calyces of the imaging with radioisotopes.
kidney, then to
the renal pelvis.
It drains from the
kidney imaging
kidney via the Glomerulus Techniques for visualizing the kidneys,
ureter. Each glomerulus acts as a filter, usually performed for diagnosis.
allowing certain dissolved substances
to pass from the bloodstream into the Ultrasound scanning is often the first
tubule, but preventing cells and large investigation and can be used to iden-
proteins from crossing over.
tify kidney enlargement, a cyst or
tumour, and the site of any blockage.
Conventional X-rays show the outline of
polycystic), diabetes mellitus, and hyper- Symptoms of chronic kidney failure de- the kidneys and most kidney stones,
tension (high blood pressure), or from velop more gradually, and may include while intravenous urography shows the
longstanding obstruction to urine flow. nausea, loss of appetite, and weakness. internal anatomy of the kidney and
SYMPTOMS The kidney damage leads to conditions ureters. Angiography is used to image
The most obvious symptom of acute kid- such as anaemia and hyperparathyroidism. blood circulation through the kidneys.
ney failure is oliguria (a reduced volume DIAGNOSIS AND TREATMENT CT scanning and MRI provide detailed
of urine). Urea and other waste products A person with suspected kidney failure cross-sectional images of kidney tissue
build up in the blood and tissues causing will initially need blood and urine and the urine-collecting system, and
drowsiness, nausea, and breathlessness. tests. Other tests, such as kidney biopsy can show abscesses or tumours.

449
 KIDNEY, POLYCYSTIC

People with a family history of this dis-

KIDNEY IMAGING ease may need genetic counselling before
starting a family. The adult form is an
The various kidney imaging techniques can provide different types of information
autosomal dominant disorder and an
to help doctors investigate and diagnose kidney disorders.
affected parent has a 50 per cent chance
MRI and CT scanning of passing on the defective gene. If both
These techniques produce cross- parents carry the gene for the juvenile
sectional images of body tissues, form (autosomal recessive disorder), their
displayed as computer-generated
pictures. They clearly show
fetus can be examined using ultrasound
structural abnormalities such as Cyst on left kidney scanning to detect kidney enlargement.
tumours and cysts. This MRI scan of
the abdomen shows a polycystic Right kidney kidney stone
kidney (on the right of the image). See calculus, urinary tract.
IVU (Intravenous urography) Right kidney kidney transplant
This is a type of X-ray in which
fluid containing a contrast Left kidney An operation in which a person with
medium (a substance opaque to chronic kidney failure receives a healthy
X-rays) is introduced into the kidney from a living or, more common-
urinary system, then X-rays are Ureters ly, a dead donor. One donor kidney can
taken. The images show how the
fluid moves through the kidneys, maintain the health of the recipient.
ureters, and bladder, and can Pelvis The new kidney is placed in the pelvis
show up any obstructions, such through an incision in the abdomen
as stones in the urinary tract. and carefully positioned so that it can
Bladder be connected easily to a nearby vein
and artery and to the bladder. The dis-
K Ultrasound scanning eased kidneys may be left in place.
This is a quick technique, which The transplant removes the need for
Outline of kidney
provides clear images of the dialysis (artificial purification of blood)
structure of the kidney. It can Cyst and often allows a return to a normal
reveal fluid-filled structures such
as cysts, which can be clearly lifestyle.The procedure is more straight-
differentiated from the kidney forward than transplantation of other
tissue surrounding them. organs. Unless the donor is an identical
twin, immunosuppressant drugs are given
Radionuclide scanning to avoid rejection of the kidney.
This produces coloured images Left kidney
to show the functioning of the kidney tumours
kidneys. (This scan is taken from
Right kidney Growths in the kidney. Kidney tumours
the back.) Areas that are brighter
than normal show overactive cells, may be cancerous (see kidney cancer) or
as in a tumour; colours that are noncancerous.The latter type, which in-
less intense than normal show clude fibromas, lipomas, and leiomyomas,
underactivity, as in kidney failure.
are often symptomless, although a hae-
mangioma (composed of a collection of
blood vessels) may grow very large and
Two types of radionuclide scanning are TYPES cause blood to appear in the urine.
used: DMSA and DTPA scanning. DMSA There are two types of polycystic dis-
is given by intravenous injection and ease. The most common type usually Right Left kidney
kidney
binds to cells in the kidney tubules, giv- appears in middle age, producing ab-
ing a single, static picture of the dominal swelling, pain, and blood in
kidneys. DTPA, also given intravenously, the urine. As the disease progresses,
is filtered in the kidneys and passes out hypertension (high blood pressure) and
in the urine. Pictures taken at intervals kidney failure may result.
record its clearance by the kidney, pro- The second type of polycystic dis-
viding an indicator of kidney function. ease, which is rare, causes enlargement
of the kidneys and kidney failure in
kidney, polycystic infants and young children.
An inherited disorder in which both TREATMENT AND PREVENTION
kidneys develop numerous cysts that There is no effective treatment for pre- Spine Tumour
gradually enlarge until most of the serving kidney function in either type
normal tissue is destroyed. Polycystic of the condition, but symptoms of kid- CT scan of a kidney tumour
In this scan, the body is seen from below, with the
kidney disease is distinguished from ney failure can be treated by dialysis spine at the base of the image. The kidneys are the
multiple simple kidney cysts, which (artificial purification of the blood) and round shapes on either side. A tumour (dark mass)
occur commonly with increasing age. kidney transplant. can be seen on the left kidney (right of image).

450
 KIDNEY TUMOURS

PROCEDURE FOR A KIDNEY TRANSPLANT

A kidney transplant is performed

when a person’s kidneys have lost DIALYSIS AND TRANSPLANTATION
almost all of their normal function (so-
called end-stage kidney failure). Just A significant proportion of patients with end-stage kidney failure are
one healthy donor kidney can allow a suitable for a kidney transplant, but many have to remain on dialysis for some
patient to have a normal lifestyle. The time until a suitable donor kidney becomes available. A computer system
donated kidney comes from a close is used to match donors with the most suitable recipients. The number of
relative of the patient, or from any available donor kidneys is considerably less than the number of people
person who consented to medical use waiting for a transplant.
of his or her organs after death. To
prevent rejection of the kidney by
the recipient’s immune system, the The surgeon inserts
tissue-type and blood group of the donated kidney
recipient and donor must be a close in its new position in
the pelvis.
match (see Transplant surgery).

Donor kidney
(from living
donor)

Site of incision
The donor kidney is inserted
low in the patient’s pelvis,
K
close to the bladder and
major blood vessels.

The donor kidney is removed. Usually

1donors,
the left kidney is removed from living
because it has a longer vein than
the right and is easier to remove safely.
With donation from people who have died
(cadavers), both kidneys are used and each
kidney usually goes to a separate recipient.
Kidneys from a cadaver can be maintained
for transplantation by a machine that passes
a cooling saline solution through them.
Donor organs may need to be transported
over long distances, and occasionally to
other countries, to reach the recipient.

Pelvis
THE DONOR
Donor kidney (AFTER THE OPERATION)
Renal artery
The health of the donor is not
Renal vein affected by having a kidney
removed because the body can
Branch of work efficiently with just one. The
iliac artery
remaining kidney enlarges to
Ureter increase its capacity and takes
over full function.
Bladder
Enlarged
kidney

2 After removal, a donor kidney is flushed

with chilled saline solution in order to
3kidneyThe donor kidney is usually placed in the
pelvis. The renal artery and vein of the donor
are joined to a convenient artery (usually a
Original
size
preserve the tissues and internal structures. branch of the external iliac artery) and vein of the
The donor kidney should be transplanted as recipient. The lower end of the donor ureter is
soon as possible, but there is a reasonable connected to the recipient’s bladder. The donor
success rate even if transplantation is delayed kidney usually begins working immediately after
for up to 48 hours. transplantation into the recipient.

451
 KIEL CLASSIFICATION

A biopsy of the tumour may be needed with a family history of the disorder ing a complement of XXY instead of
to confirm that it is not cancerous. may wish to consider genetic coun- XY. The risk of a baby having the condi-
Treatment is usually not needed for selling before having children. tion increases with maternal age.
noncancerous tumours unless they are SYMPTOMS AND SIGNS
large or painful. kiss of life Features of the syndrome vary in severi-
A common name for artificial respiration. ty and may not become apparent until
Kiel classification the child reaches puberty, when gynae-
A system that is used for ranking non- Klebsiella comastia (breast enlargement) occurs
Hodgkin’s lymphoma (see lymphoma, A genus of rod-shaped bacteria that is and the testes remain small. Affected
non-Hodgkin’s), any of several cancerous commonly found in the human intes- males are usually infertile (see infertili-
tumours of the lymphoid tissues in tine. They may cause pneumonia, lung ty). They tend to be tall and thin with a
which the cells divide unchecked. The abscess, or peritonitis in people with female body shape and absence of body
cancer is classified as high-grade or ascites (excess fluid in the peritoneal hair. Incidence of learning difficulties is
low-grade according to the type of cell cavity) due to liver disease. One type, higher in people with Klinefelter’s syn-
and how rapidly the cells are dividing. KLEBSIELLA GRANULOMATIS, is the cause of drome than in the general population.
Once widely used, Kiel classification has the sexually transmitted infection gran- TREATMENT
now been replaced by WHO classification. uloma inguinale or donovanosis, which There is no cure, but hormonal treat-
is common in the tropics and produces ment can induce signs of puberty (see
Kienböck disease a rash and ulceration of the genital area. sexual characteristics, secondary) such as
Death of tissue cells (see necrosis) in the the growth of facial hair, and surgery
wristbone known as the lunate bone. kleptomania may be used to correct gynaecomastia.
The disorder, characterized by pain and A recurring inability to resist impulses
stiffness in the wrist, is caused by an to steal, often without any desire for the Klippel–Fiel syndrome
inadequate blood supply, often the stolen objects. The condition is usually a A condition characterized by an abnor-
result of an undiagnosed or unsuccess- sign of an immature personality. It is mally short neck, due to fused cervical
K fully treated fracture. Treatment usually sometimes associated with depression, vertebrae. Affected people have restrict-
consists of resting the joint; in a few and may also result from dementia or ed neck movement and a low hairline.
cases, surgery is needed. some forms of brain damage.
Klippel–Trenaunay–Weber
killer T-cell Klinefelter’s syndrome syndrome
A type of white blood cell, also known A chromosomal abnormality in which a A rare condition, usually affecting a
as a cytotoxic T-lymphocyte or a CD8 male has one, or occasionally more, limb, in which massive malformation of
lymphocyte, that has an important role in extra X chromosomes in his cells, giv- blood vessels (including both arteries
the immune system. Killer T-cells destroy and veins) leads to overgrowth of the
an abnormal, cancerous, or virus-infect- affected area.
ed cell after a foreign antigen on its LOCATION OF THE KNEE JOINT
surface has been recognized by helper T- Klumpke’s paralysis
The knee is the joint
cells. (See also natural killer cells.) Paralysis of the lower arm, with wasting
between the femur and
the tibia. The bones are of the small muscles in the hand, and
kilocalorie separated by two menisci. numbness of the fingers (but not the
The unit of energy equal to 1,000 calo- The patella lies across the thumb) and the inner forearm.
ries, abbreviated to kcal. In dietetics, a front of the knee joint. Klumpke’s paralysis is caused by
kilocalorie is sometimes referred to injury to the eighth cervical and first
simply as a calorie (or C). thoracic nerves (two of the spinal
nerves) in the brachial plexus (the net-
kilojoule Femur work of nerves located behind the
The unit of energy equal to 1,000 shoulderblade), which usually results
joules, abbreviated to kJ. One kcal (see from injury to the shoulder.
Patella
kilocalorie) equals 4.2 kJ.
knee
kinky-hair disease The hinge joint between the femur
A genetic disorder, also called Menkes’ Medial (thighbone) and tibia (shin). The patella
syndrome, in which body cells do not meniscus (kneecap) covers the front of the joint.
absorb sufficient copper. The condition Lateral STRUCTURE
is present from birth. It causes brittle, meniscus Two protective discs of cartilage called
kinky hair; hypotonia (abnormal muscle Tibia menisci (see meniscus) cover the surfaces
slackness); feeding difficulties; seizures; of the femur and tibia to reduce friction.
Fibula
and degeneration of brain tissue. Affec- Bursas (fluid-filled sacs) located above
ted children die after a few years. and below the patella, and behind the
Kinky-hair disease is an X-linked dis- knee, cushion the joint. External liga-
order; it affects only male babies, but ments on either side of the knee provide
females may carry the gene. People support, and cruciate ligaments within

452
 KNOCK-KNEE

the joint prevent overstraightening and

PROCEDURE FOR A KNEE REPLACEMENT overbending. The quadriceps muscles, at
This procedure is carried out to
the front of the thigh, straighten the
replace a diseased or eroded knee knee, and the hamstring muscles at the
joint. The surgeon usually makes Femur back of the thigh bend it.
a long, straight incision, cutting DISORDERS
through the joint capsule and Skin incision Injuries of the knee are common, and
synovial membrane, then pushes
Patella
include ligament sprains, torn menis-
aside the patella to reach the joint. cus, dislocation of the patella, and
Special instruments are used to make fracture of any of the bones. A painful
precise measurements and cut away Tibia inflammatory condition, chondromalacia
areas of bone so that the artificial patellae, is common in adolescents, and
knee replacement components will Fibula
knock-knee and bowleg are common tem-
fit and move correctly.
porary defects in children.
kneecap
See patella.
knee-jerk reflex
An involuntary response, also known as
a patellar reflex, that occurs when the
tendon just below the kneecap (patella)
is tapped. The tendon stretches and the
thigh muscles contract, straightening
the knee. (See also reflex.)
1intoThe lower end of the femur (thigh-
bone) is shaped and holes are drilled
The upper end of the tibia (shin-bone)
2to accept
is shaped, and holes are drilled into it K
it to accept the femoral component of the tibial component of the knee-joint replacement
the prosthesis (see inset). Accuracy is prosthesis. The cutting and drilling of the
achieved by using the surgical equivalent bone are again carried out using the special Surgery to replace a diseased knee joint
of a mitre box. orthopaedic instruments. with an artificial one, usually made of
metal or plastic. Knee-joint replacement
is most commonly carried out on older
people whose knees are severely affec-
ted by the inflammatory conditions
osteoarthritis or rheumatoid arthritis.

Kniest syndrome
A very rare inherited disorder due to
abnormal collagen (a protein in bone,
cartilage, and connective tissue). It caus-
es severe dwarfism (see short stature) with
3In thisOften the patella is left undamaged, but
repairs may be carried out to its surface.
case, the back part of the patella is
After achieving a satisfactory fit using trial
4prosthesis
components, the three parts of the final
are then cemented in place. Any
curvature of the spine (kyphoscoliosis).

cut away to leave a flat surface. Small holes excess cement is then removed from around knock-knee
are then drilled into this surface to accept the new joint and a final check is made of Inward curving of the legs so that the
the patellar component of the artificial joint. the joint movements. knees touch, causing the feet to be posi-
tioned further apart than normal.
Femur Tibia Femoral component CAUSES
Knock-knee is common in children
between the ages of three and five and
may be part of normal development. In
Metal some children, knock-knee may be
with caused by rickets, a disease that softens
plastic
surface the bones. In adults, causes include
osteoarthritis and rheumatoid arthritis of
Tibial component
the knee. A leg fracture that has not
healed correctly may also cause knock-
Knee prosthesis
The main artificial components knee in children or adults.
X-ray of arthritic knee fit over the femur and tibia (the X-ray of artificial knee TREATMENT
Severe wear and tear of the patellar component is not This X-ray shows the three In children, the condition usually disap-
bone and cartilage can easily shown). The prostheses come components of the prosthesis pears by about seven years. Knock-knee
be seen on this knee X-ray. in different types and sizes. in position after surgery.
that persists, or is due to a disorder, may
require osteotomy, a surgical procedure

453
 KNUCKLE

Koplik’s spots consequences. The advanced stages are

Tiny spots that appear in the mouth dur- marked by jaundice, drowsiness, and a
ing the incubation period of measles. fall in body temperature.
TREATMENT
Korsakoff’s psychosis Initially, the child is fed small, frequent
See Wernicke–Korsakoff syndrome. amounts of milk, and vitamin and min-
eral tablets. A nutritious diet is then
Krabbe’s disease gradually introduced. Most treated chil-
A very rare inherited metabolic disorder dren recover, but those under two years
(see metabolism, inborn errors of) that may have permanently stunted growth.
causes death in early childhood. Krabbe’s
disease is caused by deficiency of an kyphoscoliosis
enzyme (a substance that promotes a bio- A combination of the two types of
chemical reaction) called galactocere- spinal curvature: kyphosis and scoliosis.
brosidase. The deficiency leads to the
accumulation of toxic chemicals within
The appearance of knock-knee
cells of the nervous system. Symptoms, Affected
This condition is common in young children but including seizures, deteriorating vision, area
almost always disappears by the age of seven. deafness, and muscle weakness, usually
begin to develop by nine months.
in which the tibia (shin) is cut and re-
aligned to straighten the leg. In adults, kraurosis vulvae
knee-joint replacement may be needed. See vulvitis.
knuckle kuru
K The name for a finger joint. A rare, fatal infection of the brain that
affects some inhabitants of New Guinea.
Koch’s bacillus Kuru is caused by a “slow” virus, or
Another name for MYCOBACTERIUM TUBER- prion, which has a long incubation peri-
CULOSIS , the microorganism responsible od and is spread by cannibalism. Signs
for tuberculosis. include progressive difficulty in con-
trolling movements and dementia.
Koebner’s phenomenon The study of scrapie in sheep led to Normal Kyphosis of the
A reaction in people with skin disorders the identification of prions, which also curvature thoracic spine
such as psoriasis and lichen planus. New play a role in Creutzfeldt–Jakob disease
The appearance of kyphosis
lesions develop, often due to scratching. and BSE. (See also slow virus diseases). In kyphosis, the thoracic part of the spine is
excessively curved (as indicated by the arrow,
koilonychia Kveim test above), producing a humped appearance.
A condition in which the nails are brit- A skin test used to diagnose sarcoidosis
tle and thin, and become spoon-shaped. (tissue inflammation). It involves inject- kyphosis
It may be congenital, and may be asso- ing Kveim antigen (a protein from the Excessive outward curvature of the
ciated with iron-deficiency anaemia or spleens of people with sarcoidosis) into spine. Kyphosis usually affects the spine
the skin disease lichen planus. the skin, then taking biopsies from the at the top of the back, resulting in a
injection site four to six weeks later to hump or pronounced rounding of the
see if nodules of sarcoid tissue have back. When kyphosis is combined with
developed. The test has largely been a curvature of the spine to one side (sco-
replaced by analysis of lung tissue taken liosis), it is known as kyphoscoliosis.
during bronchoscopy (examination of The condition may be caused by a
the airways with a viewing tube) or variety of spine disorders, or a congenital
biopsy of other affected tissue. abnormality. Treatment is of the under-
lying disorder, but is rarely successful.
kwashiorkor
A severe form of malnutrition in young
children that occurs principally in poor
The appearance of koilonychia
rural areas in the tropics.
In koilonychia, the nails look fragile and are flattened SYMPTOMS AND COMPLICATIONS
in the middle and elevated at the ends. Affected children have stunted growth
and a puffy appearance due to oedema
Konakion (accumulation of fluid in the tissues).
A brand name for the vitamin K supple- The liver often enlarges, dehydration
ment phytomenadione, given routinely to may develop, and the child loses resis-
newborn babies to prevent bleeding. tance to infection, which may have fatal

454
 LACTASE DEFICIENCY

labile

L
TREATMENT
A term meaning “unstable” or “likely to Viral labyrinthitis clears up on its own,
undergo change”. but symptoms may be relieved by anti-
histamine drugs. Bacterial labyrinthitis
labour needs immediate treatment with antibi-
See childbirth; induction of labour. otic drugs, otherwise permanent deafness
or meningitis (inflammation of the mem-
labour pains branes covering the brain) may result.
Painful muscle contractions in the uterus
during childbirth. The contractions dilate laceration
(widen) the cervix and then move the A torn, irregular wound.
Laband’s syndrome baby through the birth canal for delivery.
An autosomal dominant genetic disorder lacrimal apparatus
affecting tissues throughout the body. labyrinth The system in the eye that produces and
It causes bone deformities; overly flexi- The collective term for the structures of drains tears. The lacrimal apparatus in-
ble joints; clubbing of the fingers, and the inner ear. The first part of the cludes the main and accessory lacrimal
missing nails. Other features include a labyrinth is the cochlea, which contains glands and nasolacrimal drainage duct
bulbous nose, overgrowth of the gums, the mechanisms that enable hearing. Situ- (see lacrimal apparatus box, overleaf).
thickened ears, and an enlarged liver ated behind the cochlea are two sacs The main lacrimal glands lie just
and spleen. Some people may also have (the saccule and the utricle) and three within the upper and outer margin of
learning difficulties. fluid-filled semicircular canals, all of the eye orbit and drain onto the conjunc-
which are concerned with balance. tiva (the transparent membrane covering
labetolol the white of the eye and the inside of
A beta-blocker drug that is used to treat labyrinthitis the eyelids). They secrete tears during
hypertension (high blood pressure) and Inflammation of the labyrinth, in the crying and when the eye is irritated.
angina pectoris (chest pain caused by an inner ear. The disorder is almost always The accessory glands lie within the
impaired blood supply to the heart). caused by bacterial or viral infection. conjunctiva, and maintain the normal
Possible adverse effects include indiges-
tion and nausea; in rare cases, the drug
Viral labyrinthitis may develop during
illnesses such as influenza. The bacterial
tear film, secreting it directly onto the
conjunctiva; the fluid is spread across the
L
may cause depression and, in men, tem- form is a complication of otitis media eye surfaces by blinking.
porary impotence. (middle-ear infection). Tears drain from the eye through the
SYMPTOMS lacrimal puncta, tiny openings towards
labia The main symptom of labyrinthitis is the inner ends of the upper and lower
The folds of skin of the vulva that pro- vertigo. Nausea, vomiting, nystagmus (ab- eyelids. The puncta are connected by
tect the vaginal and urethral openings. normal, jerky movements of the eye), narrow tubes to the lacrimal sacs, which
There are two pairs of labia. The outer tinnitus (ringing in the ears), and hear- lie within the lacrimal bones on the
pair, the labia majora, are fleshy folds ing loss may also occur. sides of the nose. Leading from the sacs
that contain sweat glands and grow hair. are the nasolacrimal ducts, which open
They cover the smaller, hairless inner inside the nose.
folds, the labia minora, which meet to
form the hood of the clitoris. lactamase
An enzyme, also called penicillinase or
beta-lactamase, that is produced by STA-
LOCATION OF THE LABIA
PHYLOCOCCUS bacteria (see staphylococcal
infections). Lactamase inactivates antibiotic
The labia majora extend forwards
drugs of the penicillin and cephalo-
from the perineum and fuse at the
front at the mons pubis. The labia sporin groups, making them ineffective
minora lie within. against the bacteria.
lactase deficiency
Labyrinth A condition in which there is an ab-
Mons pubis
sence of lactase, an enzyme that breaks
Inner ear
Clitoris down lactose (milk sugar), in the cells
Middle ear of the small intestine. Lactase deficiency
Labia
majora reduces ability to digest lactose. This is
Cochlea
Labia called lactose intolerance and usually
minora appears in adolescence or adulthood;
Perineum Mechanism of labyrinthitis rarely, it is present at birth (especially in
In labyrinthitis, inflammation of the fluid-filled premature babies). Lactase deficiency
Anus
chambers (labyrinth) of the inner ear causes
disruption of the individual’s sense of balance.
may also occur temporarily after gas-
The inflammation is usually caused by viral troenteritis or treatment with antibiotics,
or bacterial infection. particularly in young children.

455
 LACTATION

lactobacillus
FUNCTIONS OF THE LACRIMAL APPARATUS A type of rod-shaped bacteria found in
fermented plant and dairy products.
Tear production must be sufficient to compensate for evaporation and maintain
the tear film. Accessory lacrimal glands in the conjunctiva perform this function.
Some types of lactobacilli colonize the
The main lacrimal glands secrete tears when excess fluid is required. Surplus tears human intestine and the vagina, where
drain into the nose through the lacrimal puncta, lacrimal sac, and lacrimal duct. they prevent the overmultiplication of
harmful bacteria.
Upper eyelid Accessory
lacrimal glands lactose
One of the sugars present in milk; a di-
Lacrimal gland saccharide carbohydrate.
lactose intolerance
The inability to digest lactose (see lac-
Conjunctiva
tase deficiency).

Iris lactulose
An osmotic laxative drug that is used to
Accessory lacrimal treat constipation.
glands

Lower eyelid Lafora-body disease

A degenerative disease of the nervous
Lacrimal puncta system that causes epilepsy. The disease
is an autosomal recessive genetic disorder
that first appears in childhood or ado-
lescence, often with seizures. Subsequent
signs include impaired movement and
Iris
L coordination, and dementia. There is no
treatment. Death usually occurs within
Lacrimal bone
Lower eyelid 10 years of onset.
Lacrimal sac
Flow of tears
Lambert–Eaton syndrome
Lacrimal duct A neuromuscular disorder in which nerve
(leading to
an outlet into
cells fail to release sufficient amounts of
the nose) the neurotransmitter acetylcholine. It is
often associated with the type of lung can-
cer known as small cell carcinoma. The
main symptom is profound muscle weak-
ness in the trunk and limbs.
SYMPTOMS lactation
The undigested lactose ferments in the The production and secretion of breast lambliasis
intestines, causing symptoms such as milk (see breast-feeding). Another name for giardiasis.
abdominal cramps, bloating, flatulence,
and diarrhoea. lactic acid laminectomy
DIAGNOSIS AND TREATMENT A weak acid that is produced when The partial surgical removal of one of
The condition may be diagnosed by body cells break down glucose by anaer- the laminae (the bony arches on each
testing faeces for the presence of lac- obic metabolism (chemical processes vertebra). Laminectomy is performed as
tose. Alternatively, an exclusion diet may that do not require oxygen) to generate the first stage of spinal canal decom-
be used, in which consumption of dairy energy. Lactic acid is produced by mus- pression (see decompression, spinal canal)
products is stopped for a few days and cles during vigorous exercise and is one or in the treatment of a prolapsed disc
then resumed to see if this causes any of the factors that contribute to cramp. (see disc prolapse).
changes in the symptoms. Lactic acid is also produced in body
Treatment is with a lactose-free diet. tissues when they receive insufficient Lamisil
Some people are able to tolerate small oxygen through impairment of their A brand name for the antifungal drug
amounts of dairy produce but others blood supply. This situation may be the terbinafine.
must avoid dairy products completely, result of a myocardial infarction (heart
including milk, yoghurt, cream, butter, attack) or shock. lamivudine
and cheese. It is possible to obtain milk Normally, lactic acid is removed from A reverse transcriptase inhibitor drug used
products in which lactose has already the bloodstream by the liver. If this does in the treatment of HIV infection, to
been broken down, and enzyme sup- not happen, the lactic acid accumulates slow the progression of the illness. It is
plements containing lactase, which can in the body and causes a condition always prescribed in combination with
be added to milk, or eaten with food. known as lactic acidosis. another drug for HIV, to prevent the

456
 LAPAROTOMY

virus from becoming resistant to it. Landouzy–Dejerine dystrophy breathing difficulties develop, the affec-
Often, when treatment is started, three See facioscapulohumeral dystrophy. ted individual should stop using the
drugs are used: two reverse transcrip- drug immediately and seek urgent
tase inhibitors and a third drug from language disorders medical help.
another class, such as a protease inhi- Problems affecting a person’s ability to
bitor. Lamivudine may also be used to communicate and/or comprehend the lanugo hair
treat longstanding hepatitis B infections. spoken and/or the written word (see The fine, soft, downy hair that covers a
Nausea, vomiting, and diarrhoea are speech; speech disorders). fetus. Lanugo hair first appears in
the most common side effects; others the fourth or fifth month of gestation
include a cough, headache, and pins lanolin and usually disappears by the ninth
and needles. Side effects such as fever, A mixture of purified water and a month. It can still be seen in some pre-
rash, hair loss, jaundice, or sore throat yellow, oily substance that is obtained mature babies.
should be reported to a doctor. If severe from sheep’s wool. Lanolin is used as Lanugo hair sometimes reappears in
abdominal pain develops, the person an emollient in the treatment of dry skin adults who have cancer. It may also
should seek urgent medical help. and mild dermatitis. In occasional cases, occur in those with the eating disorder
lanolin may cause an allergic reaction. anorexia nervosa or be a side effect of
lamotrigine certain drugs, especially ciclosporin.
An anticonvulsant drug used either alone Lanoxin
or in combination with other anticon- A brand name for the digitalis drug laparoscopy
vulsants in the treatment of epilepsy. digoxin. Examination of the interior of the abdo-
lamotrigine can cause various minor men using a viewing instrument called
side effects such as rash, nausea, head- lansoprazole a laparoscope, which is a type of endo-
ache, and blurred vision. Rarely, serious A drug used to treat disorders that are scope. Laparoscopy is carried out in
skin reactions may occur, particularly in caused by excess stomach acid, such as order to investigate the possible causes
children. In addition, there may be flu- peptic ulcer and acid reflux. Lansoprazole of abdominal pain, such as appendicitis.
like symptoms, bruising, sore throat, belongs to a group of drugs known as The procedure is also used in gynaecol-
and facial swelling, which should be proton pump inhibitors. These drugs work ogy for the diagnosis of disorders and
reported to a doctor promptly. by inhibiting the production of stom-
ach acid.
investigation of infertility. Laparoscopy
is also used to perform minimally invasive
L
lance Common side effects of lansoprazole surgery such as appendicectomy, cholecys-
To incise (cut into) using a lancet or a include abdominal pain, constipation, tectomy, and female sterilization (see
surgical scalpel. diarrhoea, headache, fatigue, and dizzi- sterilization, female).
ness. More serious side effects include
lancet muscle or joint pain, swollen hands and laparotomy
A small, pointed, double-edged knife feet, and excessive bruising; all of these Any operation in which the abdomen is
used to open and drain lesions, such as symptoms should be reported to a opened either for diagnostic purposes
boils and abscesses. doctor. If a rash, itching, wheezing, or or for surgical treatment.

PROCEDURE FOR LAPAROSCOPY

A hollow needle is inserted into Sites of Laparoscope

the abdomen just below the navel incision
(under anaesthesia), and carbon Entry Gas-filled
dioxide gas is pumped through to point for area
laparoscope Bladder
expand the abdominal cavity. The
laparoscope is inserted through Entry point
another incision to view the for surgical
internal organs. The gas is instruments
removed afterwards but small
amounts may remain for a day or
two and cause some discomfort.

THE LAPAROSCOPE

Intestine Fallopian tube Uterus

Gynaecological laparoscopy
Laparoscopy is used in diagnosis and is also
sometimes used for removing ova for in vitro
Viewing lens Rigid tube Eyepiece fertilization. Laparoscopy is commonly used
to perform female sterilization.

457
 LARGACTIL

Largactil
A brand name for the antipsychotic and PROCEDURE FOR LARYNGOSCOPY
anti-emetic drug chlorpromazine.
There are two techniques for examination of the larynx. The patient’s throat is
large intestine examined with the use of a mirror in indirect laryngoscopy. In direct laryngoscopy,
the patient’s throat is viewed with an instrument called a laryngoscope. If a flexible
The last section of the gastrointestinal tract. laryngoscope is used, only local anaesthesia is needed; if a rigid laryngoscope is
It begins at a pouch called the caecum used, general anaesthesia is required.
(from which the appendix hangs). The
main part, the colon, has four sections: INDIRECT LARYNGOSCOPY DIRECT LARYNGOSCOPY
the ascending, transverse, descending, and
sigmoid colon. The intestine ends at the Flexible
laryngoscope
rectum, which is connected to the anus.
The large intestine processes the re-
mains of food after nutrients have been
extracted. It reabsorbs water, vitamins,
and mineral salts into the bloodstream,
and expels the waste material as faeces.
Lariam Larynx
The brand name for the antimalarial
drug mefloquine. Angled Flexible laryngoscope
mirror
A flexible laryngoscope is passed down the
larva migrans Tongue
throat via the nostril; a rigid laryngoscope is
passed via the mouth.
Infections that are characterized by the
presence of the larval (immature) forms Larynx View of larynx
of certain parasitic worms in the body. This view was
Visceral larva migrans (toxocariasis) is obtained with a
Indirect laryngoscopy laryngoscope.
L caused by a type of worm that normally
parasitizes dogs. Cutaneous larva migrans
The patient sticks out his or her tongue and The vocal cords
the doctor rests an angled mirror on the soft are at the centre
(creeping eruption) is caused by a form palate. A lamp or mirror on the doctor’s head and the epiglottis
of hookworm infestation; the larvae pene- illuminates the larynx, which is visible in forms the arc at
the angled mirror. the top.
trate the skin and move around, leaving
intensely itchy red lines that are some-
times accompanied by blistering. Both
types of larva migrans can be treated laryngeal nerve or soon after, when it is known as con-
with anthelmintic drugs. One of a pair of nerves that carry genital stridor; the cause is thought to
instructions from the brain to the larynx be abnormal softness of the cartilage in
(voicebox) and send sensations from the larynx (laryngomalacia).
LOCATION OF the larynx to the brain. Congenital laryngeal stridor rarely
LARYNGEAL NERVES
causes serious problems and usually
laryngeal nerve palsy corrects itself as the baby grows. How-
Both nerves leave the brain at the
base of the skull and pass down the Paralysis of one or both of the laryngeal ever, medical or surgical treatment may
neck. One hooks around an artery nerves. Larangeal nerve palsy may be be needed if the condition interferes
behind the right clavicle, the other caused by disorders that cause pressure with breathing.
hooks around the aorta; both return on the nerve, such as an aneurysm (local-
to the larynx. ized swelling) in the aorta or a tumour laryngectomy
in the thyroid gland, oesophagus, or Surgical removal of all or part of the lar-
lung. The condition may also result from ynx (voicebox) to treat advanced cancer
infections or poisoning affecting the (see larynx, cancer of). If the entire larynx
Right
nerves, or damage during surgery on is removed, a stoma (opening) is then
laryngeal the thyroid gland, lung, or heart. Laryn- made in the trachea (windpipe), through
nerve geal nerve palsy causes complete or which the patient will breathe. After the
Left partial vocal cord paralysis, resulting in operation (called a tracheotomy) normal
laryngeal varying degrees of voice loss. speech is no longer possible, but many
nerve
patients learn to speak using oesophageal
laryngeal stridor speech. There are also electronic devices
A form of stridor (an abnormal, high- available that help to generate speech.
pitched sound during breathing) that
Aorta emanates from the larynx (voicebox). It laryngitis
may occur if the larynx is inflamed, or Inflammation of the larynx (voicebox)
partially blocked by an inhaled object. that may be acute, lasting only a few days,
The condition may also appear at birth, or chronic, persisting for a long period.

458
 LARYNX

CAUSES abnormal noises during breathing (such

Acute laryngitis is usually caused by a viral as stridor). Indirect laryngoscopy can LOCATION OF THE LARYNX
infection, such as a cold. It can also be due show clear abnormalities, such as inflam-
The larynx, commonly called the
to an allergy or straining the laryngeal mation, paralysis of the vocal cords (see voicebox, is situated deep in the
muscles. Chronic laryngitis may be caused laryngeal nerve palsy), singer’s nodes, or throat between the pharynx and
by overusing the voice; violent coughing; tumours. Direct rigid laryngoscopy is the trachea (windpipe).
irritation from tobacco smoke or fumes; usually performed under general anaes-
or damage during surgery. Alcohol, partic- thesia, and direct flexible laryngoscopy
ularly spirits, may aggravate laryngitis. is usually carried out using local anaes-
SYMPTOMS thesia. These techniques enable doctors
Hoarseness is the most common symptom to examine the tissues of the larynx
and may progress to loss of voice.Throat more closely, as well as to take a biopsy
pain or discomfort and a dry, irritating (sample of tissue) or remove foreign
cough may also occur. Laryngitis due to bodies or benign tumours.
a viral infection is often accompanied
by fever and a general feeling of illness. laryngotracheobronchitis
TREATMENT Inflammation of the larynx (voicebox), Tongue
Treatment depends on the cause. Acute trachea (windpipe), and bronchi (main Thyroid
laryngitis due to a viral infection usually airways to the lungs), caused by a viral cartilage
disappears by itself. There is no treat- or a bacterial infection. The disorder is Pharynx
ment for chronic laryngitis other than usually mild but in some cases can be
resting the voice, taking mild analgesic life-threatening. It is a common cause of Epiglottis
drugs (painkillers) if needed, using croup in young children. Vocal cord
steam inhalation, and avoiding tobacco
smoke and alcohol. If hoarseness persists larynx Larynx

for more than two weeks, medical advice The organ in the throat responsible for Trachea
should be sought in order to exclude voice production, commonly called the
the possibility of laryngeal cancer (see
larynx, cancer of). In some cases, chronic
voicebox. It lies between the pharynx
(throat) and the trachea (windpipe).
L
laryngitis responds to speech therapy. STRUCTURE AND FUNCTION Within the larynx, stretching between
The larynx consists of areas of cartilage, the thyroid and arytenoid cartilages, are
laryngoscopy the largest of which is the thyroid carti- two fibrous sheets of tissue called the
Examination of the larynx (voicebox) lage, which projects forwards to form vocal cords. The cords vibrate to produce
using a mirror held against the back of the Adam’s apple. Below the thyroid car- vocal sounds when air from the lungs
the palate (indirect laryngoscopy), or a tilage is the cricoid cartilage, which passes through them. These vibrations
rigid or flexible viewing tube known as joins it to the trachea. Situated on the are modified by the tongue, mouth, and
a laryngoscope (direct laryngoscopy). back of the cricoid cartilage are two lips to produce speech.
Laryngoscopy is performed to inves- pyramid-shaped structures called the Attached to the top of the thyroid
tigate pain in the throat; difficulty in arytenoid cartilages. The inside of the cartilage is the epiglottis, which is a
swallowing; persistent hoarseness; and larynx is lined with mucous membrane. leaf-shaped flap of cartilage that closes

DISORDERS OF THE LARYNX

Disorders of the larynx (voicebox) Congenital defects (see larynx, cancer of), which may cause
usually cause hoarseness; other Rarely, a baby is born with a soft, limp persistent hoarseness.
symptoms of a disorder include larynx and epiglottis, a condition called
breathing difficulties, stridor (an laryngomalacia.This defect causes Other disorders
abnormal sound during breathing), noisy breathing (see laryngeal stridor). Lesions, infection, or other disorders
sore throat, and coughing. affecting the throat tissues, or surgery
Tumours on the throat, may damage the nerves
Inflammation Various kinds of noncancerous supplying the larynx. As a result, one
Laryngitis (inflammation of the tumour may develop on the vocal or both of the vocal cords may become
larynx) is the most common cords.The most common is a polyp paralysed (see laryngeal nerve palsy).
laryngeal disorder in adults. Croup (a noncancerous swelling caused by
(inflammation of the airways) is smoking, an infection such as INVESTIGATION
common in young children, up to influenza, or straining the voice).
the age of about four. Much rarer Warts and small noncancerous Disorders of the larynx are investigated
is epiglottitis (inflammation of the growths called singer’s nodes can also by laryngoscopy. Sometimes a biopsy
epiglottis, the flap of cartilage that occur on the vocal cords.The larynx sample is taken.
covers the larynx). may also develop cancerous tumours

459
 LARYNX, CANCER OF

over the larynx to prevent food and The argon continuous laser emits a light Lasix
liquid from passing into the trachea that is easily absorbed by the blood, A brand name for the diuretic drug
during swallowing. causing it to clot. This laser has applica- furosemide (frusemide).
tions in ophthalmology (particularly in
larynx, cancer of the treatment of abnormalities in the Lassa fever
A cancerous tumour of the larynx (voice- retina as a result of diabetes mellitus), sur- A serious infectious disease caused by a
box). In more than half of the cases, the gery on the inner ear, and reduction of rodent-borne virus. Lassa fever, which is
tumour develops on one of the vocal birthmarks such as port-wine stains. transmitted though contact with the
cords; in the remainder, tumours arise Another versatile laser is the yttrium- urine, faeces, or saliva of rodents, is
just above or below the cords. aluminium-garnet (YAG) system for largely confined to West Africa. Symp-
CAUSES treatments such as dentistry, hair and toms appear after an incubation period
The exact causes are not known, but tattoo removal, and lithotripsy (break- of three to 21 days with fever, head-
smoking and high alcohol consumption ing up of kidney stones).Tattoo removal ache, muscular aches, and a sore throat.
are known risk factors. and other dermatological treatments are Later, severe diarrhoea and vomiting
SYMPTOMS also often carried out with a system develop. In extreme cases, the condition
Hoarseness is the main symptom, par- known as the ruby laser, the light from leads to fatal heart or kidney failure.
ticularly when the tumour originates on which is strongly absorbed by the pig- Treatment of Lassa fever is with the
the vocal cords. At an advanced stage, ment melanin in hair and skin. antiviral drug ribavirin, and serum con-
symptoms may include difficulty in taining antibodies to the virus.
breathing and swallowing, and cough- LASIK
ing up blood. The cancer may have The abbreviation for laser-assisted in-situ Lassar’s paste
spread to the lymph nodes in the neck; if keratomileusis, a type of eye surgery in A traditional skin preparation that is
so, the nodes will be enlarged. which a laser is used to reshape the used in scaling conditions such as psor-
DIAGNOSIS AND TREATMENT cornea (transparent front part of the eye). iasis. Lassar’s paste contains salicylic acid
If laryngoscopy reveals a tumour on the LASIK is performed to correct refractive and zinc oxide. Sometimes, dithranol is
larynx, a biopsy (tissue sample) is taken. errors (see refraction) such as shortsight- added to the paste.
If the tumour is small, radiotherapy or edness (see myopia) and astigmatism. A
L laser treatment may be used to destroy it. flap is cut partway through the cornea, lassitude
For unresponsive or large tumours, par- some of the area beneath is removed by A term describing a feeling of tiredness,
tial or total laryngectomy (removal of the laser, and the flap is replaced. weakness, or exhaustion.
larynx) may be considered.
laser USE OF A LASER
A device that produces an intense beam
of light. Lasers have many medical uses The concentrated beam of light produced Protective goggles

(see laser treatment). by a laser has a variety of medical uses.

Among its applications are removal of skin
laser treatment lesions, including birthmarks and tattoos,
surgery on the eye and inner ear, treatment
Use of a laser beam in a variety of med- of tumours, and dentistry. Laser devices
ical procedures. Lasers can cut through operate at varying wavelengths and
tissues, seal blood vessels, and destroy energy levels for precise control;
abnormal cells. They can be focused some are used to treat specific
precisely so that tissues surrounding an conditions only.
operation site are not damaged.
TYPES
There are many different medical laser
Laser
systems, and they can be operated in a
variety of ways. Some emit light in brief
bursts and are known as pulsed lasers;
others emit a steady beam and are called
continuous wave lasers.
One of the most commonly used
devices is the carbon dioxide (CO2)
laser, which can be operated in either Removing skin blemishes
These photographs, which were
continuous or pulsed mode. Of all taken before and after laser
lasers, the CO2 laser has an action most treatment, show the removal
similar to that of a conventional scalpel. of a port-wine stain (a type of
It is used both for internal surgery, haemangioma). In some cases,
treatment is less successful,
including excision of brain tumours, leaving scars.
and for skin treatments, such as the
removal of noncancerous moles and Before treatment After treatment
scarring, and the reduction of wrinkles.

460
 LEAD POISONING

latanoprost laughing gas absorbed as they pass through the di-

A prostaglandin drug used as eye-drops The popular name for nitrous oxide, used gestive tract. They contain particles that
in the treatment of the eye condition with oxygen in general anaesthesia. absorb many times their own volume of
glaucoma (increased pressure of fluid water, thereby increasing the volume
within the eyeball). Laurence–Biedl–Moon and softness of the faeces and making
syndrome them easier to pass. Stimulant laxatives
lateral A rare inherited disorder characterized prompt the intestinal wall to contract
Relating to, or situated on, one side. by obesity, retinitis pigmentosa (degener- more strongly and speed up the elimi-
“Bilateral” means “on both sides”. ation of the retina that may lead to nation of faeces. Lubricant laxatives
blindness), learning difficulties, polydactyly soften and facilitate the passage of fae-
lateral cutaneous nerve (extra digits), and hypogonadism (under- ces. Osmotic laxatives cause water to be
entrapment activity of the ovaries or testes). (See retained in the intestine, thus increasing
Compression of the thigh’s lateral cuta- also genetic disorders.) the softness and volume of the faeces.
neous nerve, which supplies the skin of POSSIBLE ADVERSE EFFECTS
the front and outer areas of the thigh. lavage, gastric If they are used in excess, laxative drugs
The nerve passes underneath the ingui- Washing out the stomach with water, may cause abdominal cramps, diar-
nal ligament (the fibrous band of tissue usually to remove toxins. The person is rhoea, flatulence, and disturbances in
that extends across the crease of the laid on one side, with the head lower body chemistry. Lubricants may prevent
groin); if, for any reason, the ligament than the stomach. One end of a lubri- the fat-soluble vitamins (A, D, E, and K)
puts pressure on the nerve the result is cated, flexible tube is passed down the from being absorbed in the intestine.
a burning, tingling sensation and some- oesophagus (gullet) into the stomach. Prolonged use of stimulant laxatives
times a condition known as meralgia The other end is attached to a funnel. may lead to dependence on them for
paraesthetica (numbness in the thigh). Water is poured into the tube until the normal bowel function. For these rea-
In many cases, the problem is due to stomach is full, then the funnel end is sons, laxatives should be used only if
obesity. It may also result from over- lowered, allowing the stomach contents absolutely necessary, and for as little
stretching of the hip joint, for example, to drain into a bucket. The procedure is time as possible. When taken to relieve
when playing sport, or wearing con- repeated until the water runs clear. constipation, their use should be dis-
stricting clothes around the hips.
There is no specific treatment. In
Lavage is not used if a corrosive poi-
son has been swallowed because of the
continued as soon as normal bowel
movements have resumed. If constipa-
L
obese people, weight loss may help to risk that the tube may perforate tissues tion lasts for more than a week, a
relieve the symptoms. Rarely, surgery is in the oesophagus or stomach. doctor should be consulted.
performed to try to reduce the pressure
on the nerve. laxative drugs lazy eye
COMMON DRUGS A term for the visual defect that common-
latex fixation test BULK-FORMING • Ispaghula • Methylcellulose ly results from squint (see amblyopia).
Also called the latex agglutination test, a • Sterculia
procedure that is performed on body STIMULANT • Bisacodyl • Co-danthramer LDL
fluids, such as urine, blood, and saliva, • Co-danthrusate, • Docusate sodium • Senna See low density lipoprotein.
in order to detect the presence of par- • Sodium picosulfate
ticular infections. Tiny beads of latex are LUBRICANT • Docusate sodium lead poisoning
coated with antibodies (proteins pro- • Liquid paraffin Damage to the brain, nerves, red blood
duced by the immune system) against a OSMOTIC • Lactulose • Magnesium citrate cells, and digestive system caused by
certain infectious organism and then • Magnesium hydroxide • Magnesium inhaling lead fumes or swallowing lead
added to a sample of body fluid. If the sulphate • Sodium acid phosphate salts. Acute poisoning, which occurs
organism is present in the sample, it when a large amount of lead is taken
reacts with the antibodies on the beads, A group of drugs used to treat consti- into the body over a short period of
causing them to clump together. pation by making faeces pass through time, is sometimes fatal but is rare.
the intestines more quickly and easily. Chronic poisoning can be caused by
latissimus dorsi Laxatives are also given to people with exhaust fumes from vehicles running
A large, flat, triangular muscle in the haemorrhoids (piles), to prevent strain- on leaded petrol, or by old paint or
back. One end of the muscle is fixed to ing during defecation. In addition, they water pipes containing lead.
the lower chest vertebrae and the back may be used to clear the intestine SYMPTOMS AND SIGNS
of the pelvis, while the other end of before investigative procedures such as Symptoms of acute poisoning include
the muscle is joined to the top of the colonoscopy or barium enema, or before severe, colicky abdominal pain, diar-
humerus (upper arm bone). Contraction abdominal surgery. rhoea, and vomiting. There may also be
of the latissimus dorsi muscle moves TYPES anaemia, appetite loss, and, in chronic
the arm downwards and backwards. There are various types of laxative, all lead poisoning, a blue, grey, or black
of which work on the large intestine, line along the gum margins.
laudanum either by increasing the speed with Chronic poisoning can have especi-
A solution of opium, formerly used as a which faeces pass through the bowel, or ally severe effects on children: it can
sedative and painkiller and in the treat- by increasing their bulk and/or water damage the brain and nervous system,
ment of diarrhoea. content. Bulk-forming laxatives are not leading to behavioural and learning

461
 LEARNING

difficulties, and cause kidney problems as egg yolk, offal, and whole grains, and legionnaires’ disease
and hearing difficulties. In adults, it can can be extracted from soya to be used A form of pneumonia that is caused by
harm the kidneys, and the nervous and as an emulsifier in processed foods. (See LEGIONELLA PNEUMOPHILA, a bacterium that
digestive systems. also nutrition.) breeds in warm, moist conditions and
DIAGNOSIS AND TREATMENT stagnant water. Legionnaires’ disease can
Lead poisoning may be confirmed by leech occur in outbreaks. The source of infec-
blood and urine tests. Chelating agents, A type of bloodsucking worm with a tion is often an air-conditioning system
such as penicillamine, may be prescribed; flattened body and a sucker at each end. in a large public building; the disease is
they bind to the lead and enable the Leeches of various types mainly inhabit contracted by the inhalation of droplets
body to excrete it at a faster rate. tropical forests and waters. They bite of contaminated water.
painlessly, introducing their saliva into The first symptoms include headache,
learning the wound before sucking blood. Leech muscular and abdominal pain, diarrhoea,
The process by which knowledge or saliva contains an anticlotting substance and a dry cough. Over the next few days,
abilities are acquired, or by which called hirudin, which may cause the pneumonia develops, resulting in high
behaviour is modified. wound to bleed for hours. fever, shaking chills, coughing up of
Various theories about learning have thick sputum (phlegm), drowsiness, and
been proposed. Behavioural theories sometimes delirium. Liver and kidney
emphasize the role of conditioning, and damage may occur.
cognitive theories are based on the con- Treatment is with antibiotic drugs
cept that learning occurs through the such as clarithromycin and rifampicin. The
building of abstract “cognitive” models, majority of people recover but mortali-
using mental capacities such as insight, ty rates are higher among the elderly.
memory, intelligence, and understanding.
No one theory, however, can account leg, shortening of
for the complexities of learning. Shortening of the leg is usually caused
by faulty healing of a fractured femur
learning difficulties Use of leeches to drain blood (thigh-bone) or tibia (shin). Other
L Problems with learning, which result
from a range of mental and physical
Leeches such as this are used in medicine (to drain
a haematoma from the outer ear following injury,
causes are an abnormality present from
birth, surgery on the leg, or muscle
for example). The bites are painless, but the saliva
problems. Possible causes include deaf- contains an anticlotting agent, and the wound may weakness associated with poliomyelitis or
ness, speech disorders, and disorders of bleed for several hours. another neurological disorder.
vision, as well as genetic and chromoso-
mal problems. Learning difficulties may Leeches are sometimes used in medi- legs, restless
be either general or specific. cine in order to drain a haematoma See restless legs.
In general learning difficulties, all (collection of blood) from a wound. In
aspects of mental and physical function- addition, sometimes leeches are used leg ulcer
ing may be affected. Depending on the in an effort to improve the circulation An open sore on the leg that is slow to
severity of the problem, a child with in tissues after surgery. heal, usually resulting from poor blood
general learning difficulties may need circulation in the area.
to be educated in a special school. left atrium TYPES
Specific learning difficulties include The upper left chamber of the heart. In There are two main types of leg ulcer:
dyslexia (difficulty in reading and/or each heartbeat, the left atrium fills with venous (also called gravitational or sta-
writing), dyscalculia (inability to solve oxygenated blood, which travels from sis) and arterial. Venous ulcers are by far
mathematical problems), and dysgra- the lungs via the pulmonary veins. The
phia (a writing disorder). An affected mitral valve then opens, allowing blood
child has problems in a particular area to be squeezed into the left ventricle, to
of learning but has normal intelligence. be pumped around the body.
Treatment includes correction of any
physical problems that interfere with left bundle branch block
learning, such as vision or hearing See heart block.
problems, and specialized teaching.
left ventricular failure
learning disability A disorder in which the left ventricle
A learning difficulty. fails to empty normally, despite in-
creased pressure from the blood within
Leber’s hereditary optic atrophy it. (See also heart failure.)
See optic atrophy.
leg, broken
lecithin See femur, fracture of; fibula; tibia. Venous ulcer on the leg
This type of ulcer, also known as a stasis ulcer, is
A phospholipid (fatty substance) that is caused by impaired drainage of blood from the leg
an important component of cell mem- Legg-Calvé-Perthes’ disease by the veins. It is usually accompanied by oedema
branes. Lecithin is found in foods such See Perthes’ disease. (fluid accumulation) in the lower leg.

462
 LENTIGO

the most common and occur mainly ica, and also occurs in some Mediter-
near the ankles and on the lower legs. ranean countries. In addition, there are LOCATION OF THE LENS
They are caused by valve failure in veins several types of cutaneous leishman-
This elastic, transparent structure
and usually appear in conjunction with iasis, some of which are prevalent in
lies behind the iris and is suspended
varicose veins. the Middle East, North Africa, and the on delicate fibres from the ciliary
Arterial ulcers, which form on the Mediterranean. body. Its full name, the crystalline
foot, are caused by poor blood flow SYMPTOMS lens, differentiates it from the cornea
through arteries. These ulcers are most Kala-azar causes persistent fever, en- (which also acts as a lens).
likely to occur in people with diabetes largement of the spleen, anaemia, and,
Lens Cornea
mellitus and sickle cell anaemia. later, darkening of the skin. The illness
TREATMENT may develop any time up to two years
Treatment depends on the cause of the after infection, and, if untreated, may be
ulcer. The affected area should be ban- fatal. The cutaneous forms of the disease
daged in order to prevent infection, have the appearance of a persistent ulcer
reduce swelling, and improve the circu- at the site of the sandfly bite.
lation. If an ulcer is exuding pus, a TREATMENT
dressing is applied under bandages and All varieties of leishmaniasis can be
changed every few days. Measures such treated with drugs, such as sodium sti-
as exercising regularly, wearing support bogluconate, given by intramuscular or
stockings, and keeping the leg raised intravenous injection.
when sitting may also help to improve People visiting areas in which leish- Iris
circulation. A leg ulcer may take several maniasis occurs should take measures to
Sclera Ciliary body
months to heal, however, and the prob- minimize the risk of sandfly bites.
lem often recurs. In rare cases, a skin
graft is necessary.
lens dislocation
leiomyoma Displacement of the crystalline lens
A noncancerous tumour of smooth
muscle. Leiomyomas, also called fibroids,
from its normal position in the eye.
Lens dislocation is almost always due to
L
usually occur in the uterus. More rarely, an injury that ruptures the fibres con-
they develop in the walls of blood ves- necting the lens to the ciliary body. In
sels in the skin, forming tender lumps. people with the genetic disorder Marfan
Leiomyomas may require surgical re- syndrome, these fibres are particularly
moval if they cause symptoms. weak; lens dislocation is common in
Leishmaniasis ulcer such individuals.
leiomyosarcoma This skin ulcer, which has developed at the site
of a sandfly bite, is typical of the lesions found A dislocated lens may produce severe
Also known as LMS, leiomyosarcoma is on the skin of people who are suffering from visual distortion or double vision. If it
a cancerous tumour of the smooth mus- cutaneous leishmaniasis. slips forwards, it may cause a form of
cle. Leiomyosarcomas most commonly glaucoma (increased pressure within the
occur in the stomach, small intestine, lens eyeball) if drainage of fluid from the
bladder, uterus, and prostate and are The internal part of the eye that is front of the eye is affected. If glaucoma
among the most common types of sar- responsible for focusing; also called the is severe, the lens may need to be
coma (connective tissue cancer) of soft crystalline lens (to distinguish it from removed. (See also aphakia.)
tissue. Leiomyosarcomas mainly affect the cornea, which is also a form of
adults; they are rare in children. lens). The lens is a disc of elastic, trans- lens implant
Treatment of a leiomyosarcoma is parent tissue situated behind the iris and A plastic prosthesis (artificial substitute)
with surgery, to remove the tumour and suspended on delicate fibres from the used to replace the removed opaque
surrounding tissue, and chemotherapy ciliary body. It is slightly less convex on lens in cataract surgery.
and/or radiotherapy if the tumour can- the front surface than on the back.
not be removed completely. The lens directs light precisely on to lentigo
the retina (the layer of light-sensitive A flat, brown area of skin that is also
leishmaniasis cells lining the eyeball). The muscles of known as an age spot or liver spot.
Any of a variety of diseases caused by the ciliary body act on it to change its Lentigines (the plural of lentigo) are
single-celled parasites called leishmania. curvature and thus alter its focus, so similar to freckles, except that they
These parasites are harboured by dogs that near or distant objects can be seen occur on both covered and exposed
and rodents and are transmitted by the sharply (see accommodation). areas of skin and do not fade in winter.
bites of sandflies. One common disorder that may They are usually harmless and need
TYPES affect the lens is cataract (a condition in no treatment. Any raised, darker brown
The most serious form of leishmaniasis which the lens tissue gradually turns areas within a lentigo need to be inves-
is called kala-azar or visceral leishmani- opaque, restricting sight). Other possi- tigated, however, because they could
asis. This disease is prevalent in some ble problems are lens dislocation and develop into malignant melanomas
parts of Asia, Africa, and South Amer- aphakia (absence of the lens). (see melanoma, malignant).

463
 LEPROSY

leprosy faster than chronic).They are also classi- reveal the presence of abnormal white
See Hansen’s disease. fied according to the type of white cell cells, but diagnosis is confirmed by a
that is proliferating abnormally. If the bone marrow biopsy.
leptin abnormal cells are lymphocytes or lym- Treatment is divided into two phases:
A protein that has a role in the regula- phoblasts (precursors of lymphocytes), remission induction to control the dis-
tion of fat storage by the body. the leukaemia is called lymphocytic or ease, and consolidation, which prevents
lymphoblastic leukaemia. If the abnor- the disease from recurring. Procedures
leptospirosis mal cells are derived from other types include transfusions of blood and
A rare disease that is caused by a type of of white cell or their precursors, the platelets; the use of anticancer drugs to
spirochaete bacterium harboured by disease is called myeloid, myeloblastic, kill abnormal cells in the bone marrow;
rodents and excreted in their urine. It is or granulocytic leukaemia. (See also and possibly radiotherapy to destroy any
usually transmitted to humans by con- leukaemia, acute; leukaemia, chronic lym- abnormal cells in the brain. A bone mar-
tact with contaminated water or soil. phocytic; leukaemia, chronic myeloid.) row transplant or stem cell transplant may
Symptoms of leptospirosis develop also be required.
one to three weeks after infection. They leukaemia, acute OUTLOOK
include fever, chills, intense headache, A type of leukaemia in which excessive Chemotherapy has increased success rates,
severe muscle aches, and a skin rash. If numbers of immature white blood cells but the outlook depends on the type of
the disease is left untreated, the nervous called blasts are produced in the bone leukaemia and the age of the patient.
system may also be affected, often marrow. If left untreated, acute leuk- People with ALL generally respond bet-
producing signs of meningitis (inflam- aemia can cause death within a few ter to treatment than those with AML,
mation of the membranes covering the weeks or months. and many children with ALL can now
brain). The most severe form of lep- TYPES make a full recovery. Treatment of AML
tospirosis is known as Weil’s disease; it The abnormal cells may be of two main is less likely to be successful in people
causes widespread internal bleeding, as types: lymphoblasts (immature lympho- over the age of fifty.
well as kidney and liver damage. cytes) in acute lymphoblastic leukaemia,
Antibiotic drugs are effective but the or ALL, and myeloblasts (immature forms leukaemia, chronic lymphocytic
recovery of kidney and liver function of other types of white blood cell) in A type of leukaemia caused by a proli-
L may be slow. acute myeloblastic leukaemia, or AML.
CAUSES
feration of mature lymphocytes (white
blood cells that are normally involved in
lesion In most cases, the cause of acute leuk- fighting infection and harmful cells).
An all-encompassing term for any ab- aemia is unknown. However, exposure There is no cure for the disease, but it is
normality of structure or function in to certain chemicals (such as benzene) not always fatal. The cause is unknown.
any part of the body. The term may refer or high levels of radiation may be a risk SYMPTOMS
to a wound, infection, tumour, abscess, factor. Previous treatments for cancer Symptoms develop slowly, often over
or chemical abnormality. may also increase the risk of leukaemia many years. There may be enlargement
developing. Inherited factors are thought of the liver, spleen, and lymph nodes, per-
lethargy to play a part; there is increased inci- sistent raised temperature, and night
A feeling of tiredness, drowsiness, or dence in individuals who have certain sweats. Recurrent infections and anaemia
lack of energy. genetic disorders (such as Fanconi’s an- also are common.
aemia) and chromosomal abnormalities DIAGNOSIS AND TREATMENT
leucocyte (such as Down’s syndrome). In addition, Diagnosis is by blood tests and a bone
An alternative spelling for leukocyte, a people who have blood disorders such marrow biopsy. In many mild cases,
type of blood cell. as aplastic anaemia (see anaemia, aplastic) treatment is not needed. If symptoms
or primary polycythaemia are at increa- become troublesome, drug treatment is
leukaemia sed risk because their bone marrow is started, often with chlorambucil.
Any of several types of cancer in which already abnormal.
there is a disorganized proliferation of SYMPTOMS AND SIGNS leukaemia, chronic myeloid
abnormal white blood cells in the bone The symptoms and signs of acute leu- Also known as chronic granulocytic
marrow.This increase in white cells inter- kaemia are due to the abnormal white leukaemia, a type of leukaemia caused by
feres with production of normal blood cells crowding the bone marrow and overproduction of granulocytes (a type
cells in the marrow. A reduced number infiltrating the bloodstream and body of white blood cell) or, in particular,
of red blood cells leads to anaemia, tissues (see Leukaemia box, opposite). neutrophils (a type of granulocyte). The
while a reduction in normal white cells They include bleeding gums, headache, cause of the condition is unknown but
increases the body’s susceptibility to easy bruising, bone pain, enlarged lymph almost all affected people have a chromo-
infection. Inadequate numbers of plate- nodes, and symptoms of anaemia, such somal abnormality called the Philadelphia
lets may cause abnormal bleeding (see as tiredness, pallor, and breathlessness chromosome, in which part of one
thrombocytopenia). Also, organs such as on exertion. There may also be repeated chromosome is attached to another.
the liver, spleen, lymph nodes, or brain chest or throat infections. Chronic myeloid leukaemia usually
may cease to function properly if they DIAGNOSIS AND TREATMENT has two phases: a chronic phase, which
become infiltrated by abnormal cells. Blood tests (and, in some cases, tests on may last for several years, and an accel-
Leukaemias are classified as acute or the cerebrospinal fluid, which sur- erated, or acute, phase that may last
chronic (acute types generally develop rounds the brain and spinal cord) may for several months.

464
 LEUKODYSTROPHIES

LEUKAEMIA

In all forms of leukaemia, abnormal is a risk of death from overwhelming

white cells proliferate in the bone infection or blood loss, but modern HOW LEUKAEMIA
marrow and spill into the blood. treatment has greatly improved ATTACKS THE BODY
There are four main types: acute survival rates, particularly in
lymphoblastic leukaemia (ALL), acute childhood leukaemias. Leukaemia is a form of cancer, but
myeloblastic leukaemia (AML), chronic The chronic forms of leukaemia with the abnormally growing cells
lymphocytic leukaemia (CLL), and progress much more gradually than (mutated white blood cells) forming
chronic myeloid leukaemia (CML). The the acute types, but many of them in the bone marrow rather than
acute types have a rapid onset. There are essentially incurable. grouped into a tumour in a specific
area. The abnormal cells may spill
into the bloodstream and infiltrate
Symptoms of Headache and interfere with the function of
acute leukaemia Headache may be caused
Symptoms are caused partly other organs. But worse, these cells
by abnormal white cells
by the abnormal white cells affecting the nervous “take over” the marrow and prevent
crowding out the bone marrow system. it from making enough normal blood
(so that it fails to produce cells (including normal white cells,
sufficient normal blood cells red cells, and platelets). This leaves
of all types) and partly by the the sufferer highly susceptible to
invasion of other body organs serious infections, anaemia, and
by abnormal cells. Enlarged lymph nodes bleeding episodes.
The lymph nodes in the
neck, armpits, and groin
may be swollen with huge White cells fight
numbers of immature white infection
cells. The liver, spleen, and
Gum bleeding testes may also be swollen. Platelets help
Gums may bleed as a result blood to clot
of insufficient production
of platelet cells by the bone
marrow; platelets are needed Red cells
for the arrest of bleeding. transport oxygen L
Anaemia
Anaemia develops if there Normal appearance of blood
is insufficient production of In a normal blood smear, there are large
red blood cells by the bone numbers of red cells, many platelets, and
marrow. Anaemia causes a few white cells.
Bone tenderness tiredness, breathlessness
Tenderness of the bones may on exertion, and pallor.
be felt as the bone marrow
becomes packed with Abnormal white
immature white cells. cells (susceptibility
to infection)

Fewer platelets
(bleeding tendency)
Infections
White blood cells play a
major part in the defence Fewer red cells
Easy bruising and bleeding against infection. However, (anaemia)
Reduced numbers of platelets in acute leukaemia, only
may lead to bleeding from immature, nonfunctioning Appearance of blood in leukaemia
nose and gums and bruising white cells are made, so the In leukaemia, the blood usually contains
after mild trauma. patient may suffer from many abnormal white cells, and fewer red
repeated chest or throat
infections, herpes zoster, cells and platelets.
or skin and other infections.

SYMPTOMS The symptoms of the accelerated phase leukocyte

During the chronic phase, symptoms are are like those of acute leukaemia (see Any type of white blood cell.
not always obvious, although they may leukaemia, acute).
include fever, night sweats, and weight DIAGNOSIS AND TREATMENT leukodystrophies
loss. High numbers of white cells may The diagnosis is made from blood tests A rare group of inherited childhood
cause the blood to become very thick and and a bone marrow biopsy. Treatment of diseases in which the myelin sheaths that
unable to flow through the smallest ves- the chronic phase includes anticancer form a protective covering around
sels, leaving tissues starved of oxygen.The drugs or alpha interferons. A bone marrow many nerves, particularly in the brain
results include visual disturbances, as transplant is also possible if a suitable and the spinal cord, are destroyed. The
blood vessels in the eye are affected, and donor can be found. When the disease leukodystrophies cause severely dis-
abdominal pain due to the death of tissues transforms into the acute phase, the abling conditions, such as impaired
in the spleen; priapism (persistent, painful treatment is similar to that given for speech, blindness, deafness, and para-
erection of the penis) may also occur. acute leukaemia. lysis, and are always fatal.

465
 LEUKOPLAKIA

leukoplakia levonorgestrel due to poor hygiene.) Their tiny eggs

Raised white patches on the mucous A progestogen drug used in some oral (nits) are attached to hairs close to the
membranes of the mouth or vulva due to contraceptives and, in combination with scalp. The bites from head lice cause
tissue thickening. It is most common in an oestrogen drug, in hormone replace- intense itching.
elderly people and in those with AIDS. ment therapy (HRT). Norgestrel is a related BODY LICE
CAUSES drug with a similar action. Body lice live and lay eggs on clothing
Leukoplakia in the mouth, which most next to the skin. They can transmit epi-
commonly occurs on the tongue, is levothyroxine demic typhus and relapsing fever.
usually due to smoking or to rubbing by A synthetic version of the thyroid hor- CRAB LICE
a rough tooth or denture. It is not mone thyroxine, which is used to treat Crab lice live in pubic hair or, more
known what causes the condition to hypothyroidism (underactivity of the thy- rarely, in armpits, beards, or eyelashes;
develop on the vulva. roid gland). Side effects, such as rapid they are usually transmitted during sexu-
SYMPTOMS AND TREATMENT heartbeat and tremor, may occur if the al contact (see pubic lice).
The raised patches are usually harmless initial dose is too high. TREATMENT
and painless, but they occasionally result Various preparations can be applied to
in a cancerous change in the affected Lewy-body dementia kill lice and their eggs. In addition, lice
tissue. For this reason, leukoplakia A form of dementia in which spherical on clothes, bedding, and items such as
should always be reported to a doctor. structures called Lewy bodies develop hairbrushes can be killed by washing
If the condition persists, the patches in the brain. There may be fluctuating the items in very hot water.
are removed under either general or episodes of confusion and visual hallu-
local anaesthesia and the tissue is exam- cinations. Falls are also common. lichenification
ined microscopically for any signs of Thickening and hardening of areas of
malignant change. (See also mouth can- Leyden–Mobius muscular the skin caused by repeated scratching,
cer; vulva, cancer of.) dystrophy often to relieve the intense itching of
A form of muscular dystrophy, also called skin disorders such as atopic eczema or
leukorrhoea limb-girdle muscular dystrophy, that lichen simplex.
See vaginal discharge. affects the areas where the limbs join
L the body. Leyden–Mobius muscular dys- lichen planus
leukotriene receptor trophy can occur in either sex, and it A common skin disease of unknown
antagonists usually appears in childhood. It causes cause that usually affects middle-aged
A group of antiallergy drugs that are used muscle weakness and wasting in the people. Small, shiny, intensely itchy, pink
to prevent the symptoms of mild to pelvic girdle (pelvifemoral muscular or purple raised spots appear on the skin
moderate asthma. Leukotriene receptor dystrophy) or the shoulder girdle (scapu- of the inner wrists, forearms, or lower
antagonists, which include montelukast lohumeral muscular dystrophy). legs. There is often a lacy network of
and zafirlukast, work by blocking the white spots covering the inside lining
effects of leukotrienes (naturally occur- LH of the cheeks.The disease is treated with
ring substances that are released in the The abbreviation for luteinizing hormone. topical corticosteroid drugs.
lungs during an allergic reaction).
Leukotriene receptor antagonists are LH-RH lichen sclerosus et atrophicus
not bronchodilator drugs and will not re- The abbreviation for luteinizing hormone- A chronic skin condition of the anogen-
lieve an existing asthma attack. Instead, releasing hormone. ital area. The skin is scarred and white,
they are usually used with bronchodila- and the anatomy of areas such as the
tors and inhaled corticosteroids to reduce libido vaginal opening or foreskin may become
the frequency of attacks. Sexual desire. Loss of libido may be a distorted. Treatment is with potent topi-
Side effects of the drugs can include symptom of many physical illnesses; cal corticosteroid drugs.
gastrointestinal disturbances and head- psychological difficulties such as and
ache. In addition, hypersensitivity and depression; drug abuse; and alcohol abuse. lichen simplex
skin reactions may occur. (See also sexual desire, inhibited.) Patches of thickened, itchy, and some-
times discoloured, skin that result from
levamisole lice repeated scratching. Typical sites are the
An anthelmintic drug given by mouth in a Small, wingless insects that feed on neck, wrist, elbow area, and ankles.
single dose to eliminate roundworm in- human blood. There are three species Lichen simplex is most common in
festation. Side effects are rare but can that infest humans: PEDICULUS HUMANUS women and is often stress-related. Treat-
include mild nausea or vomiting. CAPITIS (the head louse), PEDICULUS HUMANUS ment is with oral antihistamine drugs and
CORPORIS (the body louse), and P HTHIRUS creams containing corticosteroid drugs,
levodopa PUBIS (the crab, or pubic, louse). All have and may also involve addressing any
A drug used to treat Parkinson’s disease. flattened bodies and may measure up to underlying stress or anxiety.
Levodopa is usually combined with car- 3 mm across.
bidopa or benserazide, substances that HEAD LICE lid lag
enhance levodopa’s effects and help to Head lice live on the scalp and are A momentary delay in the normal
reduce its side effects, including nausea, spread by direct contact. (The lice pre- downward movement of the upper eye-
vomiting, nervousness, and agitation. fer clean hair, and their spread is not lids that occurs when the eye looks

466
 LIMB, ARTIFICIAL

down. Lid lag is a characteristic feature life support ligation

of thyrotoxicosis (overactivity of the thy- The process of keeping a person alive The surgical process of tying off a duct
roid gland), and usually occurs in by artificially inflating the lungs (see or a blood vessel with a ligature (a piece
conjunction with exophthalmos (protru- ventilation) and, if necessary, maintain- of thread or similar material). Ligation
sion of the eyeball). ing the heartbeat. is carried out to stop bleeding from
blood vessels, or to close a duct or other
lidocaine ligament tubal body structure. The term is used
A local anaesthetic (see anaesthesia, local) A band of tough, fibrous, partly elastic in tubal ligation, a form of sterilization
that is used to numb tissues prior to tissue that connects or supports certain in which the fallopian tubes are tied off
minor surgical procedures. Lidocaine is body structures. Ligaments are most (see sterilization, female).
also used as a nerve block. The drug is commonly found in joints; they bind
commonly given by injection, but it the ends of the bones together and ligature
may also be applied to the surface of the prevent excessive movement. Some liga- A length of thread or other material
skin as an anaesthetic cream; to mucous ments are also involved in supporting used for ligation.
membranes as a spray or gel; or to the various internal organs, such as the
eyes as eye-drops. uterus, bladder, and liver. lightening
In addition, lidocaine may be given Ligaments, especially those in the A feeling that is experienced by many
by intravenous injection after a myocar- ankle or knee joints may sometimes be pregnant women at the time when the
dial infarction (heart attack), to suppress damaged by injury. Minor ligament in- baby’s head descends into the pelvic
ventricular tachycardia and reduce the risk juries such as sprains are treated with cavity. Lightening usually occurs in the
of ventricular fibrillation (both of which ice, bandaging, and sometimes physio- final three weeks of pregnancy, and,
are life-threatening abnormalities in the therapy. If a ligament has been torn because it leaves more space in the
heart rhythm). (ruptured), the joint is either immobi- upper abdomen, it relieves pressure
lized by a plaster cast, which allows under the diaphragm.
lie healing to occur, or is repaired surgically.
In pregnancy, the position of the fetus lightheadedness
relative to the mother’s body. Normal- A general term for unsteadiness and a
FUNCTION OF LIGAMENTS
ly, by the end of pregnancy, the long
(head to tailbone) axis of the fetus is
feeling of faintness. (See also dizziness;
fainting.)
L
These tough, fibrous bands of tissue
parallel to that of the mother. If the
bind bone ends together. light reflex
fetus is lying at an angle to the moth-
er’s body, or is horizontal (transverse Front of A form of inborn reflex in which the
lie), this may cause malpresentation in Left knee pupil of the eye automatically responds
labour: the fetus’s shoulder or body, Femur to the amount of light falling on the
rather than the head, is positioned over Medial eye. Normally, the pupil constricts in
ligament
the cervix and delivery by caesarean response to bright light, to restrict the
section is needed. Cruciate amount of light entering the eye, and
ligament
dilates (widens) in response to dim
life cycle Lateral light. Abnormal light reflex can be a
ligament
The series of stages through which an sign of disease in the eye or brain.
organism passes as it begins its life, Tibia
reaches maturity, reproduces, and even- light treatment
Fibula
tually dies. The term is most often used See phototherapy.
in the context of animals that assume
various forms at different stages of life, lignocaine
such as insects and worms. Torn ligament The former name for lidocaine.
A common injury of
life expectancy football players, torn limb, artificial
knee ligaments usually
The number of years for which an indi- result from twisting An artificial leg or arm, known medical-
vidual at a specified age can expect to stress when the knee ly as a prosthesis, which is fitted to
live. Life expectancy is often measured is turned while weight replace a limb that has been missing
from birth. Assuming that patterns of is on that leg. from birth (see limb defects) or lost as a
health and illness in a community do result of amputation.
not change, it is possible to estimate life Prosthetic limbs enable the wearer to
expectancy. The proportion of a popula- carry out many normal activities, such
tion that reaches its natural lifespan (the as walking. In addition, some prosthet-
Rupture of
number of years for which people live ligament due ic arms and hands contain electronic
in the absence of disease) depends on to stress circuitry that detects and responds to
the general health of the population; for impulses from the wearer’s nervous
this reason, life expectancy may be used system. This enables the wearer to per-
to compare levels of general health form complex hand and finger actions,
within or between countries. such as gripping objects.

467
 LIMB DEFECTS

limb defects and extends from the xiphoid process enic acid can be synthesized by the body
The incomplete development of one or (the lowest part of the breastbone) to from linoleic acid obtained in the diet.
more limbs at birth. Limb defects are the pubic symphysis (the joint between
rare and may be inherited or form part the two pubic bones). The skin over the lint
of a syndrome. linea alba becomes pigmented during A soft, absorbent fabric used in surgical
In a condition called phocomelia, pregnancy (see linea nigra). dressings.
hands, feet, or tiny finger- or toe-buds
are attached to limb stumps or grow linea nigra liothyronine
directly from the trunk. The sedative A pigmented, vertical line that appears A thyroid hormone used as replacement
drug thalidomide, when taken by preg- down the front of the abdomen during therapy in hypothyroidism (underactivity
nant women, is known to have caused pregnancy. The linea nigra is a visible of the thyroid gland). Liothyronine acts
phocomelia in fetuses. form of the linea alba and often fades faster than levothyroxine and is cleared
again after childbirth. from the body more rapidly.
limbic system
A ring-shaped area in the centre of the linear accelerator lip
brain consisting of a number of con- A device for accelerating subatomic par- One of two fleshy folds around the
nected clusters of nerve cells.The limbic ticles, such as electrons, to a speed entrance to the mouth. The main sub-
system plays a role in influencing the approaching that of light so that they structure of the lips is a ring of muscle
autonomic nervous system, which auto- have extremely high energies. A linear that helps to produce speech. Smaller
matically regulates body functions; the accelerator can also be used to generate muscles at the corners of the lips are
emotions; and the sense of smell. The high-energy X-rays. High-energy elec- responsible for facial expression.
system is extensive, and contains vari- trons or X-rays are used in radiotherapy Disorders of the lips include chapped
ous different substructures including to treat certain cancers. skin, cheilitis (inflammation, cracking,
the hippocampus, the cingulate gyrus, and dryness), cold sores, and lip cancer.
and the amygdala. lingual
A term meaning “of the tongue”, as in lipaemia
limb, phantom “sublingual drug” (a drug that is An abnormally high level of fat in the
L See phantom limb. administered under the tongue). blood. (See also hyperlipidaemias.)
limited cutaneous systemic liniment lip cancer
sclerosis A liquid that is rubbed on the skin to A malignant tumour (usually a squamous
See systemic sclerosis. relieve aching muscles and stiff joints. cell carcinoma), commonly on the lower
Liniments may contain rubefacients lip. Lip cancer is largely confined to
limp (substances that increase blood flow be- older people, particularly those who
An abnormal pattern of walking in neath the skin), or certain drugs, such have been exposed to a lot of sunlight
which the movements of one leg (or of as nonsteroidal anti-inflammatory drugs. and those who have smoked cigarettes
the hip on one side of the body) are dif- or a pipe for many years.
ferent from those of the other. If a child linkage analysis The first symptom is a white patch
is limping, a doctor should be con- A type of gene mapping. Linkage analysis that develops on the lip and soon
sulted within 24 hours, because the determines the presence or absence of becomes scaly and cracked with a yel-
problem may result from a hip disorder an abnormal gene by detecting another low crust. The affected area grows and
that requires prompt treatment. gene located close to it on the same eventually becomes ulcerated. In some
chromosome. cases, the cancer spreads to the lymph
linctus nodes in the jaw and neck.
A bland, usually sweetened mixture linkage, sex Lip cancer is diagnosed by biopsy
taken to soothe irritation caused by an The association of a particular genetic (taking a sample of the lip tissue for
inflamed throat. A simple linctus con- disorder with the sex chromosomes (see microscopic examination). Treatment is
tains no active drug, but linctuses are sex-linked inheritance). surgical removal, radiotherapy, or a com-
commonly used as a basis for cough bination of both.
suppressants (see cough remedies). linoleic acid
An essential fatty acid found principally in lipectomy, suction
lindane plant seed oils, such as maize oil and soya A type of body contour surgery, com-
A drug formerly used to treat infesta- bean oil. Linoleic acid is used by the body monly known as liposuction, in which
tion by scabies and some types of lice. in the synthesis of prostaglandins and cell excess fat is sucked out through small
Lindane has now been replaced by membranes. Linoleic acid has to be skin incisions, using a cannula (thin
other, less toxic drugs. obtained from the diet because the body tube) attached to a vacuum device.
cannot manufacture its own supplies.
linea alba lipid disorders
A vertical line of fibrous tissue running linolenic acid Metabolic disorders that result in abnor-
down the middle of the abdominal An essential fatty acid, found in fish oils mal amounts of lipids (fats) in the body.
wall. The linea alba is the site of attach- and some plant seed oils, that is used by The most common lipid disorders are
ment of the rectus abdominis muscles the body to form prostaglandins; linol- the hyperlipidaemias, which are charac-

468
 LISINOPRIL

terized by high levels of lipids in the amount of bile in the digestive tract. less and harmless, but may be surgically
blood. Hyperlipidaemia can cause ather- They may also reduce the absorption of removed for cosmetic reasons.
osclerosis (narrowing of the arteries by fat-soluble vitamins.
deposits of fatty material) and pancrea- Fibrates may cause an increased sus- lipoprotein
titis (inflammation of the pancreas). ceptibility to gallstones, while statins A small particle that is made up of a
There are also some very rare lipid dis- need to be used with care in people fatty core surrounded by a water-sol-
orders, such as Tay–Sachs disease, that who have a history of liver disease. uble form of fat (known chemically as
are due solely to heredity. Rarely, combinations of drugs that act a phospholipid) and a protein (apo-
on the liver may cause a painful muscle protein). Lipoproteins are the form in
lipid-lowering diet condition called rhabdomyolysis. which fats are transported in the
A diet containing low levels of choles- bloodstream.
terol and of saturated fats (which are lipidosis
found in meat and whole-milk dairy Any disorder involving the metabolism liposarcoma
products). By lowering the blood levels (chemical transformation) of lipids in A rare cancer of fatty tissue that most
of lipids, such diets help to prevent ath- body cells. An example of a lipidosis is commonly develops during late middle
erosclerosis (the accumulation of fatty Gaucher’s disease, which causes a build- age. Liposarcomas produce firm swell-
deposits on the walls of arteries). up of fatty deposits in the liver, spleen, ings, usually in the abdomen or the
bone marrow, and sometimes the brain. thigh. The tumours can generally be
lipid-lowering drugs removed by surgery but tend to recur.
COMMON DRUGS lipids
FIBRATES • Bezafibrate • Ciprofibrate A general term for fats and oils. Lipids Lipostat
• Fenofibrate • Gemfibrozil include triglycerides (simple fats), phos- The brand name for the lipid-lowering
STATINS • Atorvastatin • Fluvastatin pholipids (important constituents of drug pravastatin.
• Pravastatin • Simvastatin cell membranes and nerve tissue), and
NICOTINIC ACID AND DERIVATIVES • Acipimox sterols, such as cholesterol. liposuction
• Nicotinic acid The popular term for suction lipectomy
DRUGS THAT BIND TO BILE SALTS • Colestipol lipoatrophy (see lipectomy, suction).
• Colestyramine
OTHER DRUGS ACTING ON THE LIVER • Omega-3
Wasting of the subcutaneous fat layer,
which lies just beneath the skin. This lip-reading
L
marine triglycerides condition may be associated with lipo- A way of understanding speech by
OTHER DRUGS • Ispaghula dystrophy and also sometimes occurs at interpreting movements of the mouth
sites of insulin injections in people with and tongue. Lip-reading is often used
A group of drugs that are used to treat, diabetes mellitus. by people who are deaf.
or provide protection against, hyperlipi-
daemia (abnormally high levels of the lipodystrophy liquid paraffin
fatty substances cholesterol and triglycer- A type of disorder in which the metab- A lubricant laxative drug obtained from
ides in the blood). These drugs help to olism (chemical transformation) of fat petroleum. It can cause anal irritation, and
prevent, or slow the progression of, in the body is disturbed, leading to prolonged use may impair the absorption
severe atherosclerosis (narrowing of the abnormalities in body fat distribution. of vitamins from the intestine into the
arteries due to deposits of fatty materi- TYPES blood. It has largely been superseded by
al) and coronary artery disease. One type of lipodystrophy occurs in docusate sodium.
HOW THEY WORK people undergoing treatment with pro-
Most groups of lipid-lowering drugs act tease inhibitor drugs for HIV; it causes liquor
on the liver to inhibit the processes by wasting of the limbs, buttocks, and A medical term for a liquid, particularly
which fatty acids are converted into face, but excessive fat deposits in the a water-based solution, that contains a
lipids. Statins cause the liver to produce abdominal cavity, chest or breasts, back, medicinal substance. The term is also
less cholesterol, while fibrates and nico- and neck. Affected people also have used to describe body fluids, such as
tinic acid reduce the formation of both raised levels of lipids in the blood. amniotic fluid.
cholesterol and triglycerides. Omega-3 Another form, total lipodystrophy, is
marine triglycerides reduce the levels of due to an autosomal recessive genetic liquorice
triglycerides. disorder. In this disorder, loss of fat over The dried root of the liquorice plant
Drugs that bind to bile salts reduce the whole body is associated with raised (GLYCYRRHIZA GLABRA) used as a sweetener; a
the absorption of these salts (which basal metabolic rate, hirsutism (exces- liquorice derivative is used to treat pep-
contain high levels of cholesterol) from sive body hair), liver enlargement, and tic ulcers; and it is used as an expectorant
the small intestine into the blood- insulin-resistant diabetes mellitus. (a medication that encourages cough-
stream. The lowered blood levels of bile ing up of sputum from the airways).
salts stimulate the liver into converting lipoma
more cholesterol into bile salts. A common noncancerous tumour of lisinopril
POSSIBLE ADVERSE EFFECTS fatty tissue. Lipomas are slow-growing, An ACE inhibitor drug commonly used to
Drugs that bind to bile salts may cause soft swellings that may occur anywhere treat hypertension (high blood pressure)
constipation, and sometimes nausea and on the body, most commonly on the and heart failure.The first dose of lisinopril
diarrhoea, as a result of the increased thigh, trunk, or shoulder. They are pain- may cause a rapid fall in blood pressure,

469
 LISP

especially in someone who is also taking a lithotomy lithotripsy

diuretic; a person should lie down for a Surgical removal of a calculus (stone) The use of highly concentrated shock
couple of hours after taking it. The drug from the urinary tract. The procedure is waves or ultrasonic waves to break up
may also produce various minor side performed only for large stones; smaller calculi (stones) inside the kidneys, upper
effects, such as a persistent dry cough stones are usually crushed and removed ureters, and gallbladder so that they can
or a disturbance in taste sensation. using cystoscopy, or pulverized ultrason- be comfortably excreted.
ically by lithotripsy. The most common type is extracor-
lisp poreal shock-wave lithotripsy (ESWL),
A common speech disorder caused by lithotomy position which is performed to break up small
protrusion of the tongue between the A position in which a patient lies on his stones. ESWL uses a machine called a
teeth so that the “s” sound is replaced or her back with the hips and knees lithotripter, which produces shock waves
by “th”. In most cases, there is no phys- bent and the legs wide apart; the feet that are transmitted into the body
ical cause, but sometimes it is due to a may be supported on firm surfaces or through a water- or gel-filled cushion
cleft palate (see cleft lip and palate). in stirrups. Once used for lithotomy placed over the organ being treated.
Unless there is an underlying cause, (removal of bladder stones), the posi- Ureteric colic (severe spasmodic pain
lisping usually disappears by the age of tion is now widely used for pelvic in the side, occurring if the ureter is
about four. If it persists beyond this examinations and some types of surgery. obstructed by small fragments of stone)
time, speech therapy may be needed.
listeriosis LITHOTRIPSY
An infection that is common in animals
Calculi (stones) can sometimes be broken up by lithotripsy, a procedure that uses
and also affects humans. ultrasonic or shock waves. In extracorporeal shock-wave lithotripsy (ESWL), the
CAUSE most common form of the treatment, no major surgery is needed. If the stones are
Listeriosis is caused by the bacterium in the kidney or ureter, fragments of the stones are passed in the urine.
LISTERIA MONOCYTOGENES, which is wide-
spread in the environment, especially in EXTRACORPOREAL SHOCK-WAVE LITHOTRIPSY (ESWL)
soil. Possible sources of human infec-
Lead apron X-ray receiver
L tion with listeriosis include soft cheese,
ready-prepared coleslaw and salads, and
improperly cooked meat.
X-ray beam
SYMPTOMS Monitors
Control unit
In most otherwise healthy adults, the
only symptoms may be fever, aching
muscles, diarrhoea, and abdominal pain. Water- or gel-
However, in elderly people, those with filled cushion
reduced immunity, and newborn babies,
listeriosis can be life-threatening. Pneu-
monia, septicaemia (blood poisoning),
and meningitis (inflammation of the
membranes covering the brain) may de-
velop. In pregnant women, infection
may cause a miscarriage or stillbirth.
DIAGNOSIS AND TREATMENT
The condition is diagnosed by blood
testsand analysis of other body fluids,
such as cerebrospinal fluid. Treatment is
Shock-wave generator
with antibiotic drugs such as ampicillin
and gentamicin.
X-ray source Staghorn
lithium Shock waves calculus

A mood-stabilizing drug used in the Patient receiving ESWL Kidney stone

long-term treatment of mania and manic- The patient is given a general or epidural This X-ray shows a
anaesthetic. The lithotripter produces shock staghorn calculus
depressive illness, and to help prevent waves that are focused on the stone. The (stone) in the left
recurrence of severe depression. Side image intensifier (X-ray equipment) allows the kidney (on the right
effects include nausea, vomiting, tremor, operator to locate the stones and adjust the in the X-ray). With
and excessive thirst. The dosage must be lithotripter to ensure that the shock waves lithotripsy, stones
target the stones accurately. Nearly all the such as these can be
monitored by regular blood tests to pre- energy is dissipated in the stone, shattering removed without the
vent serious adverse effects. High levels it. The patient then drinks liberally to flush need for surgery.
of lithium may cause blurred vision, out stone fragments. There may be some
drowsiness, rash, and possibly hypothy- blood in the urine and abdominal bruising,
roidism and kidney damage. Side effects but serious complications are uncommon.
should be reported promptly to a doctor.

470
 LIVER CANCER

may occur after ESWL. People treated The chemicals produced by the liver may be identified by examination of a
for gallstones may need drug treatment include important proteins for blood blood or tissue sample. The abscess can
to aid the elimination of stone residues. plasma, such as albumin and clotting fac- sometimes be treated by aspiration
tors. The liver also produces cholesterol (sucking out the pus through a needle),
lithotripter and proteins that help the blood to but often surgery is needed.
The machine used in extracorporeal carry fats around the body. In addition,
shock-wave lithotripsy (ESWL) to des- liver cells secrete bile, which removes liver biopsy
troy small calculi (stones). waste products from the liver and aids A diagnostic test in which a small sam-
the breakdown and absorption of fats in ple of tissue is removed from the liver,
Little’s area the small intestine (see biliary system). usually under local anaesthesia. The
An area near the front of the nasal sep- Another major function is the process- main purpose of this test is to aid diag-
tum (partition between the nostrils) ing of nutrients for use by cells. The nosis of liver diseases. (See also biopsy.)
that is richly supplied with blood ves- liver also stores excess glucose as glyco-
sels and is a common site of nosebleeds. gen. In addition, it controls the blood liver cancer
level of amino acids (the building blocks A cancerous tumour in the liver. The
Little’s disease of proteins). If the level of amino acids is tumour may be primary (originating in
See spastic diplegia. too high, the liver converts the excess the liver) or, far more commonly, sec-
into glucose, proteins, other amino ondary (having spread from elsewhere,
live birth acids, or urea (for excretion). often the stomach, pancreas, or large
The delivery of a baby that breathes Finally, the liver helps to clear the blood intestine). There are two main types of
spontaneously and has a heartbeat. Sta- of drugs and poisons. These substances primary tumour: a hepatocellular carcino-
tisticians may calculate the number of are broken down and excreted in the bile. ma, also known as a hepatoma, which
live births per year per 1000 women of develops in the liver cells; and a cholan-
childbearing age (usually 15 to 44), a liver abscess giocarcinoma, which arises from cells
measure called the fertility rate, to help A localized collection of pus in the liver. lining the bile ducts. Hepatocellular car-
them assess the health and growth of a The most common cause is an intestinal cinomas are often linked to hepatitis B
population (see statistics, vital). infection. Bacteria may spread from areas infection and to cirrhosis.
livedo reticularis
inflamed by diverticulitis or appendicitis,
and amoebae may invade the liver as a
SYMPTOMS
The most common symptoms of any
L
A netlike, purple or blue mottling of result of amoebiasis. Symptoms are high liver cancer are loss of appetite, weight
the skin, usually on the lower legs, fever, pain in the upper right abdomen, loss, lethargy, and sometimes pain in the
caused by enlargement of blood vessels and (especially in the elderly) confusion. upper right abdomen. The later stages of
under the skin. It is more common in Ultrasound scanning usually reveals the the disease are marked by jaundice (yel-
people with vasculitis (inflammation abscess, and the organism responsible lowing of the skin and the whites of the
of the blood vessels) and those who
suffer from excessive sensitivity to
cold. The condition is harmless, and LOCATION OF THE LIVER
tends to be worse in cold weather.
The liver is a large, red-brown organ, made up of two lobes, that occupies the
liver upper right-hand portion of the abdominal cavity. It lies immediately beneath
the diaphragm, to which its upper side is attached. Its base is in contact with
The largest organ within the body, this the stomach, right kidney, and intestines. Tucked within a depression on the
wedge-shaped, reddish-brown structure underside of the liver is the gallbladder.
lies in the upper right abdominal cavity,
directly below the diaphragm.
STRUCTURE
The liver is divided into two main lobes,
each consisting of many lobules. The Diaphragm
lobules are surrounded by branches of
the hepatic artery, which supplies the
liver with oxygenated blood, and the Left lobe
portal vein, which supplies nutrient-rich
blood from the small intestine. Deoxy- Right lobe
Stomach
genated blood from the liver drains into
the hepatic veins. A network of ducts car-
ries the digestive juice bile from the liver
to the gallbladder and the small intestine.
Large
FUNCTION intestine
The liver plays a vital role in the body
because it produces and processes a
wide range of chemical substances (see
Disorders of the liver box and Structure and
function of the liver box overleaf).

471
 LIVER, CIRRHOSIS OF

DISORDERS OF THE LIVER

The most common cause of liver disease from elsewhere in the body (in which paracetamol can lead to severe liver
in developed countries is excessive case they are known as secondary damage. Poisoning by certain types of
alcohol consumption. Alcohol-related tumours of the liver). Primary tumours mushroom can cause acute liver failure.
disorders (see liver disease, alcoholic) of the liver (those that originate in the
include hepatitis (liver inflammation) liver) are much rarer. (See liver cancer.) Other disorders
and cirrhosis. Many other types of liver In Budd–Chiari syndrome, the veins
disorder may occur, including infections, Metabolic disorders draining the liver become blocked
tumours, metabolic disorders, and Two main metabolic disorders affect the by blood clots, which causes painful
congenital defects. liver: haemochromatosis (in which there swelling of the liver. Obstruction of
Liver failure (complete loss of liver is too much iron in the body) and the portal vein is one cause of portal
function) may occur as a result of acute Wilson’s disease (in which there is an hypertension (high blood pressure in
hepatitis, poisoning, or cirrhosis. Jaundice excess of copper in the liver). the portal vein), which can lead to
and hepatomegaly (enlargement of the oesophageal varices (swollen veins in
liver) are common signs of liver disease. Congenital defects the oesophagus) and ascites (collection
Occasionally, defects of liver structure of fluid in the abdomen).
Infection and inflammation are present from birth. Abnormalities Enlargement of the liver is a
Hepatitis is a general term for such as these principally affect the common symptom of leukaemias and
inflammation of the liver. It can be bile ducts. A choledochal cyst is a lymphomas. Liver failure (complete loss
caused by viruses (see hepatitis, viral) malformation of a main bile duct. of liver function) may be caused by
or bacteria, which may spread up the These cysts require surgery because, acute hepatitis, poisoning, or cirrhosis.
biliary system to the liver, causing in infants, they may obstruct the flow
cholangitis (inflammation of the bile of bile, causing jaundice. Biliary atresia,
duct) or liver abscess. Parasitic diseases, in which the bile ducts are missing, INVESTIGATION
including schistosomiasis, liver fluke, also causes jaundice.
Disorders of the liver may be
amoebiasis, and hydatid disease, can
L also affect the liver. Poisoning and drugs
investigated by liver biopsy (removal
of a tissue sample for examination),
Normally, the liver can break down liver-function tests, and liver imaging
Tumours drugs and toxins. However, drug (which includes ultrasound scanning,
The liver is a common site for overdose or allergy may damage liver CT scanning, and MRI).
cancerous tumours that have spread cells in the process, and overdose of

eyes, due to accumulation of the bile related liver disease increases the risk of in the blood, liver failure causes the
pigment bilirubin) and ascites (excess developing liver cancer. levels of the toxins to rise, affecting the
fluid in the abdomen). The longer that heavy alcohol con- functioning of other organs, particu-
DIAGNOSIS AND TREATMENT sumption goes on, the more severe the larly the brain.
Blood tests (see liver-function tests) may damage. The initial effect is the forma- SYMPTOMS
be used to assess liver function, which tion of fat globules inside liver cells, a Symptoms of acute liver failure deve-
can be disturbed by cancer. Tumours are condition called fatty liver, followed by lop rapidly; they may include impaired
often detected by ultrasound scanning, CT alcoholic hepatitis (liver inflammation). memory, agitation, and confusion, fol-
scanning, or MRI; diagnosis may be con- Damage progresses to cirrhosis (scarring lowed by drowsiness. The functioning
firmed by liver biopsy (tissue sampling). of liver tissue), resulting in severe struc- of other organs may also become im-
A hepatocellular carcinoma can some- tural damage eventually leading to loss paired, and the condition may lead to
times be cured by total removal of the of liver function. coma and death.
tumour and a surrounding area of nor- Liver-function tests show a character- Features of chronic liver failure deve-
mal tissue. In other cases, anticancer drugs istic pattern of abnormalities, and liver lop much more gradually. They include
can help to slow the the disease’s progress. biopsy (tissue sampling) may be needed jaundice; itching; easy bruising and
It is usually not possible to cure second- to assess the severity of damage.There is bleeding; ascites (swollen abdomen due
ary liver cancer, but anticancer drugs or, no particular treatment, but abstinence to accumulated fluid); red palms; and,
in some cases, removal of a solitary met- from alcohol prevents further damage. in males, gynaecomastia (enlarged
astasis (secondary cancerous tumour) Treatment for alcohol dependence may breasts) and shrunken testes. Chronic
may significantly improve the outlook. be required in some cases. liver failure may suddenly deteriorate
into acute liver failure.
liver, cirrhosis of liver failure TREATMENT
See cirrhosis. Severe impairment of liver function Acute liver failure requires urgent hos-
that develops suddenly (acute liver fail- pital care. Although no treatment can
liver disease, alcoholic ure) or at the final stages of a chronic repair damage that has already occurred
Damage to the liver resulting from liver disease (chronic liver failure). in acute or chronic liver failure, certain
excessive alcohol consumption. Alcohol- Because the liver breaks down toxins measures, such as prescribing diuretic

472
 LIVER TRANSPLANT

drugs to reduce abdominal swelling, may liver spot part of the liver may be donated by a
be taken to reduce the severity of symp- See lentigo. living relative of the patient.
toms. Consumption of alcohol should WHY IT IS DONE
cease in all cases. liver transplant Liver transplants are most successful in
OUTLOOK Replacement of a diseased liver with a treating advanced liver cirrhosis in peo-
The prognosis for sufferers of chronic healthy liver removed from a donor. In ple with chronic hepatitis or primary
liver failure varies depending on the most cases, the donor is a dead person, biliary cirrhosis. People with primary liver
cause, but some people survive for but sometimes (for example, when a cancer may be considered for a trans-
many years. For both chronic and acute liver transplant is performed on a child) plant if the tumour is relatively small.
liver failure, a liver transplant is necessary
to increase the chances of survival.
STRUCTURE AND FUNCTION OF THE LIVER
liver fluke
The liver is a large organ with numerous functions. It absorbs nutrients from blood
Any of various species of flukes (flat-
that has come from the intestines, and regulates the blood’s glucose and amino-
worms) that infest the bile ducts in the acid levels. It helps break down drugs and various toxins, and manufactures
liver. The only significant fluke in the UK important proteins, such as albumin and blood coagulation factors. The liver also
is FASCIOLA HEPATICA, which causes the produces bile, which contains waste products and helps with the digestion of fats
disease fascioliasis. in the small intestine.
Fascioliasis has two stages. During the
first stage, young flukes migrate through Hepatic vein
Blood leaves the liver
the liver, causing it to become tender via this vein and carries
and enlarged; other symptoms include carbon dioxide and
fever and night sweats. In the second plasma proteins.
stage, adult worms occupy the bile ducts.
Their presence may lead to cholangitis
(inflammation of the bile duct) and bile
duct obstruction, which can cause jaun-
dice. Treatment with an anthelmintic drug
may be effective.
Hepatic portal vein
Blood from the intestines and spleen carries
L
nutrients, such as fats and glucose, to the
liver via this vein. The nutrients are used by
liver-function tests the liver or stored within it.

Tests of blood chemistry that can detect

changes in the way the liver is making Hepatic duct
new substances and breaking down Bile leaves the liver through a network
of ducts, the bile ducts. They increase
and/or excreting old ones. The tests in size until they fuse to form the right
can also show whether liver cells are and left hepatic ducts, which join and
carry bile to the gallbladder.
healthy or damaged (see Liver function
tests table, overleaf).

liver imaging Hepatic artery

Oxygenated blood from the heart (about
Techniques that produce images of the one quarter of the heart’s entire output)
liver, gallbladder, bile ducts, and blood reaches the liver via this artery. The artery
subdivides into many branches within the
vessels supplying the liver, to aid the liver to provide oxygen to all the liver cells.
detection of disease. Liver cells
Ultrasound scanning is the most widely responsible for Branch of
absorbing nutrients hepatic vein
used technique for imaging the liver; CT Liver lobules
scanning and MRI are also commonly used. The liver consists of many
lobules, each surrounded by
Radionuclide scanning may reveal cysts branches of the hepatic artery
and tumours and show bile excretion. and the hepatic portal vein.
X-ray imaging techniques include chol-
angiography, cholecystography, and ERCP Bile duct leading
(endoscopic retrograde cholangiopancrea- to hepatic duct
tography). In these procedures, a contrast
medium, which is opaque to X-rays, is Branch of
hepatic portal vein
used to outline the biliary system. Angiog-
raphy reveals the blood vessels in the liver.

liver palms Branch of

hepatic artery
Redness accompanied by warmth in the Section through a liver lobule
palms of the hands. This combination of Blood passes to the central vein (a branch of the
symptoms is often associated with hepatic vein) via pathways between the cells.
chronic liver disease. (See liver failure.)

473
 LIVE VACCINE

lobectomy
LIVER-FUNCTION TESTS An operation performed to cut out a
Test Significance lobe in the liver (see hepatectomy, par-
tial), the lung (see lobectomy, lung), or
Serum bilirubin Bilirubin is the yellow breakdown product of red blood cells that is
the thyroid gland (see thyroidectomy).
passed to the liver and excreted in bile. It is this substance that gives
the yellow colour to the skin in jaundice. High blood bilirubin levels lobectomy, lung
may indicate excessive breakdown of red blood cells, obstruction to An operation to cut out one of the lobes
bile flow, defective processing of bile by the liver, or Gilbert’s syndrome. of a lung, usually to remove a cancerous
tumour in the lung.
Serum albumin Albumin is one of the main proteins in blood. Made by the liver, one of
its actions is to hold fluid inside the blood vessels. A low level is found lobotomy, prefrontal
in many chronic liver disorders and is often associated with ascites and
ankle oedema (fluid collection in the abdomen and around the ankles). The cutting of some of the fibres that
link the brain’s frontal lobes to the rest
Serum alkaline Alkaline phosphatase is an enzyme found in the cells that line the bile of the brain. This operation was form-
phosphatase ducts and also in other tissues such as bone. The blood level of this erly used to treat severe psychiatric
enzyme rises when there is obstruction to the flow of bile (cholestasis). disorders. It often caused harmful per-
sonality changes, however, and is now
Gamma-glutamyl An enzyme present in liver cells. When the flow of bile is obstructed, very rarely performed.
transpeptidase the blood level of this enzyme is raised, along with a raised level of
alkaline phosphatase. A gamma-glutamyl transpeptidase level raised Lobstein’s syndrome
in isolation is related to alcohol intake. its measurement can also be
used as a screening test for glutamyl transpeptidase deficiency.
See osteogenesis imperfecta.
lobular
Serum The aminotransferases are enzymes released from liver cells into the
aminotransferases blood when the liver cells are damaged. The levels will be raised in any A word meaning “relating to a lobule”.
(transaminases) condition that damages liver cells, including poisoning, and acute and
chronic hepatitis. lobule
L A smaller division of a lobe of an organ
such as the liver or lung. Lobules are
Prothrombin time A normal result in this test of blood clotting depends on the presence
in the blood of a protein made by the liver from a fat-soluble vitamin, separated by boundaries such as septa
vitamin K. The test result can be abnormal in two types of disorder: (dividing walls).
when the protein is not made because of liver cell damage, and when
there is a blockage to bile flow in the liver, causing a lack of bile in the local anaesthetic
intestines (which interferes with fat and vitamin K absorption).
See anaesthesia, local.
localized amnesia
HOW IT IS DONE living will Loss of memory for all events occurring
During this procedure, the liver, the A written declaration, signed by an within a particular period of time. See
gallbladder, and portions of the con- adult of sound mind, that outlines the also amnesia.
nected blood and bile vessels are extent of life-prolonging treatment des-
removed. The donor organs and blood ired in the event of the person being localizing sign
vessels are then connected to the recipi- incapable of communication. In the UK, A sign that is found during a physical
ent’s vessels. a living will has no legal force, but doc- examination that pinpoints the cause
RECOVERY PERIOD tors try to respect patients’ wishes. of a disorder.
After the transplant, the recipient is
monitored in an intensive care unit for a LMS lochia
few days and remains in hospital for The abbreviation for leiomyosarcoma. The discharge, after childbirth, of
up to four weeks. Immunosuppressant blood and fragments of uterine lining
drugs to prevent rejection of the new Loa loa from the area where the placenta was
organ must be taken for life. The parasitic worm responsible for the attached. The discharge is bright red
disease loiasis. for the first three or four days and then
live vaccine becomes paler. The amount of lochia
A vaccine containing live but weakened lobar pneumonia decreases as the placental site heals,
(attenuated) forms of an infectious A form of pneumonia (inflammation of and the discharge usually ceases com-
organism. Live vaccines include those the lung) in which only one lobe of a pletely within six weeks.
for measles, mumps, rubella, poliomyelitis, lung is affected.
and tuberculosis. locked knee
lobe A temporary loss of the ability to move
Livial One of the clearly defined parts into the knee joint. A locked knee may be the
The brand name for tibolone, a drug that which certain organs, such as the brain, result of a torn cartilage or of small
is used in the treatment of the symp- liver, and lungs, are divided. The term fragments of bone or cartilage in the
toms of menopause. may also be used to describe the earlobe. joint (loose bodies).

474
 LOTION

lockjaw Lomotil cause drowsiness than some other anti-

A painful spasm of the jaw muscles that A brand-name antidiarrhoeal drug con- histamines. Side effects are uncommon;
makes it difficult or impossible for a taining atropine and diphenoxylate. they include headache, fatigue, and
person to open the mouth. Lockjaw is nausea. Fainting or palpitations (the
the most common symptom of tetanus. longevity sensation of a rapid, forceful heartbeat)
A term meaning length of life or the may also occur; in this situation, the
locomotor condition of being long-lived. affected person should stop taking the
Relating to movement from one place drug and consult a doctor.
to another, as in locomotor ataxia. longsightedness
See hypermetropia. lorazepam
locus A benzodiazepine drug used in the treat-
The medical term for a region or site in loop of Henlé ment of insomnia and anxiety, or for
the body. In genetics, the word is used Part of the long renal tubule within premedication prior to an operation or
to describe the position of a gene on a each of the kidney’s filtering units, or other procedure.
chromosome. nephrons. The U-shaped loop of Henlé
absorbs water and certain soluble sub- lordosis
lofepramine stances back into the bloodstream. Inward curvature of the spine. This cur-
A tricyclic antidepressant drug used in the vature is normally present to a minor
long-term treatment of depression. Lof- loose bodies degree in the lower back, but lordosis
epramine is particularly helpful if the Fragments of bone, cartilage, or capsule can become exaggerated by poor pos-
depression is accompanied by lethargy. linings within a joint. Loose bodies may ture or by kyphosis (excessive curvature
Possible side effects include dry mouth, occur whenever there is damage to a of the upper spine). Pronounced lordo-
sweating or flushed skin, drowsiness, or joint, as in injury, osteoarthritis, or osteo- sis is usually permanent and can lead to
blurred vision. If the drug causes con- chondritis dissecans. disc prolapse (slipped disc) or osteo-
stipation, difficulty in passing urine, or The fragments can cause a joint to lock, arthritis of the spine.
dizziness, a doctor should be consulted. resulting in severe pain. X-rays or arth-
roscopy (viewing of the interior of a joint
Löffler’s syndrome with an endoscope) may reveal their L
A rare form of allergic reaction affecting presence. Gentle manipulation of the
the lungs. Possible causes of Löffler’s joint may be required, in order to
syndrome include drug allergy and unlock it. If locking occurs frequently,
roundworm infestation of the lungs the loose bodies may be removed dur-
(see ascariasis).The symptoms include a ing arthroscopy or by surgery.
dry cough, fever, wheezing, shortness
of breath, and chest pain. The disease loperamide
often disappears spontaneously. An antidiarrhoeal drug that slows intesti-
nal activity and reduces the loss of
log-roll technique water and salts from the body. It is usu-
A method of turning a casualty on to ally used to treat sudden and recurrent
his or her back without altering the bouts of diarrhoea (but not if the diar-
position of the spine. The technique is rhoea is due to infection).
used if a spinal injury is suspected and Loperamide occasionally produces a
resuscitation is needed (see cardiopul- rash; other rare adverse effects are abdo- Normal and abnormal lordosis
monary resuscitation). The aim is to minal cramps, and bloating. If these The normal inward curvature of the spine (left)
prevent further injury by keeping the effects are severe, they require prompt is exaggerated in abnormal lordosis (right).
head, trunk, and toes in a straight line. attention from a doctor.
losartan
loiasis Lorain-Lévi syndrome An angiotensin II antagonist drug used to
A form of the tropical parasitic disease A form of dwarfism in which a child treat hypertension (high blood pressure).
filariasis, which is caused by an infesta- retains the appearance of an infant, due Side effects are rare and mild; they
tion by the worm LOA LOA. The worms to insufficient secretion of growth hor- include dizziness, diarrhoea, and fatigue.
travel beneath the skin, producing itchy mone and a lack of gonadotrophin.
areas of inflammation known as Calabar Losec
swellings, and can sometimes be seen Lorain’s disease The brand name for the anti-ulcer drug
moving across the front of the eye. See Lorain-Lévi syndrome. omeprazole.
Loiasis is treated with a course of di-
ethylcarbamazine to kill the worms. loratadine lotion
An antihistamine drug used to relieve A liquid drug preparation applied to the
loin symptoms of allergic rhinitis, such as skin. Some examples of drugs prepared
The part of the back on each side of the sneezing, runny nose, and itching eyes, as a lotion include calamine and beta-
spine between the lowest pair of ribs and and to treat allergic skin problems such methasone, both of which are used to
the top of the pelvis. as chronic urticaria. It is less likely to treat skin inflammation.

475
 LOU GEHRIG’S DISEASE

Lou Gehrig’s disease vitamin D treatment.The brain disorders wig’s angina occurs most commonly in
The most common type of motor neuron include learning difficulties, behavioural people who tend to have poor oral
disease; also known as amyotrophic lat- problems, and sometimes seizures. hygiene habits.
eral sclerosis (ALS). Symptoms include fever; pain and
lozenge swelling in the mouth; and difficulty in
low birthweight A medicated sweet or tablet that dis- opening the mouth and swallowing. If
See birthweight. solves in the mouth, usually taken to left untreated, the disorder may cause
relieve a sore mouth or throat. life-threatening swelling in the throat
low-density lipoprotein that obstructs breathing and needs im-
One of a group of proteins combined LSD mediate treatment with antibiotic drugs.
with lipids in the blood plasma. Low- The abbreviation for lysergic acid diethy-
density lipoproteins (LDLs) are involved lamide, a synthetic hallucinogenic drug that lumbago
in the transport of cholesterol in the is derived from the fungus ergot. LSD is A general term for lower back pain.
bloodstream; they also deposit choles- used illegally as a recreational drug. It Lumbago may be due to an interverte-
terol around the body. An excess of LDLs causes visual and sometimes auditory bral disc prolapse (slipped disc). It may
(see hyperlipidaemias) is associated with hallucinations (perceptions that occur also arise if synovium (joint membrane)
atherosclerosis (narrowing of the arter- with no external stimulus); it may also is trapped between the surfaces of a
ies by deposits of fatty material). (See produce unusual emotional states such small intervertebral joint, or if there is
also high-density lipoprotein.) as “mystical” experiences. The user may momentary subluxation (partial dislo-
also have abnormal thoughts, such as cation) of an intervertebral joint with
lower back pain believing that he or she can fly unaided. sprains of the ligaments. In many cases,
See back pain. LSD sometimes produces panic and however, no cause is found.
physical side effects such as nausea and Treatment is with analgesic drugs
Lowe’s syndrome dizziness. In addition, individuals who (painkillers) and gentle physical acti-
A rare, X-linked genetic disorder affect- have used it frequently may experience vity. (See also lumbosacral spasm.)
ing the eyes, kidneys, and brain. Lowe’s “flashbacks” (recurrences of the hallu-
syndrome is a metabolic disorder in cinations) for months or even years lumbar
L which an enzyme found in cell mem-
branes does not function. Only males
after their last use of the drug. LSD is
not addictive but regular users rapidly
A word referring to the part of the
back between the lowest ribs and the
are affected. develop tolerance. top of the pelvis. The lumbar part
Eye problems include glaucoma; catar- of the spine is made up of the five lum-
acts; and nystagmus (abnormal, jerky eye Ludwig’s angina bar vertebrae.
movements).The kidney dysfunction cau- A rare bacterial infection that affects
ses chemical imbalances such as acidosis the floor of the mouth, usually due to lumbar disc protrusion
and a form of rickets that is resistant to an infected tooth or area of gum. Lud- See disc prolapse.

LOCATION AND STRUCTURE OF THE LUNGS

The lungs lie in the chest within the ribcage. Air bronchioles. These in turn lead to alveoli, where the
entering the body through the nose and mouth exchange of oxygen and carbon dioxide takes place.
travels down the trachea to the main bronchi, During expiration (breathing out), air leaves the body
which divide into smaller bronchi and then into by the same routes.

Trachea
Bronchus

Left lung
Right lung

Sternum

Bronchiole
Ribcage
Alveolus
Blood vessels in the lungs
The tiniest “twigs” of this extensive blood vessel “tree”
form into capillaries that surround the alveoli (air sacs)
in the lung. Oxygen and carbon dioxide are exchanged
between the alveoli and the capillaries.

476
 LUNG CANCER

lumbar lordosis lumen grapelike air sacs called alveoli (see alve-
See lordosis. The space within a tubular organ or olus, pulmonary). Oxygen and carbon
structure such as the intestine. dioxide diffuse into or out of the blood
lumbar puncture through the thin walls of the alveoli.
A procedure in which a hollow needle is lumpectomy Each lung is enclosed in a double
inserted into the lower part of the spinal A surgical treatment for breast cancer in membrane called the pleura; the two
canal, between two lumbar vertebrae, to which only the cancerous tissue is layers of the pleura secrete a lubricating
withdraw cerebrospinal fluid or to inject removed, rather than the entire breast. fluid that enables the lungs to move
drugs or other substances. (See also mastectomy; quadrantectomy.) freely as they expand and contract dur-
Lumbar puncture is usually carried ing breathing. (See also respiration.)
out to collect a sample of cerebrospinal lumpy jaw
fluid in order to diagnose and investi- A nonmedical name for actinomycosis. lung cancer
gate disorders of the brain and spinal The second most common form of can-
cord (such as meningitis and subarach- lunacy cer in the UK (after skin cancer).
noid haemorrhage). The procedure takes An outdated term for serious mental CAUSES
about 15 minutes and is carried out disorder. Smoking of tobacco is the main cause
under local anaesthesia. of lung cancer. Passive smoking (the
lung inhalation of tobacco smoke by non-
lumbosacral spasm One of the two main organs of the res- smokers) and environmental pollution
Excessive tightening of the muscles that piratory system.The lungs supply the (with radioactive minerals or asbestos,
surround and support the lower region body with the oxygen needed for aero- for example) are also risk factors.
of the spine, causing back pain. Treatment bic metabolism and eliminate the waste TYPES
of lumbosacral spasm may include product carbon dioxide. There are several types of lung cancer,
analgesic drugs (painkillers) and muscle- STRUCTURE AND FUNCTION each of which affects a different group
relaxant drugs. Air is delivered to the lungs through of lung cells. The most common types
the trachea (windpipe); this air passage are squamous cell carcinoma and small
lumbosacral spine divides into two main bronchi, with cell (or oat cell) carcinoma; the other
The area of the lower spine consisting of
the lumbar vertebrae and the sacrum
one bronchus supplying each lung. The
main bronchi divide again into smaller
main types are adenocarcinoma and
large cell carcinoma.
L
(the fused vertebrae that form the back bronchi and then into bronchioles, which Each form of lung cancer has a par-
of the pelvis). lead to air passages that open out into ticular growth pattern and response to

DISORDERS OF THE LUNG

The lungs are continuously exposed to provoke allergic disorders in susceptible condition in which a clot obstructs a
airborne particles, such as bacteria, people. The most significant of these blood vessel in the lung).
viruses, and allergens, all of which can disorders is asthma. Another such disorder Oxygen intake may be severely
cause disease. Disorders may also arise is allergic alveolitis, which is usually a impaired by diseases affecting the tiny
within the lung tissue or in associated reaction to dust of plant or animal origin. air sacs in the lungs (see alveolus,
structures such as blood vessels. pulmonary). In emphysema, the alveoli
Tumours are destroyed, thereby reducing the
Infection Lung cancer is one of the most common area of lung tissue where oxygen is
Lung infections are common. These of all cancers; cancerous tumours may absorbed into the blood (see also
include pneumonia (inflammation of the also spread to the lungs from other areas. pulmonary disease, chronic obstructive).
lung), tracheitis (inflammation of the Noncancerous tumours of the lung are Respiratory distress syndrome in adults
lining of the windpipe), and croup (a far less common. occurs when fluid leaks into the
viral infection in young children). alveoli from the tiny blood vessels
Bronchitis and bronchiolitis, which are Injury surrounding them, thereby preventing
inflammatory disorders affecting the Injury to the lung, usually by penetration the alveolar walls from absorbing
airways within the lungs, can be of the chest wall, can allow air or blood to sufficient oxygen.
complications of colds or influenza. collect between the two layers of the
The disorder bronchiectasis (abnormal pleura (the membrane around each lung),
INVESTIGATION
widening of the bronchi) may be a and the lung may collapse (see pneumo-
complication of bacterial pneumonia thorax; haemothorax). Injury to the interior Lung disorders are investigated by
or cystic fibrosis. of the lungs can be due to inhalation of chest X-ray, CT scanning, bronchoscopy,
toxic substances (see asbestosis; silicosis). pulmonary function tests, sputum
Allergies analysis, and blood tests. Sometimes,
Inhalation of certain substances, such Other disorders a lung biopsy (removal of a tissue
as pollen, dander (skin cells from The blood supply to the lungs may be sample) is performed.
animals), and house mite faeces, can reduced by pulmonary embolism (a

477
 LUNG, COLLAPSE OF

treatment. Small cell carcinoma is the lung-function tests Noncancerous tumours occur less fre-
most highly malignant form of lung can- See pulmonary function tests. quently than cancers. The most common
cer; it grows rapidly and spreads very of these tumours is a bronchial adeno-
quickly throughout the body. In con- lung imaging ma, which arises in the lining of a
trast, squamous cell carcinoma grows Techniques that are used to provide bronchus. Adenomas often cause bron-
more slowly than the other forms and images of the lungs in order to facilitate chial obstruction; affected people may
does not spread outside the lung until the diagnosis of lung disease. Most lung also cough up blood. Treatment of
late in the course of the disease. disorders can be detected by means of adenoma involves surgical removal of
SYMPTOMS chest X-ray. CT scanning and MRI play an the tumour.
The first and most common symptom important role in detecting the presence Other rare noncancerous tumours
of lung cancer is a persistent cough. and the spread of lung tumours. Ultra- include fibromas (which consist of fib-
Other symptoms include coughing up sound scanning is sometimes used to rous tissue) and lipomas (which consist
blood, shortness of breath, and chest reveal pleural effusion (buildup of fluid of fatty tissue). No treatment is neces-
pain. The tumour may obstruct the air- around a lung). Radioisotope scanning is sary for these, unless the tumours are
way, causing pneumonia (inflammation used to detect evidence of pulmonary causing problems.
in the lung), or involve the pleura (the embolism (in which a clot obstructs a
double-layered membrane covering blood vessel in a lung); alternatively, lupus erythematosus
the lung), causing an accumulation of a pulmonary angiogram contrast X-ray An autoimmune disorder that causes
fluid called pleural effusion. A tumour may be performed. inflammation of connective tissue. The
developing at the top of the lung may most common type of this disorder
press on the nerves supplying the arm is discoid lupus erythematosus (DLE),
on that side, causing pain and weak- which affects only exposed areas of
ness in the arm. skin. The more serious form, systemic
Lung cancer can spread to other parts lupus erythematosus (SLE), affects many
of the body, especially the liver, brain, of the body systems, including the skin.
and bones, causing pain and other SYMPTOMS
problems in these areas. In both varieties of lupus erythemato-
L DIAGNOSIS AND TREATMENT
In most cases, the cancer is revealed in a
sus, the symptoms periodically subside
and recur with varying severity.
chest X-ray or diagnosed from abnormal In DLE, the rash starts as one or
cells in a sputum sample. A doctor may more red, circular, and thickened areas
also perform a bronchoscopy to view of skin. These areas of skin subsequent-
inside the airways. To confirm the diag- ly become scarred. The patches may
nosis, a biopsy (tissue sample) is taken occur on the face, behind the ears, and
and is examined microscopically for on the scalp.
Chest X-ray
the presence of cancerous cells (see This is the most important lung imaging technique. SLE causes a variety of symptoms. A
cytology). Blood tests, and CT scanning or It provides information about the lungs, their blood characteristic red, blotchy, butterfly-
MRI, may be used in order to determine vessels and main airways. shaped rash may appear on the cheeks
whether or not the cancer has spread and the bridge of the nose; other symp-
to other areas. Bronchi Sternum Pulmonary toms include fatigue, fever, nausea, loss
blood vessel
If lung cancer is diagnosed at an early of appetite, joint pain, and weight loss.
stage, pneumonectomy (removal of the There may also be associated problems
whole lung) or lobectomy (removal of including anaemia, neurological or psy-
the diseased lobe of the lung) may be a chiatric problems, kidney failure, pleurisy
possibility. Surgery is usually considered (inflammation of the membrane that
only in cases in which the tumour is lines the lungs), arthritis, and pericar-
still relatively small and has not spread ditis (inflammation of the membrane
beyond the lung. Anticancer drugs and surrounding the heart).
radiotherapy may be used in order to DIAGNOSIS AND TREATMENT
contain the spread of the tumour and to Spine Lung Rib
Diagnosis is made by blood tests and
treat any metastases (cancerous cells sometimes a skin biopsy. DLE is usually
CT scanning of the lungs
that have spread to other areas of the This scan shows detailed horizontal slices through treated with topical corticosteroid drugs.
body). Small cell carcinoma is usually the lungs. CT scans are useful for showing the Both DLE and SLE may be treated with
treated by means of radiotherapy and extent and spread of lung tumours. the antimalarial drug hydroxychloro-
chemotherapy. quine. Sufferers of mild forms of SLE
lung lobectomy may have near normal health for many
lung, collapse of See lobectomy, lung. years, and treatment with corticosteroid
See atelectasis; pneumothorax. drugs and immunosuppressant drugs can
lung tumours improve life expectancy. Other treat-
lung disease, chronic Growths in the lungs. These tumours ments are available to treat specific
obstructive may be either cancerous (see lung features of the disease; however, SLE is
See pulmonary disease, chronic obstructive. cancer) or noncancerous. still a potentially fatal disorder.

478
 LYMPHANGITIS

LH-RH may cause headache, nausea, hot includes wearing clothes that cover the
flushes, vaginal dryness, and irregular body and fit closely at the wrists and
menstrual periods. ankles, and taking care not to walk
through thick undergrowth.
Lyell’s syndrome
Also known as toxic epidermal necroly- lymph
sis, a life-threatening drug reaction in A watery or milky body fluid contain-
which the skin, mucous membranes, ing lymphocytes (a type of white blood
and lining of internal organs such as the cell), proteins, and fats. It plays an im-
bladder and intestine blister and slough portant role in the immune system and in
off. Drugs that are known to have absorbing fats from the intestine.
Systemic lupus erythematosus on face
The disease can cause a skin eruption across the caused this condition include penicillin, Lymph accumulates outside the blood
nose and cheeks. The distinctive pattern this carbamazepine, and nonsteroidal anti- vessels in the intercellular spaces of
causes is known as a butterfly rash. inflammatory drugs (NSAIDS). Cases of body tissues, and is collected by the ves-
Lyell’s syndrome require treatment in sels of the lymphatic system. This system
lupus pernio an intensive care unit. filters the fluid and eventually returns it
A form of sarcoidosis affecting the to the bloodstream.
skin, in which purple swellings resem- Lyme arthritis
bling chilblains appear on the ears, Inflammation of the joints as a result of lymphadenitis
nose, or cheeks. Lyme disease (infection transmitted by A medical term for inflammation of the
the bite of a deer tick). Arthritis affects lymph nodes, which is a common cause
lupus vulgaris up to half of those infected with Lyme of lymphadenopathy.
A rare form of tuberculosis affecting the disease. It develops within a few weeks
skin, especially on the head and neck. to two years of the original infection lymphadenopathy
Painless, clear, red-brown nodules ap- and causes joint pain and swelling. The The medical term for swollen lymph nodes
pear and ulcerate; the ulcers eventually knee is most commonly affected. (see glands, swollen).
heal, leaving deep scars.
Lyme disease lymphangiography L
Lüscher colour test A disease caused by the bacterium BOR- A diagnostic procedure that involves
Developed in the 1960s by Dr. Max RELIA BURGDORFERI , which is transmitted injecting a contrast medium into lymph
Lüscher, the Lüscher colour test is by ticks that usually live on deer. vessels (see lymphatic system) in order
based on the idea that psychological SYMPTOMS that the vessels and lymph nodes, and
information about a person can be At the site of a tick bite, a red dot may any abnormalities, can be seen on X-rays.
gained through that person’s choices appear and gradually expand into a circ- Lymphangiography has been superseded
and rejections of eight colours: grey, ular area up to 15 cm across. Symptoms largely by CT scanning and MRI.
blue, green, red, yellow, violet, brown, including fever, headache, and muscle
and black. The test is sometimes used in pain usually develop; they are followed lymphangioma
the workplace to test job applicants for by joint inflammation, which typically A rare, noncancerous tumour consisting
suitability. It can also be a useful tool affects the knees and other large joints. of a mass of lymph vessels and often
for psychologists when they are trying Symptoms of Lyme disease may vary in affecting the skin and the deeper
to determine the current state of mind severity and occur in cycles lasting for tissues. It may be present from birth.
of an individual. about one to three weeks. Lymphangiomas are sometimes removed
COMPLICATIONS with laser treatment.
luteinizing hormone If Lyme disease is not treated promptly,
Also known as LH, a gonadotrophin hor- complications may develop; these in- lymphangitis
mone produced by the pituitary gland. clude meningitis (inflammation of the Inflammation of the lymphatic vessels
membranes covering the brain), facial (see lymphatic system) due to the spread
luteinizing hormone-releasing palsy, and an abnormal heartbeat (see of bacteria (commonly streptococci)
hormone arrhythmia, cardiac). The most serious from an infected wound.The inflamma-
A naturally occurring hormone, also long-term complications of Lyme dis- tion causes the appearance of tender red
known as LH-RH, that is released by the ease are Lyme arthritis and persistent streaks on the skin overlying the lym-
hypothalamus in the brain. This hormone neurological disorders that are similar phatic vessels. These red streaks extend
is also prepared synthetically as a drug. to multiple sclerosis. from the infection site towards the
Natural LH-RH stimulates the release of TREATMENT nearest lymph nodes. The affected nodes
gonadotrophin hormones from the pitu- Treatment of Lyme disease is with anti- become swollen and tender, and the
itary gland. Gonadotrophin hormones biotic drugs and is most effective when affected individual usually has a fever
control the production of oestrogen hor- given soon after initial infection. Non- and a general feeling of illness.
mones and androgen hormones. Synthetic steroidal anti-inflammatory drugs are given Lymphangitis requires urgent treat-
LH-RH, also called synthetic gonadorelin, to relieve joint pain. ment with antibiotic drugs to prevent
is used to treat delayed and precocious In areas that are known to be infested septicaemia (a life-threatening disorder
puberty and to treat infertility in with the ticks, people should take mea- resulting from high levels of bacteria,
women by desensitizing the pituitary. sures to prevent tick bites. Such action and bacterial toxins, in the blood).

479
 LYMPHATIC SYSTEM

lymphatic system lymph gland as tumour cells, cells that have been
A system of vessels (lymphatic vessels) A popular name for a lymph node. (See invaded by viruses, and those in trans-
that drains lymph from tissues all over also lymphatic system.) planted tissue) and release chemicals
the body back into the bloodstream.The that help to destroy the abnormal cells.
lymphatic system is part of the immune lymph node Suppressor T-cells act to “damp down”
system and has a major function in A small organ lying along the course the immune response. Helper T-cells
defending the body against infection of a lymphatic vessel (see lymphatic enhance the activities of the killer
and cancer. The lymphatic system also system). Lymph nodes are commonly, T-cells and the B-cells, and also orches-
plays a part in the absorption of fats but incorrectly, called lymph glands. trate the immune response.
from the intestine. Lymph nodes vary in size; they can MEMORY FUNCTION
STRUCTURE AND FUNCTION be microscopic or can be up to about Some B- and T-lymphocytes do not par-
All body tissues are bathed in lymph, a 2.5 cm in diameter. ticipate directly in immune responses
watery fluid that is derived from the STRUCTURE but serve as a memory bank for anti-
bloodstream. Much of this fluid is A lymph node is composed of a thin, gens that have been encountered. These
returned to the bloodstream through fibrous outer capsule and an inner mass lymphocytes are created when the
the walls of the capillaries (see circula- of lymphoid tissue. Penetrating the cap- immune system cells respond to an
tory system), but the remainder of the sule are several small lymphatic vessels, infection, and they contain information
fluid is transported to the heart through which transport lymph into the node. on how to deal with that infection.
the lymphatic system. Each lymph node contains sinuses Once the immune response is over, the
Lymph is moved along the lymphatic (spaces) in which the lymph is filtered. memory cells are then stored in the
vessels during physical activity, in A single, larger vessel carries lymph out body in order to aid subsequent
which the contraction of muscles com- of the node. immune responses to that infection.
presses the vessels; valves inside the FUNCTION
vessels ensure that the lymph always Lymph nodes act as a barrier to the lymphocytosis
flows in the correct direction. spread of infection by destroying or fil- An increase in the number of lympho-
Situated on the lymphatic vessels are tering out bacteria before they can pass cytes, a type of white blood cell that
lymph nodes, through which the lymph into the bloodstream. As lymph passes mounts the immune response, either by
L passes. These nodes filter the lymph and
trap or destroy infectious microorg-
through a node, narrow channels in
the sinuses slow down its movement;
attacking foreign cells directly or by
producing antibodies that cause their
anisms or other foreign bodies. Also this reduction in the flow of lymph destruction. Lymphocytosis, which can
included in the lymphatic system are allows macrophages (white blood cells be detected by blood test, most com-
the spleen and the thymus, which pro- that engulf and destroy foreign and monly occurs in viral infections. Rarely,
duce lymphocytes (white blood cells that dead material) to filter microorganisms a massive increase in lymphocytes may
fight infection or harmful cells). from the lymph. In addition, germinal be due to leukaemia.
DISORDERS centres, which are located in the lymph
If infection or inflammation occurs in node, release white blood cells known lymphoedema
any part of the body, the lymph nodes as lymphocytes. These cells also help to An abnormal accumulation of lymph in
in that particular area may become fight infection. the tissues, which occurs when the nor-
swollen and tender as the white blood mal drainage of lymph is disrupted (see
cells within them try to combat the lymphocyte lymphatic system).
organisms or cells causing the problem. Any one of a group of white blood cells CAUSES
If an infection is particularly severe, the that are of crucial importance to the There are various possible causes for
lymphatic vessels leading from the immune system because they combat lymphoedema. Cancer can lead to the
nodes may also become inflamed (see infectious organisms and cancer. There condition if the vessels become blocked
lymphangitis). are two principal types of lymphocyte: by deposits of cancer cells. Surgical re-
If a lymphatic vessel becomes ob- B- and T-lymphocytes. moval of lymph nodes under the arm (as
structed (for example, by worms or B-LYMPHOCYTES in radical mastectomy) or in the groin,
by cell debris), lymph will collect in B-lymphocytes produce immunoglobu- or radiotherapy to an area containing
the nearby tissues, which will lead to lins or antibodies (proteins that attach lymph nodes, may also result in lymph-
lymphoedema. themselves to antigens (proteins) on the oedema. In the tropical disease filariasis,
Cancer commonly spreads to other surfaces of bacteria). This action starts a the lymphatic vessels may be blocked by
parts of the body through the lymph- process that leads to the destruction of parasitic worms. Rarely, the condition is
atic system. If a primary tumour invades the bacteria. due to a congenital abnormality of the
the lymphatic vessels, cells from the tu- T-LYMPHOCYTES lymphatic vessels known as Milroy’s
mour may break off and enter the The T-lymphocytes are classified in two disease. In addition, lymphoedema may
vessels (see metastasis). They may then main groups, according to the type of occur for no known reason.
become lodged in lymph nodes situated antigens found on their surfaces. One SYMPTOMS
nearby, where they may then grow into group (known as CD8) includes killer Lymphoedema causes painless swelling
secondary tumours. In breast cancer, (cytotoxic) and suppressor cells; the in the tissues and thickening of the skin
for example, the cells from a breast other group (CD4) includes helper over the affected area. It usually devel-
tumour may spread to the lymph nodes cells. The killer T-lymphocytes attach ops in the legs; the swelling may start at
in the armpit. themselves to abnormal cells (such the ankle and extend up the leg, and

480
 LYMPHOEDEMA

STRUCTURE AND FUNCTION OF THE LYMPHATIC SYSTEM

The lymphatic system is a collection of organs, ducts, and White cells that are produced by the bone marrow, thymus,
tissues that has the dual role of draining tissue fluid (lymph) and spleen are present in lymph nodes, or they circulate
back into the bloodstream and of fighting infection. Lymph is through the lymphatic system and the bloodstream, providing
drained by a system of channels (the lymphatic vessels). defences against infection.

The lymphatic network

Right lymphatic duct
The lymphatic system consists
of a network of lymph nodes Thoracic duct
connected by lymphatic Right subclavian vein
vessels. The nodes generally Left subclavian vein
occur in clusters, mainly Lymph
around the neck, armpits, and
Superior vena cava
groin. The lymphatic system
also includes organs such as
the spleen and thymus. Lymphatic drainage
Just below the neck, the thoracic duct and right
lymphatic duct drain into the two subclavian
veins. These veins unite to form the superior
vena cava, which passes into the heart; in this
Thoracic duct
way, the lymph fluids rejoin the circulation.

Liver Lymphatic vessels

Spleen
Collagenous capsule

Follicle
Cisterna
chyli
Artery

Lymph node Vein

L
Lymph
Lymphatic
vessels
White blood cells

Structure of a lymph node

MOVEMENTS OF BODY FLUIDS Any fluid absorbed into the lymphatic system
passes across at least one lymph node before
Lymph is constantly moving around it returns to the circulation. The fluid filters
the body, but the lymphatic system Heart
through a mesh of tightly packed white blood
has no central pump equivalent to cells – some of which are grouped into follicles
consisting of similar cells – which attack and
the heart. Lymph is circulated by the Arteries destroy harmful organisms. Every lymph node
movement of the body’s muscles; is supplied by its own tiny artery and vein.
a system of one-way valves in the Veins
lymphatic vessels ensures that
it moves in the right direction.
Lymphatic
Exertion also pushes fluid from vessels
body tissues into the bloodstream.
Capillaries
Remaining fluid passes from tissues to
lymphatic system
Lymphatic Tissue
Cells vessel fluid

Fluid exchange
During a 24-hour period, approximately 24 litres
of serumlike fluid pass from the bloodstream to
the body’s tissues. This fluid bathes the cells
and provides them with oxygen and nutrients.
During the same period of time, approximately
20 litres of fluid pass back from the tissues to Enlarged lymph nodes
the bloodstream, carrying carbon dioxide and This photograph shows a child with an enlarged
other waste products. The remaining 4 litres pass lymph node in the neck. One cause of such
from the tissues to the lymphatic system and enlargement is infection. Enlarged nodes may
Fluid passes from Capillary Fluid passes from return eventually to the circulation from there.
tissues into blood blood into tissues also be a result of Hodgkin’s disease, a rare
cancer of the lymph nodes.

481
 LYMPHOGRANULOMA VENEREUM

may occur to an incapacitating degree come involved, leading to diverse of which an enzyme is missing from
in some individuals. If a limb that is symptoms ranging from headache to the lysosome within cells. This absence
affected by lymphoedema is subsequ- skin ulceration. In some cases, there leads to a buildup of abnormal sub-
ently injured, infection can easily enter may be fever, marked weight loss, and stances within the cells that causes
the site of injury and spread rapidly recurrent infections. tissue damage.
through the body tissues. DIAGNOSIS
TREATMENT Diagnosis is based on a biopsy, usually lysosome
There is no known cure for lymphoed- taken from a lymph node. Further One of a variety of structures present
ema. Treatment consists of taking diuretic investigations, such as chest X-ray, CT within every cell that are responsible,
drugs, wearing an elastic bandage or scanning, MRI, bone marrow biopsy, and when the cell dies, for breaking down
compression sleeve, massage, and spe- lymphangiography, may be needed to the components of the cell for the pur-
cial exercises; these measures may bring assess the extent of the disease. poses of recycling.
about some improvement. TREATMENT
In cases where the lymphoma is con- lysozyme
lymphogranuloma venereum fined to a single group of lymph nodes, An enzyme found in tears, saliva, sweat,
A sexually transmitted disease caused by treatment consists of radiotherapy. More nasal secretions, breast milk, and many
a chlamydial infection; it is most common often, however, the disease is more tissues. It destroys bacteria by disrupt-
in tropical areas. extensive, and in such cases anticancer ing their cell walls.
The first sign of lymphogranuloma drugs are given. A bone marrow transplant,
venereum may be a small genital blister with drug treatment and/or radiothera-
that heals in a few days. There may also py, may be considered for some people.
be fever, headache, muscle and joint
pains, and a rash. The lymph nodes, par- lymphopenia
ticularly in the groin, become painfully A decrease in the number of lympho-
enlarged and inflamed. Abscesses may cytes, a type of white blood cell that
form, and persistent ulcers may devel- mounts the immune response, either by
op, on the skin over the affected nodes. a direct attack on abnormal cells or
L Treatment is with antibiotic drugs. invading organisms or by producing
antibodies that cause their destruction.
lymphoma This condition may occur when the
Any of a group of cancers in which the bone marrow fails to produce enough
cells of lymphoid tissue (found princi- blood cells, as in aplastic anaemia (see
pally in the lymph nodes and the spleen) anaemia, aplastic) or treatment with
multiply unchecked. radiotherapy or anticancer drugs.
Lymphomas fall into two principal
categories. If certain characteristic ab- lymphosarcoma
normal cells (Reed–Sternberg cells) are The former name for a condition that is
present, the condition is called Hodg- now classified as a type of non-
kin’s disease . All other forms are known Hodgkin’s lymphoma (see lymphoma,
as non-Hodgkin’s lymphoma (see lym- non-Hodgkin’s).
phoma, non-Hodgkin’s).
lysergide
lymphoma, non-Hodgkin’s see LSD.
Any cancer that affects the lymphoid
tissue (found mainly in the lymph nodes lysis
and spleen) other than the condition A medical term for breaking down or
Hodgkin’s disease. destruction. The term lysis is usually
CAUSES applied to the destruction of cells by
In most cases, non-Hodgkin’s lymph- disintegration of their outer membrane.
oma has no known cause. Occasionally, A common example is haemolysis, the
however, the disease is associated with breakdown of red blood cells.
suppression of the immune system, par- Lysis may be caused by chemical
ticularly after an organ transplant. One action, for example the action of an
type of non-Hodgkin’s lymphoma, enzyme , or by physical action, for
called Burkitt’s lymphoma, is associated example the action of heat or cold. The
with the Epstein–Barr virus. term “lysis” is also occasionally used to
SYMPTOMS refer to a sudden recovery from a fever.
There is usually painless swelling of
lymph nodes in the neck or groin. The lysosomal storage disease
liver and spleen may enlarge, and lym- One of several different conditions, also
phoid tissue in the abdomen may be known as inborn errors of metabolism
affected. Many other organs may be- (see metabolism, inborn errors of) in most

482
 MADURA FOOT

M
disorder causing enlargement of several Wet macular degeneration is usually
body parts). It is also caused by some remedied by laser treatment. There is no
tumours of the tongue, such as a hae- treatment for the dry form of the condi-
mangioma or a lymphangioma. tion, although the affected individual
may benefit from visual aids such as
macrognathia magnifying instruments.
An abnormally large upper and/or low-
er jaw. Macrognathia can be a feature macule
of the condition acromegaly. (See also A spot that is level with the skin’s sur-
prognathism). face and discernible only by difference
in colour or texture.
macro- macrolide drugs
A prefix meaning “large”, as in macro- A class of antibiotic drugs used to treat a maculopathy, diabetic
phage (a large type of cell found in the wide range of infections including those A complication of diabetes mellitus that
immune system) or macroglossia (enlarg- of the ear, nose, throat, respiratory and is characterized by damage to the macu-
ement of the tongue). gastrointestinal tracts, and skin. Com- la, at the back of the retina. Usually, the
mon macrolides include azithromycin remainder of the retina is also affected
macrobiotics and erythromycin. (see retinopathy).
A dietary system in which foods with a
balance of yin and yang are eaten. Foods macrophage madarosis
are classed as yin or yang depending on A cell in the immune system. Macro- Loss of the eyelashes or eyebrows.
factors such as colour, texture, and taste. phages are large phagocytes, which can
engulf and destroy microorganisms and mad cow disease
macrocytosis other foreign particles. They are found The commonly used name for bovine
A condition in which the red blood in most body tissues. spongiform encephalopathy (BSE).
cells are larger than normal. Macrocyto-
sis has many possible causes, the most macroscopic Madelung’s disease
common of which are megaloblastic Visible to the naked eye. The development of multiple, symmet-
anaemia (see anaemia, megaloblastic) and rical, fatty masses resembling lipomas
the effects of alcohol. macula under the skin of the head, neck, upper
The specific area of the retina (the light- trunk, and upper arms. The disease, also M
macroglobulinaemia, sensitive layer at the back of the eye) called multiple symmetrical lipomatosis
Waldenström’s that is responsible for seeing fine detail. or Lanois–Bensaude syndrome, occurs
A type of lymphoma in which lympho- The macula surrounds the fovea, the primarily in adult men.
cytes (a type of white blood cell) produce part of the retina that contains the high- The cause is unknown, but Made-
excessive amounts of a protein called est density of visual cells. lung’s disease has been associated with
immunoglobulin M (IgM), which is long-term, excessive alcohol use (see
normally created to fight disease (see macular degeneration alcohol-related disorders).
immunoglobulins). It tends to occur most A progressive, painless deterioration of
commonly in men over 50 years old. the macula. It is a common disorder in Madopar
The excess IgM causes the blood to elderly people, and is the most com- A brand-named drug, containing levo-
become overly viscous (thick), impair- mon cause of visual impairment in the dopa with benserazide (a drug that
ing its flow through the smallest blood UK. The cause is unknown. enhances the effect of levodopa), used
vessels. Signs and symptoms include There are two forms of macular in the treatment of Parkinson’s disease.
fatigue; headache; dizziness; visual dis- degeneration: dry and wet. In dry mac-
turbances; easy bruising and bleeding; ular degeneration, cells within and just Madura foot
and numbness and tingling in the hands beneath the macula die. In wet macular A fungal and/or bacterial infection of
and feet. The spleen, liver, and lymph degeneration, fragile new blood vessels the foot that occurs in tropical or sub-
nodes may become enlarged. grow beneath the macula; and these tropical regions such as Central and
There is no cure, but treatment can vessels may easily leak blood or other South America, Africa, India, and South-
relieve the symptoms. Blood viscosity fluid, which damages the cells. Both east Asia. Madura foot usually affects
can be lowered by plasmapheresis, in forms of macular degeneration produce men aged 20 to 40, often as a result of
which a machine removes excess IgM a roughly circular area of blindness that outdoor work.
from the blood plasma. Anticancer drugs increases in size. It does not cause total The infection enters the foot through
and corticosteroids may also be given. blindness because the vision is retained broken skin. A nodule or abscess forms,
around the edges of the visual fields. and grows into a mass of diseased tissue
macroglossia Diagnosis is by ophthalmoscopy and with sinuses (abnormal channels) that
Abnormal enlargement of the tongue. vision tests. If wet macular degeneration discharge bloody or pus-filled fluid. The
Macroglossia is a feature of the chro- is suspected, fluorescein angiography fluid typically contains very small gran-
mosomal abnormality Down’s syndrome; (imaging of the blood vessels in the ules, which are fragments of infectious
hypothyroidism (an underactive thyroid retina) may be performed to detect organisms. The infection may progress
gland); and acromegaly (a hormonal abnormal blood vessels. to involve the foot bones.

483
 MAFFUCCI’S SYNDROME

Treatment involves removal of diseased ial disorder), and lymphoma (cancer of is prevalent throughout the tropics.
tissue (or, if necessary, amputation) and lymph tissue). In addition, the removal Malaria causes severe fever, and, in
the use of antibiotics or antifungal drugs of some of the small intestine, and cer- some cases, fatal complications affecting
to destroy the infection. tain operations on the stomach, may the kidneys, liver, brain, and blood.
also result in malabsorption. CAUSES
Maffucci’s syndrome SYMPTOMS There are four species of plasmodia that
A syndrome characterized by enchon- Common symptoms of malabsorption cause malaria: PLASMODIUM FALCIPARUM,
dromas (benign tumours of cartilage) are diarrhoea and weight loss. In severe PLASMODIUM VIVAX, PLASMODIUM OVALE, and
together with haemangiomas (benign cases, there may also be malnutrition PLASMODIUM MALARIAE. When a mosquito
tumours of the blood vessels) on the (see nutritional disorders), vitamin defi- carrying the infection bites a human,
skin or internal organs. The condition ciency, mineral deficiency, or anaemia. the plasmodia enter the bloodstream.
develops during childhood, and is more DIAGNOSIS AND TREATMENT They invade the liver and red blood
common in males than in females. Diagnosis may be made by tests on fae- cells, where they multiply. The red cells
ces, blood tests, barium X-ray examination then rupture, releasing the new para-
Magnapen and jejunal biopsy. In most cases, dietary sites. Some of them infect new red cells,
A brand-named antibiotic drug contain modifications or supplements are suc- and the others develop into forms that
ing ampicillin with flucloxacillin. cessful in treating the disorder. In severe can infect more mosquitoes. Falciparum
cases, intravenous infusion of nutrients malaria infects more red cells than the
magnesium is needed (see feeding, artificial). other species and thus causes a more
A mineral that is essential for the for- serious infection. Most cases of this
mation of bones and teeth, muscle maladjustment form occur in Africa.
contraction, nerve impulse transmission, Failure to adapt to a change in one’s SYMPTOMS
and activation of many enzymes. Dietary environment, resulting in inability to Symptoms of malaria include fever,
sources include cereals, milk, nuts, soya cope with daily activities. Maladjustment shaking, and chills. There may also be
beans, and fish. can occur as a reaction to stressful situa- severe headache, general malaise, and
tions such as divorce or moving house. vomiting. The fever often develops in
magnesium sulphate The person may have feelings of cycles, occurring every other day (in
A magnesium compound used as a laxa- depression or anxiety; children and adoles- vivax and ovale infections) or every
tive drug and
an anticonvulsant drug. cents may show disturbed behaviour (see third day (in malariae infections).
behavioural problems in children). Malad- Falciparum malaria can be fatal with-
M magnesium trisilicate justment often disappears when a person in days. Infected red cells become sticky
A magnesium compound that is used in is removed from the stressful situation and block blood vessels in vital organs.
antacid drugs. or if he or she manages to adapt to it. The spleen becomes enlarged and the
brain may be affected, leading to coma
magnetic resonance imaging malaise and convulsions. Destruction of red
See MRI. A vague feeling of being unwell. blood cells causes haemolytic anaemia
(see anaemia, haemolytic). Kidney failure
malabsorption malalignment and jaundice often occur.
Impaired absorption of nutrients by the Positioning of the teeth in the jaw so DIAGNOSIS AND TREATMENT
lining of the small intestine. that they do not form a smooth arch A blood film examination is carried out
CAUSES shape when viewed from above or to detect the parasites. Falciparum mal-
Malabsorption may be caused by many below (see malocclusion). aria is treated with quinine or mefloquine,
conditions. One possible cause is an The term “malalignment” may also or proguanil and atovaquone, or arte-
inflammatory disorder, such as chronic refer to a fracture in which the bone mether with lumefantrine. Chloroquine is
pancreatitis (long-term inflammation of ends are not in a straight line. the usual treatment for species other
the pancreas) or Crohn’s disease (an than falciparum. People with vivax or
inflammatory bowel condition). An- malar flush ovale malaria must also take the drug
other is infection, such as giardiasis (an A high colour over the cheekbones, primaquine to eradicate parasites in the
infection of the small intestine). with a bluish tinge caused by reduced liver. In severe cases, blood transfusions
Genetic disorders resulting in abnor- oxygen concentration in the blood. may be necessary.
mal intestinal structure or function can Malar flush is considered to be a sign of PREVENTION
also cause malabsorption, as in lactase mitral stenosis (narrowing of one of the People who live in or visit malarial
deficiency (lack of an enzyme needed to heart valves), which often follows rheu- areas should take precautions in order
digest milk sugar), cystic fibrosis (a dis- matic fever. However, malar flush is not to avoid mosquito bites; such measures
order in which an excess of mucus is always present in mitral stenosis, and include keeping the arms and legs cov-
produced in the intestines), or coeliac many people with this colouring do not ered and using insect repellents and
disease (hypersensitivity to gluten, a have heart disease. mosquito nets. In addition, travellers to
substance in certain cereals). such areas should take preventive anti-
Other causes of malabsorption in- malaria malarial drugs.The course of drugs must
clude amyloidosis (a condition in which A serious disease caused by protozoa be started up to three weeks before the
a starchy substance is deposited in vital called plasmodia.The infection is spread person enters the area, and should be
organs), Whipple’s disease (a rare bacter- by the bite of ANOPHELES mosquitoes and continued for one to four weeks after

484
 MALIGNANT HYPERTENSION

THE SPREAD OF MALARIA

Malaria parasites (plasmodia) are

transmitted by the bites of infected
ANOPHELES mosquitoes. The plasmodia
invade the liver and then the red
blood cells, where they multiply.
When the red blood cells rupture,
they release the parasites; some of
the plasmodia invade more red cells,
while others develop into forms that
can infect mosquitoes.

ito Infected
osqu bites hu mos qu
te d m ected man ito
ec inf y .
inf the he reb ted.
Un ites on, t g infec
b ers mi n
p eco Prevalence of malaria
p

b Pl aliva dstre
osq ca elo

as Malaria, although rare in Key

s loo
infect m s t hat dev

mo ente m.
b

the UK, is a major problem

uito n
.

Areas in which malaria is

es

dia r
a

in the tropics. It affects

into formsm odi

prevalent
in m
about 300 million people
a

worldwide, and kills more Areas with limited risk

osqu
a
Other pl

than one million people a

Areas with no malaria
ito’s

year in Africa alone.

Some pl ore red
invade m

b lo are then
nd liver

Malarial infection
ream

of blood cells
e

Some of the red

se ltip nvad

odst
asm

blood cells on this

M
d i ly a
o di cells

ea u ia i

TEM (transmission
el d m mod
a

nto

electron micrograph)
an las

contain the typical

.

“signet ring” forms

R r
re ed c e of one type of
lea el
sin ls ru vad malarial parasite.
g p p tur m od ia i n s and
Plas l l
las e
mo d , d ce
red bloo
ia.
multiply.

the visit (exact timings depend on the male cells spread from the original site to
type of drug). Doctors can provide up- The term that is used for a man or form secondary tumours in other parts
to-date advice on the choice of drugs. a boy. Male sex is determined by the of the body.
possession of a Y sex chromosome, and
Malarone by the presence of a penis and testes malignant hypertension
A brand-named antimalarial drug con- (see sexual characteristics, primary). Severe hypertension in which the blood
taining proguanil with atovaquone. pressure rises suddenly to a very high
male-pattern baldness level, usually for no obvious cause,
malathion The most common type of alopecia. resulting in damage to arterioles and
An antiparasitic drug for skin or hair in- capillaries (tiny blood vessels). The con-
festations such as lice and scabies. The malformation dition occurs in a small minority of
drug kills parasites by interfering with A deformity, particularly one that people with existing hypertension, par-
their nervous systems. Malathion is results from the faulty development of ticularly if it is due to kidney disorders;
applied as a shampoo or a lotion. If they a baby in the mother’s uterus. (See it is more common in young adults.
are used correctly, preparations that embryo and uterus). Most of the symptoms are caused by
contain malathion should not produce increased pressure in blood vessels in
adverse effects. They should not be used malignant the head; they include headache, blurred
for more than three weeks at a time, A term used to describe a condition that vision, confusion, drowsiness, nausea,
however and should not be applied to tends to become progressively worse and vomiting. There may also be chest
broken or infected skin. Some alcohol- and eventually result in death. The term pain and shortness of breath. In addi-
based lotions may give off fumes that “malignant” is primarily used with ref- tion, the pressure may produce changes
cause wheezing in people with asthma. erence to a cancerous tumour whose in internal organs; for example, it causes

485
 MALIGNANT HYPERTHERMIA

papilloedema (swelling of the optic ten days, with no special treatment re- example, the combination of large
nerve) and enlargement of the heart, quired; however, a blood transfusion may teeth and a small mouth (see overcrowd-
and may also cause retinal bleeding and sometimes be necessary. ing, dental).
acute kidney failure. If left untreated, it TREATMENT
can cause death within six months. malnutrition Orthodontic appliances (braces) may be
Diagnosis is based on measurement of See nutritional disorders. used to reposition the teeth; if there is
blood pressure and tests to detect dam- dental overcrowding, some of the teeth
age to organs such as the kidneys. An malocclusion may be extracted. Orthognathic surgery is
affected person will need hospital treat- An abnormal relationship between the used to treat severe recession or protru-
ment to lower blood pressure. upper and lower sets of teeth when they sion of the lower jaw. Treatment is best
are closed, affecting the bite or the carried out in childhood or adolescence.
malignant hyperthermia appearance of the teeth.
See hyperthermia, malignant. CAUSES malpresentation
Malocclusion usually develops during A condition in which a baby is not in
malignant melanoma childhood. In some cases, it may be the usual head-first position for child-
See melanoma, malignant. inherited. Alternatively, it may be due birth. Malpresentation includes breech
to thumb-sucking or to a mismatch presentation (in which the baby’s bot-
malingering between the teeth and jaws – for tom appears first), face presentation,
The deliberate simulation of symptoms and shoulder presentation (in which
for a particular purpose, such as taking the baby is lying across the uterus).
time off work or obtaining compen- CLASSES OF MALOCCLUSION Breech presentations are the most com-
sation. Malingering is different from mon. A breech baby may be born by
Unsatisfactory contact between the
factitious disorders and hypochondriasis, in breech delivery or caesarean section. A
upper and lower teeth is known as
which the motivation for illness is not malocclusion. There are three main shoulder presentation baby usually has
under the individual’s voluntary control. classes, as shown below. to be delivered by caesarean section.
malleolus MALT
The bony protuberance on each side of The abbreviation for mucosa-associated
the ankle. lymphoid tissue. This tissue is part of
the lymphatic system, which helps to
M mallet finger defend the body against infection. It is
Injury to the tendon or bone in a fin- found in the digestive tract, particularly
gertip that forces the tip into a bent Class 1 malocclusion in the tonsils and in areas called Peyer’s
position. A common sports injury, it In this (the most common) type, the jaw patches in the small intestine.
relationship is normal. However, because
occurs when a ball strikes a finger.
Treatment is with a splint or by tem-
the teeth are poorly spaced, tilted, or
rotated, the upper and lower set do not
maltose
porary insertion of wire through the meet properly. A sugar composed of two glucose mol-
bones to hold the finger straight. The ecules (see disaccharide). Maltose is
injury heals in two to three months. found in germinating cereal seeds.
mallet toe mammary dysplasia
See claw-toe. Normal variations in breast tissue that
cause thickening and general lumpiness
malleus of the breasts. It may develop just before
One of the three tiny bones (known Class 2 malocclusion menstruation and subside afterwards.
collectively as the auditory ossicles) that In this type –called retrognathism – the The condition is common in women
are situated in the middle ear. The lower jaw is lying too far back; the normally between 30 and 50 years of age but is
small overbite of the upper incisors is
malleus, together with the incus and the greatly increased, and the molar bite is lower in those taking oral contraceptives.
stapes, transmits sound vibrations from displaced backwards. The condition is not a disorder and
the eardrum to the inner ear. does not lead to breast cancer. In many
cases, no treatment is needed; in more
Mallory–Weiss syndrome severe cases, oral contraceptives may be
A tear at the lower end of the oesophagus, prescribed. In contrast, any distinct breast
causing vomiting of blood.The syndrome lump should be assessed by a doctor.
is commonly caused by retching and
vomiting after drinking excess alcohol, or Class 3 malocclusion
mammary gland
as a result of food poisoning. Less often, In this (the least common) type – called See breast.
violent coughing, a severe asthma attack, prognathism – the lower jaw is lying too
or epileptic convulsions may be the cause. far forward; the lower incisors meet, or mammography
lie in front of, the upper ones, and the
An endoscope is passed down the molar bite is displaced forwards. An X-ray procedure for examining the
oesophagus to confirm the diagnosis. breast. The breast is flattened between
The tear generally heals within about an X-ray plate and a plastic cover so that

486
 MANDIBLE

as much tissue as possible can be

imaged. Two images are taken of each PROCEDURE FOR MAMMOGRAPHY
breast. Mammography is used to investi-
Mammography is a simple, safe procedure and causes only slight discomfort. Only
gate breast lumps, and to screen for low-dose X-rays are used. The breast may be X-rayed from above, the side, or both;
breast cancer, because it reveals tumours and sometimes an oblique (angled) view is taken.
too small to be found in a physical
examination. It is offered every three How mammography is done
years to all women between the ages of In the method shown here, the
breast is place on the machine
50 and 65 years. and gently compressed between
the X-ray plate below and a
mammoplasty plastic cover above. This
An operation that is performed in order flattens the breast so that as
to make large breasts smaller, to enlarge much tissue as possible can be
imaged. Several views may be
small breasts, or to reconstruct a breast taken. In another method, the
following surgery for breast cancer. In breast hangs freely and is
many cases, mammoplasty is performed X-rayed from the side.
for cosmetic reasons. However, the re-
duction of excessively large breasts may
have the physical benefit of reducing
back pain.
Mammograms
The mammogram on the far
left shows a side view of the
healthy, relatively dense, breast
tissue of a younger woman. In
the mammogram on the left, a
fibroadenoma (noncancerous
tumour made up of fibrous
tissue) is present on the upper
part of the breast. A biopsy
(removal of a tissue sample for
analysis) can confirm whether
or not a tumour is cancerous.
M
Reconstruction of a breast
The right breast (left in the image) was removed in Normal mammogram Abnormal mammogram
an earlier mastectomy operation. The breast has
been reconstructed using a silicone implant.

PROCEDURES
In breast reduction, excess tissue and PROCEDURES FOR MAMMOPLASTY
skin is removed and the tissue is raised
and reshaped to correct drooping. Breast One of the most common cosmetic operations, mammoplasty is carried out to
improve the appearance of the breasts by removal of excess fat and skin or by
enlargement or augmentation involves
using an implant to increase their size.
the insertion of a soft, fluid-filled breast
implant behind the breast tissue or
BREAST REDUCTION BREAST ENLARGEMENT
behind the muscles of the chest wall.
In women undergoing a mastectomy
(removal of a breast) for cancer, breast
reconstruction may be carried out
either at the same time or as a separate
procedure. The normal contours of the
breast are restored by the insertion of
an implant.
RISKS
Breast reduction carries few risks, but
enlargement may cause complications.
These problems include leakage from
the implant, hardening of the sur- Incision lines Reduced Incision line Implant
rounding breast tissue, and scarring. breast
Procedure for breast reduction Procedure for breast enlargement
Further surgery may be needed. Incisions are made around the edge of the An incision is made in the armpit or along
nipple, in the crease under the breast, and from the crease under the breast, and a pocket is
mandible the nipple to the crease. Excess tissue and skin created behind the breast or the chest muscles
The lower jaw. The mandible consists of are removed, and the nipple is repositioned, to receive the implant. After the implant has
then the incisions are closed. been inserted, the incision is stitched.
two fused pieces of bone forming a U
shape.The upper surface bears the lower

487
 MANIA

set of teeth. The mandible is joined to disorders. Manipulation is important in due to loss of muscle and fat. Other
the rest of the skull at the temporoman- orthopaedics, physiotherapy, osteopathy, signs include sparse, brittle hair; diar-
dibular joint. It is the only skull bone and chiropractic. It may be used to treat rhoea; and dehydration.
capable of movement; it is moved by the deformity and stiffness caused by bone Treatment includes keeping the
cheek muscles for chewing and speech. and joint disorders, to realign bones in child warm and giving a high-energy,
a displaced fracture, to reposition a joint protein-rich diet. Persistent marasmus
mania after a dislocation, or to stretch a contrac- can lead to learning difficulties and
A mental disorder characterized by ture. Occasionally, manipulation is used can also cause impaired growth. (See
episodes of overactivity, elation, or irri- to help treat frozen shoulder. also kwashiorkor.)
tability. Mania usually occurs as part of a
manic–depressive illness. mannitol marble bone disease
SYMPTOMS An osmotic diuretic drug used to treat See osteopetrosis.
Manic behaviour may include extrava- oedema (accumulation of fluid) in the
gant spending; repeatedly starting new brain and to relieve glaucoma (a buildup Marburg virus disease
tasks; sleeping less than normal; an of fluid, and pressure, in the eyeball). A rare form of haemorrhagic fever, also
increased appetite for food, alcohol, sex, called green monkey disease, that is
and exercise; outbursts of inappropriate manometry transmitted by African vervet monkeys.
anger or laughter; a sudden increase in The measurement of pressure (of either The onset of the disease is sudden,
socializing; and delusions of grandeur. a liquid or a gas) using an instrument with fever; severe headache; chest and
Milder forms are called hypomania. called a manometer. Manometry is abdominal pain; vomiting; diarrhoea;
TREATMENT used to measure the blood pressure by and a rash on the trunk. The symptoms
Severe mania is usually treated in hospi- means of an instrument called a sphyg- become increasingly severe; they may
tal with antipsychotic drugs. Taking lithium momanometer. include weight loss, delirium, jaundice,
or carbamazepine may prevent relapses. massive haemorrhaging (internal bleed-
Manson’s disease ing), failure of the liver and other
manic–depressive illness See schistosomiasis. organs, and shock.
A mental disorder that is characterized There is no specific treatment for the
by a disturbance of mood. The distur- mantoux test disease; affected people must be admit-
bance may be unipolar (consisting of A skin test that is performed to detect ted to hospital, where their blood and
either depression or mania) or bipolar tuberculosis (see tuberculin tests). fluid levels will be maintained and any
M (swinging between the two). In a severe further infections treated.
form sometimes referred to as manic– manubrium
depressive psychosis, there may also be The top part of the sternum (breastbone). march fracture
grandiose ideas or negative delusions. A break in one of the metatarsal bones
CAUSES MAOI (the long bones in the foot) that is
Some people inherit a tendency to An abbreviation for monoamine oxidase caused by running or walking for long
manic–depressive illness. In addition, it drugs.
inhibitor distances on a hard surface. The fracture
is thought that abnormalities in brain results in pain, tenderness, and swel-
biochemistry, or in the structure and/or maple syrup urine disease ling; however, it may not show on X-rays
function of certain nerve pathways in (MSUD) until callus (new bone) has started to
the brain, may underlie the illness. An inherited defect in body chemistry form. Treatment for a march fracture
TREATMENT (see metabolism, inborn errors of) that involves rest and, occasionally, immobi-
Severe illness often needs hospital treat- interferes with the normal breakdown lization of the foot in a plaster cast. (See
ment. Antidepressant drugs and/or ECT of amino acids. Abnormal acids accu- also stress fracture.)
are used to treat depression, and anti- mulate in the blood and urine, giving
psychotic drugs are given to control the urine a characteristic smell of maple Marfan syndrome
manic symptoms. Carbamazepine or lithi- syrup, and causing severe ketoacidosis, A genetic disorder of connective tissue
um may be used to prevent relapse. seizures, and coma. (material that holds body structures
Group therapy, family therapy, and indi- If left untreated, MSUD leads to together) that results in skeletal, heart,
vidual psychotherapy may be useful in learning difficulties and eventually to and eye abnormalities. It is inherited in
certain circumstances. Cognitive–behav- death during infancy. The condition an autosomal dominant manner. Marfan
ioural therapy may also help. can, however, be controlled with a low- syndrome is one of the most common
OUTLOOK protein diet. disorders of connective tissue.
With treatment, most affected people The features of Marfan syndrome
improve or remain stable. Even those marasmus usually appear after the age of 10.
with severe illness may be restored to A severe form of protein and calorie Affected people are very tall and thin.
near-normal health with lithium therapy. malnutrition that usually occurs in They have long, thin limbs, fingers, and
famine or semi-starvation conditions. toes, and weak ligaments and tendons.
manipulation Marasmus is common in young chil- The chest and spine are often deformed
A therapeutic technique involving the dren in developing countries. It causes and the lens of the eye may be dislocat-
use of the hands to move parts of a stunted growth, emaciation, and loose ed. The heart is often abnormal and the
patient’s body in order to treat certain folds of skin on the limbs and buttocks aorta weakened.

488
 MASTECTOMY

features similar to those of Hurler’s syn- muscles; it may be used to relieve mus-
drome, such as coarsening of the facial cle spasm, treat muscle injury, and
features, skeletal deformities, cardiac reduce oedema (accumulation of fluid
abnormalities, and enlargement of the in body tissues). Although massage is
liver and spleen; however, the affected most effective when carried out by
child’s level of intelligence is normal. someone else, self-massage can alleviate
The condition often appears early in pain caused by muscle tension.
childhood. There is no specific treat-
ment, and death from heart failure often masseter
occurs between 20 and 30 years of age. The large muscle in the cheek that
Features of Marfan syndrome stretches between the cheekbone and
One of the characteristic features of Marfan marriage guidance the angle of the lower jaw. The muscle
syndrome is long, thin, “spider” fingers
(arachnodactyly). The condition is apparent when
See relationship counselling. lifts the lower jaw during chewing.
the hand of a person with Marfan syndrome (left)
is compared to that of a normal person. marrow, bone mass hysteria
See bone marrow. Intense emotion and irrational behav-
There is no cure for Marfan syndrome, iour that spreads through a group of
but children are monitored and any marsupialization people in response to a highly exciting
complications are treated as they arise. A surgical procedure carried out to drain or upsetting event. The term may also
Many affected children need glasses. some types of abscess or cyst and to pre- be used to describe the occurrence of
Children may also be given beta-blockers vent further abscesses. It is used to treat identical physical or emotional symp-
to help prevent weakening of the aorta, certain types of cyst affecting the pancreas toms simultaneously in a particular
and those with defects of the heart valve and liver, and cysts affecting the Bartho- group of people, such as children in the
or aorta may undergo corrective surgery. lin’s glands at the entrance to the vagina. same class or school.
If a family has a member with Marfan In marsupialization, the cyst is first
syndrome, tests may be used (see genet- cut open and drained, then its edges are mastalgia
ic counselling) to find out whether or stitched to the surrounding skin or tis- The medical term for pain in the breast.
not relatives will pass on the gene. sue (to form a pouch) so that it is kept
open until it has healed. mast cell
marijuana A type of cell that plays an important
The flowering tops and dried leaves of Marvelon part in allergy. In an allergic response, M
the Indian hemp plant CANNABIS SATIVA, A brand-named oral contraceptive con- antibodies (proteins produced by the
containing the active ingredient THC taining the synthetic female hormones immune system to neutralize an aller-
(tetra-hydrocannabinol). The leaves are ethinylestradiol (an oestrogen drug) and gen) attach themselves to mast cells.The
usually smoked but can also be drunk as desogestrel (a progestogen). cells burst and release a chemical called
tea or eaten in food. histamine, which produces an inflam-
Physical effects of marijuana include masculinization matory response in surrounding tissues,
dry mouth, mild reddening of the eyes, See virilization. thereby causing many of the symptoms
slight clumsiness, and an increased ap- of allergic conditions.
petite. The main subjective feelings are masking
usually of calmness and wellbeing, but A technique used in a hearing test that mastectomy
depression occurs occasionally. involves applying a noise to one ear The surgical removal of all of the breast,
Large doses may cause panic, fear of while testing the hearing of the other. usually performed to treat breast cancer.
death, and delusions. In rare cases, drug The term “masking” may also be Mastectomy may be used if the cancer
psychosis occurs, with symptoms such used in connection with pairs of genes cannot be removed by lumpectomy
as paranoid delusions and confusion, in which the effects of an abnormal (removal of the tumour and a small area
which usually disappear in a few days. gene are concealed by its normal equi- of surrounding tissue) or quadrantec-
There is increasing evidence that regu- valent. (See genetic disorders; inheritance.) tomy (removal of part of the breast)
lar use of marijuana can aggravate mental because of its size or position. Less
health problems, particularly depression masochism commonly, a procedure known as
and schizophrenia, in people with these A desire to be physically, mentally, or subcutaneous mastectomy may be rec-
illnesses. Adolescents are most at risk. In emotionally abused. The term “mas- ommended for women who have a very
addition, regular smoking of marijuana ochism” is primarily used to refer to high risk of developing breast cancer
may cause worse lung damage than that obtaining sexual excitement through because they carry an abnormal gene
caused by tobacco; the effect of three one’s own suffering in activities such as that causes the disease.
joints (marijuana cigarettes) is thought bondage, flagellation, and verbal abuse. HOW IT IS DONE
to be equivalent to 20 tobacco cigarettes. (See also sadism; sadomasochism.) Formerly, a procedure called radical mas-
tectomy was used; this involved removal
Maroteaux–Lamy syndrome massage of the breast together with an extensive
A form of mucopolysaccharidosis caused Rubbing and kneading areas of the area of muscle down to the chest wall.
by a deficiency in levels of the enzyme body, usually with the hands. Massage Today, however, the usual procedure is a
arylsulphatase B. The condition causes increases the blood flow and relaxes total mastectomy.This operation involves

489
 MASTICATION

removal of all of the breast tissue and Mastocytosis usually begins in the first
TYPES OF MASTECTOMY usually some or all of the lymph nodes in year of life and clears up by adolesc-
the armpit. Cells from the nodes are ence. Antihistamine drugs may be helpful
The type of operation depends on
many factors, including the size and
examined to determine whether cancer- in relieving the symptoms.
site of the tumour and the woman’s ous cells have spread. The operation is
wishes. A small tumour may be performed under a general anaesthesia mastoid
treated by lumpectomy; other cases and usually requires a stay in hospital of The lower part of the temporal bone in
may require more extensive surgery. a few days. Plastic surgery to reconstruct the skull. The mastoid has a projection,
the breast may be carried out at the called the mastoid process, which can be
LUMPECTOMY same time as the mastectomy or at a felt behind the ear. The bone is honey-
later date (see mammoplasty). combed with cavities called air cells;
RISKS these spaces are connected to a larger
After the operation, the scar may be cavity called the mastoid antrum, which
tender. If the lymph nodes have been leads into the middle ear.
removed, there is a risk of lymphoedema In some cases, infections of the
developing in the arm. middle ear (see otitis media) spread
through the mastoid bone to cause
mastication acute mastoiditis.
The process of chewing food. The
canines and incisors (front teeth) shear
the food. The tongue then pushes it LOCATION OF MASTOID
Site of incision for a lumpectomy
Only the cancerous tissue (shown here by a between the upper and lower premolars
and molars (back teeth) to be ground The mastoid is the lower part of the
dotted line) and some of the surrounding
temporal bone. The mastoid process
normal tissue is removed. Lumpectomy by movements of the lower jaw. Saliva is can be felt as a hard prominence just
leaves the breast looking relatively normal. mixed with the food to help break it behind the ear.
down for swallowing.
TOTAL MASTECTOMY Mastoid Temporal
mastitis bone bone

Inflammation of breast tissue. Mastitis is

usually caused by bacterial infection
M and sometimes by hormonal changes.
CAUSES
Mastitis usually occurs when bacteria
enter the nipple during breast-feeding. It
can also be caused by changes in levels
of sex hormones in the body – for exam- Mastoid
ple, at the onset of puberty. process
A large, elliptical incision that
1sometimes
encompasses the nipple and
the entire breast, is made.
SYMPTOMS
The condition causes pain, tenderness,
External auditory
meatus (channel
Part of the incision is extended into the for outer ear canal)
and swelling in one or both breasts.
armpit. All of the breast tissue, including Bacterial mastitis during breast-feeding
the skin and some of the fat, is dissected
(separated by cutting) down to the chest also causes redness and engorgement and
muscles. The dissection is continued under may result in a breast abscess. mastoiditis
the skin into the armpit, to free the upper TREATMENT Inflammation of the mastoid, in the skull.
and outer “tail” of breast tissue with its Mastitis due to infection is treated with CAUSE
lymph nodes.
antibiotic drugs and analgesic drugs, and Mastoiditis is due to infection spreading
by expressing milk to relieve engorge- from the middle ear (see otitis media) to
ment. Mastitis caused by hormonal the air cells in the mastoid through a
changes usually clears up in a few cavity called the mastoid antrum.
weeks without treatment. SYMPTOMS
The condition causes earache and severe
mastocytosis pain, swelling, and tenderness behind
An unusual condition in which itchy, the ear. There is usually also fever, a
irregular, yellow or orange-brown swel- creamy discharge from the ear, progres-
lings occur on the skin, most commonly sive hearing loss, and displacement of
on the trunk. Mastocytosis may also the outer ear. If the infection spreads, it
2the Allthen
of the bleeding vessels are tied off,
a drainage tube is inserted and
skin is closed with stitches or clips.
affect body organs, including the liver,
spleen, and intestine, and may cause
may lead to meningitis, a brain abscess,
blood clotting in veins within the brain,
The scar runs diagonally across the chest. symptoms such as diarrhoea, vomiting, or facial palsy.
The woman may wear a prosthesis or may and fainting. Very rarely, it leads to TREATMENT
have an implant inserted later.
anaphylactic shock (a severe form of Treatment is with antibiotic drugs. If the
allergic reaction), which can be fatal. infection persists, an operation called a

490
 MECKEL’S DIVERTICULUM

mastoidectomy may be carried out; in buildup of glycogen and low levels of blotches, and the lymph nodes may be
this procedure, the mastoid is opened glucose in the muscles. Damage to the enlarged. After three days, the rash starts
and the infected air cells removed. muscles occurs, causing myoglobinuria to fade and the symptoms subside.
(the presence of pigment from muscle COMPLICATIONS
masturbation cells in the urine); this condition, in The most common complications are
Sexual self-stimulation, usually to pro- turn, may lead to kidney failure. ear and chest infections, which usually
duce orgasm. Massaging the penis or the There is no treatment, but symptoms develop two to three days after the rash
clitoris with the hand is the usual may be relieved by eating glucose or has appeared. Diarrhoea, vomiting, and
method of masturbation. fructose before exercise. abdominal pain may occur. Febrile con-
vulsions (see convulsion, febrile) are also
maternal mortality MDMA common, but are not usually serious.
The death of a woman during preg- The hallucinogenic substance methyl- In a tiny minority of cases, enceph-
nancy, or within 42 days of childbirth, enedioxymethamfetamine, which has alitis (inflammation of the brain)
miscarriage, or an induced abortion, from the street name Ecstasy. occurs, causing headache, drowsiness,
any pregnancy-related cause. Maternal and vomiting. Seizures and coma may
mortality rate is the number of such ME follow, sometimes leading to brain dam-
deaths per 100,000 live births as mea- The abbreviation for the condition age or even death. In very rare cases, a
sured over a given year. myalgic encephalomyelitis (see chronic progressive brain disorder called sub-
Maternal deaths may be a direct result fatigue syndrome). acute sclerosing panencephalitis develops
of complications of pregnancy or may be several years after infection.
caused indirectly by a medical condi- measles If a woman has measles during preg-
tion that is worsened by pregnancy. The A potentially dangerous viral illness that nancy, the infection may be fatal to the
major direct causes of death include pul- causes fever and a rash. Measles mainly fetus; however, there is no evidence that
monary embolism (blood clots in the affects children, but can occur at any measles causes birth defects.
lungs), antepartum haemorrhage, postpar- age. It is spread primarily by airborne TREATMENT
tum haemorrhage, hypertension (high droplets of nasal secretions. It can be There is no specific treatment. Plenty of
blood pressure), eclampsia (a condition transmitted during the incubation period fluids and paracetamol are given for
causing seizures in late pregnancy), and (eight to 14 days after infection) and up fever. In addition, antibiotic drugs may be
puerperal sepsis (infection following to seven days after symptoms appear. given to treat bacterial infections that
childbirth). Indirect causes include heart SYMPTOMS AND SIGNS occur as complications.
disease, epilepsy, and some cancers. The illness starts with a fever, runny PREVENTION
M
Maternal mortality is lowest for sec- nose, sore eyes, cough, and a general To help prevent measles, immunization
ond pregnancies. After the age of 20, it feeling of being unwell. After three to with the MMR vaccination is recom-
rises with age, being greatest for women four days, a red rash appears, usually mended at between 12 and 15 months
over the age of 40. starting on the head and neck and of age. This measure produces immuni-
spreading to cover the body. The spots ty in about 90 per cent of cases, with a
maturation sometimes join to produce large red booster shot given before a child enters
The process by which full development school or nursery school.
is reached. The term “maturation” is
used with reference to cells (particularly LOCATION OF THE MAXILLA meatus
ova and sperm) and some microorgan- A canal or passageway through part of
The maxillae are a pair of bones that
isms; it may also be used of physical and form the base of the eye sockets, the the body. The term usually refers to the
emotional development in people. centre of the face, the upper jaw, and external auditory meatus, the canal in
the roof of the mouth. the outer ear that leads from the outside
maxilla of the ear to the eardrum.
Each of a pair of bones that together
form the centre of the face, the upper mebendazole
jaw, and the roof of the mouth. In addi- An anthelmintic drug that is used to treat
tion, the top of the maxilla forms the various worm infestations of the intes-
base of the orbit (eye socket). Each bone tine. Possible adverse effects include
contains a large, air-filled cavity called abdominal pain and diarrhoea.
the maxillary sinus (see sinus, facial),
which is connected to the nasal cavity. mebeverine
An antispasmodic drug used to treat irrita-
McArdle’s disease ble bowel syndrome.
A rare genetic disorder characterized by
muscle stiffness and painful cramps that Meckel’s diverticulum
increase during exertion and afterwards. A common abnormality, present at birth
The cause is a deficiency of an enzyme in about 1 in 40 people, in which a
in muscle cells that stimulates break- small, hollow, wide-mouthed sac pro-
Maxilla Mandible
down of the carbohydrate glycogen into trudes from the ileum. Symptoms only
the simple sugar glucose. The result is a occur if the diverticulum becomes

491
 MECONIUM

median nerve medical ethics

One of the main nerves of the arm. The The professional values and guidelines
Meckel’s median nerve is a branch of the brachial that govern medical decisions, particu-
diverticulum plexus and runs down the arm from the larly medical practitioners’ treatment of
shoulder into the hand. It controls the patients and their relatives and of col-
muscles that carry out bending move- leagues. Ethical requirements also play a
ments of the wrist, fingers, and thumb, part in medical research; for example,
and the muscles that rotate the forearm when new drugs or other treatments
palm-inwards. The nerve also conveys are tested on patients, the trials must be
sensations from the thumb and first designed so that they will not cause any
three fingers, and from the region of harm to the patients involved.
the palm at their base.
DISORDERS medical history
Ileum Damage to the nerve may result from See history-taking.
injury to the shoulder, a Colles’ fracture
just above the wrist, or pressure on the medical tests
Anatomy of Meckel’s diverticulum
In this common birth defect, an appendix-type sac nerve where it passes through the wrist See tests, medical.
protrudes from the ileum (the last section of the (carpal tunnel syndrome). Symptoms of
small intestine). damage include numbness and weak- medication
ness in areas controlled by the nerve. Any substance prescribed to treat dis-
infected, obstructed, or ulcerated. The ease. (See also drug; medicine.)
most common symptom is painless mediastinoscopy
bleeding from the rectum; this bleeding Viewing of the mediastinum using an medicine
may be sudden and severe, making endoscope inserted through an incision The study of human diseases and their
immediate blood transfusion necessary. just above the sternum (breastbone). causes, frequency, treatment, and pre-
Inflammation may cause symptoms The procedure is performed under gen- vention. The term “medicine” is also
very similar to those of appendicitis, eral anaesthesia. used of a substance that is prescribed to
such as lower abdominal pain. Meckel’s Mediastinoscopy is used mainly to treat an illness. In some circumstances,
diverticulum occasionally causes in- perform a biopsy of a lymph node, often it is used to refer to treatments that do
tussusception (telescoping) or volvulus in diagnosing lymphoma.The tissue sam- not involve surgery.
M (twisting) of the small intestine. ple is removed by tiny blades attached
Diagnosis of the abnormality may be to the endoscope. medicolegal
made by using technetium radionuclide A term used of matters in which medi-
scanning. If any complications develop, mediastinum cine and the law overlap. Among the
they will be treated by surgical removal The membranous partition between the issues on which medicolegal experts
of the diverticulum. lungs and the other structures within advise people are laws concerning dam-
the chest cavity. These other structures ages for injuries that are due to medical
meconium include the heart and associated blood negligence or malpractice; evidence
The thick, sticky, greenish-black faeces vessels; the trachea (windpipe); the oeso- concerning the extent of injury in a
that is passed by infants in the first day phagus; the thymus gland; lymph nodes; civil action; the use of paternity tests;
or two after birth. Meconium consists lymphatic vessels; and nerves. the mental competence of people who
of bile, mucus, and intestinal cells that have drawn up wills; and restrictions
have been shed. MedicAlert bracelet placed on mentally ill people.
Occasionally, the fetus passes meconi- An item, available from a charitable Medicolegal issues also include an
um into the amniotic fluid while still in organization called the MedicAlert foun- individual’s right to die (see brain death;
the uterus. This problem is more com- dation, that provides vital information euthanasia; living will); the necessity for
mon in those babies who experience about a person’s identity and medical informed consent to any surgical pro-
fetal distress during labour or who are status in case he or she needs urgent cedure; the legal aspects of artificial
over 40 weeks’ gestation. Meconium in medical help. The items are designed to insemination, in vitro fertilization, steriliza-
the amniotic fluid may be inhaled when be worn by individuals with a hidden tion, and surrogacy; and a patient’s right
the baby starts to breathe, sometimes medical condition (such as epilepsy or to confidentiality concerning his or her
blocking the airways and damaging diabetes mellitus) or a serious allergy illness. (For the medical aspects of
the lungs. In some babies with cystic (such as penicillin allergy). criminal law, see forensic medicine.)
fibrosis, the meconium is so thick and MedicAlert bracelets, and necklaces,
sticky that it blocks the intestine (see are engraved with an emblem that is meditation
intestine, obstruction of). instantly recognizable to medical work- Concentration on an object, a word, or
ers and carries details of important an idea with the aim of inducing an
medial medical conditions affecting the wearer. altered state of consciousness. At its
A medical term that means “situated They also carry a personal identification deepest level, meditation can resemble a
towards the midline of the body”. Less number and a 24-hour telephone num- trance. More commonly, it is a calming
commonly, the term refers to the mid- ber so that further medical details can therapy and can be a way to reduce
dle layer of a body structure. be accessed anywhere in the world. stress levels and treat stress-related dis-

492
 MEDULLOBLASTOMA

orders. A common form of meditation

LANDMARKS IN MEDICINE: DIAGNOSIS practised in Europe and North America
Date Development is transcendental meditation (TM).
Mediterranean diet
c.400 BC Disease concept Introduced by the Greek physician Hippocrates. A diet based on the traditional foods
eaten in Mediterranean countries, where
1612 Medical thermometer Devised by the Italian physician Sanctorius. people have a lower risk of cardiovascu-
lar disease and cancer than people in
northern European countries. The bulk
c.1660 Light microscope Single-lens microscope developed by the Dutch naturalist
Antonj van Leeuwenhoek, who discovered microorganisms with it. A practicable
of the diet consists of fruit, vegetables,
compound microscope was not developed until the 19th century. and grain-based foods such as pasta and
couscous. The major source of fat is
olive oil, a monounsaturated fat (see fats
1810 Stethoscope Invented by the French physician René Laennec. and oils). The diet also includes fish, but
only small amounts of meat, poultry,
1850–1900 Germ theory of disease Proposed by the French scientist Louis Pasteur and eggs, and dairy products.
developed by the German bacteriologist Robert Koch.
Mediterranean fever
1851 Ophthalmoscope Invented by the German scientist Herman von Helmholtz.
See brucellosis.
Mediterranean fever, familial
1895 X-rays Discovered by the German physicist Wilhelm Roentgen. He also produced See familial Mediterranean fever.
the first X-ray picture of the body.
medroxyprogesterone
1906 Electrocardiograph (ECG) Invented by the Dutch physiologist Willem Einthoven. A progestogen drug used to treat endo-
metriosis (a condition in which fragments
of uterine lining are found in the pelvic
c.1932 Transmission electron microscope (TEM) Constructed by the German
scientists Max Knoll and Ernst Ruska.
cavity), as well as certain types of breast
cancer and uterine cancer (see uterus,
cancer of). In addition, it is sometimes M
1938 Cardiac catheterization First performed by George Peter Robb and Israel used to treat menstrual disorders such
Steinberg in New York. as amenorrhoea (absence of menstrua-
tion). The drug can also be used as a
1957 Fibre-optic endoscopy Pioneered by the South African-born doctor Basil contraceptive, given by injection at
Hirschowitz at the University of Michigan. three-month intervals (see contraception,
hormonal methods of). Possible adverse
1972 CT scanner Invented by the British engineer Godfrey Hounsfield of EMI
effects include weight gain, swollen
Laboratories, England, and the South African-born physicist Alan Cormack of Tufts ankles, and breast tenderness.
University, Massachusetts.
medulla
The innermost part of a body structure;
1975 Monoclonal antibodies Large-scale production method for monoclonal
antibodies developed by the Argentinian-born scientist César Milstein at the for example, the adrenal medulla is the
Medical Research Council Laboratories, England. central area of an adrenal gland. In addi-
tion, the word “medulla” is sometimes
used to refer to the medulla oblongata.
1976 Chorionic villus sampling Developed by Chinese gynaecologists as an aid to
the early diagnosis of genetic disorders.
medulla oblongata
Also called the medulla, the lowest part
1981 MRI scanner Developed by scientists at Thorn-EMI Laboratories and of the brainstem. The medulla oblongata
Nottingham University, England. lies at the base of the skull. It connects
the brain to the spinal cord.
1985 Polymerase chain reaction Rapid copying of DNA sequences developed by Kary
Mullis of the Cetus Corporation, California. medulloblastoma
A type of cancerous brain tumour that
1995 Genetics Chromosome sequence of first nonviral organism, Haemophilus
occurs mainly in children. A medullo-
influenzae, identified. blastoma usually arises from the cere-
bellum, the region of the brain that is
concerned with posture, balance, and
2003 Human Genome Completion of the Human Genome Project by the International coordination. The tumour grows rapid-
Human Genome International Consortium, following first draft produced in 2001.
ly and may spread to other parts of the
brain and also to the spinal cord. A

493
 MEFENAMIC ACID

morning headache, repeated vomiting,

LANDMARKS IN MEDICINE: SURGERY and a clumsy gait develop. There are
Date Development also frequent falls.
The tumour is diagnosed by CT scan-
1545 Basic surgical principles Established by the French surgeon Ambroise Paré. ning or MRI and can often be treated
with radiotherapy. Surgery and anticancer
1842 General anaesthesia First operation using general anaesthesia performed by drugs may also be needed.
the American surgeon Crawford Long, who used ether. In 1845, the American
dentist Horace Wells used nitrous oxide (laughing gas) as an anaesthetic. In 1847, mefenamic acid
the British obstetrician James Simpson introduced chloroform anaesthesia.
An NSAID (see nonsteroidal anti-inflam-
1870 Antiseptic surgery Pioneered by the British surgeon Joseph Lister, who used a matory drugs) used to relieve pain and
carbolic acid (phenol) spray during surgery to help prevent infection. inflammation. Mefenamic acid may be
given for conditions such as headache,
1901 Blood groups ABO blood groups discovered by the Austrian pathologist Karl toothache, and dysmenorrhoea (painful
Landsteiner, so establishing the basis for safe transfusions.
menstrual periods), and to reduce men-
orrhagia (excessive menstrual bleeding).
1951 Coronary artery bypass graft First attempted by the Canadian surgeon Arthur
Vineberg at the Royal Victoria Hospital, Montreal. It may also be prescribed for long-term
relief of joint pain and stiffness in
1955 Kidney transplant First successful kidney transplant (between identical twins) osteoarthritis and rheumatoid arthritis.
performed by a team of American surgeons, led by Joseph Murray, of the Harvard Possible adverse effects are typical for
Medical School, Massachusetts. NSAIDs; they include abdominal pain,
indigestion, nausea, and vomiting.
1967 Heart transplant First human heart transplant performed by the South African
surgeon Christian Barnaard at the Groote Schur Hospital, Cape Town.
mefloquine
1976 Coronary angioplasty Introduced by the Swiss surgeon Andreas Grüntzig at the A drug used to prevent and treat malaria
University Hospital, Zurich. in parts of the world where the parasite
that causes it is resistant to chloroquine.
1987 Minimally invasive surgery The first cholecystectomy (gallbladder removal) Mefloquine is one of the preferred treat-
using laparoscopic techniques under video control performed by the French doctor
P. Mouret, in Lyon.
ments for falciparum malaria.
Side effects include nausea, vomiting,
M 1998 Robotic surgery First coronary artery bypass surgery using a robot performed by and diarrhoea. Rarely, there may be
a team under Professor Friedrich-Wilhelm Mohr, at Leipzig Heart Centre, Germany. panic attacks, hallucinations, and psycho-
sis. Mefloquine is not recommended for
people who have a history of disorders
such as depression or epilepsy.
LANDMARKS IN MEDICINE: OTHER TREATMENTS mega-
Date Development A prefix meaning “very large”, as in
megacolon, a condition in which the
c.1270 Glasses Thought to have been invented in Italy. Contact lenses were invented in colon is greatly enlarged. The prefix
1887 by the Swiss optician Eugen Frick. “megalo-” has the same meaning.
1817 Dental plate Introduced by the American dentist Anthony Plantson. megacolon
A gross distension (enlargement) of the
1891 Baby incubator Introduced by the French doctor Alexandre Lion.
colon, usually accompanied by severe,
1901 Hearing-aid (electric) Developed by the American inventor Miller Reese
chronic constipation.
Hutchinson. The first truly miniature hearing-aid was introduced in 1952 by the CAUSES
Sonotone Corporation. In children, the main causes of mega-
colon are anal fissures, Hirschsprung’s
1945 Kidney dialysis machine Developed by the Dutch surgeon Willem Kolff. disease, and psychological factors that
may have arisen during toilet-training.
1978 “Test-tube baby” Louise Brown, the first baby resulting from in-vitro fertilization, In elderly people, causes include the
was born in the UK. The IVF techniques were developed by the British
gynaecologist Patrick Steptoe and the embryologist Robert Edwards. long-term use of strong laxative drugs.
People suffering from chronic depression
1979 Shock-wave lithotripsy Pioneered by researchers at the University Hospital, or schizophrenia often have megacolon.
Munich, Germany. Other, rarer causes include hypothy-
roidism, spinal injury, and the use of
1990 Gene therapy First attempted at the US National Institute of Health, by doctors drugs such as morphine and codeine.
W. French Anderson, Michael Blaese, and Kenneth W. Culver, to treat a four-year- SYMPTOMS
old girl with a form of Severe Combined Immunodeficiency (SCID). Gene therapy
has since had some success, but to date it is still at an experimental stage. Megacolon causes constipation and ab-
dominal bloating. Some affected indivi-
duals experience loss of appetite, which

494
 MEIG’S SYNDROME

cause of megaureter is a long-standing

LANDMARKS IN MEDICINE: DRUGS blockage in the ureter that stops the
Date Development flow of urine. Another is backward flow
of urine from the bladder into the ure-
1666 Quinine The British physician Thomas Sydenham popularized the use of Jesuits’ ters while the bladder is being emptied
bark (containing quinine) for treating malaria. (see vesicoureteric reflux). In some cases,
the condition is congenital (present at
1785 Digitalis The use of digitalis to treat heart failure described by the British birth) and has no known cause.
physician William Withering. Megaureter is treated by surgery to
remove blockages or to relieve reflux.
1796 Smallpox vaccination The first vaccination to be performed, by the British
physician Edward Jenner. The first true vaccine (consisting of weakened megestrol
microorganisms), against chicken cholera, was developed in 1880 by the French
scientist Louis Pasteur. A progestogen drug that is used to treat
uterine cancer (see uterus, cancer of) and
1805 Morphine Extracted from opium and used to relieve pain, by the German
certain types of breast cancer. Megestrol
pharmacist Friedrich Sertürner. may be prescribed when a tumour is
inoperable, if a tumour has recurred
1911 Salvarsan Introduced by the German bacteriologist Paul Ehrlich to treat syphilis.
after surgery, or when other anticancer
drugs or radiotherapy prove ineffective.
Possible adverse effects of the drug
1928 Penicillin Antibacterial action first recognized by the British bacteriologist
Alexander Fleming. Produced as a drug in 1940, by the Australian-born British include swollen ankles, weight gain,
pathologist Howard Florey and the German-born British biochemist Ernst Chain. nausea, dizziness, headache, rash, and,
rarely, raised blood calcium levels.
1935 Sulphonamides Antibacterial action discovered by the German pharmacologist
Gerhard Domagk. meibomian cyst
See chalazion.
1951 Oral contraceptive Developed by the American doctors Gregory Pincus and John
Rock, and the Austrian-born American chemist Carl Djerassi. meibomian gland
A small sebaceous (oil-secreting) gland
situated under the conjunctiva (membra-
1959 Librium (chlordiazepoxide) The first benzodiazepine minor tranquillizer,
introduced by the Swiss pharmaceutical company Hoffmann-LaRoche. nous lining) of each eyelid. If one of M
the glands becomes blocked, it enlarges
1962 Nethalide (pronethalol) The first beta-blocker heart drug, developed by to create a swelling within the lid,
scientists at Imperial Chemical Industries, England. which is known as a chalazion.

1984 Genetically engineered human insulin Developed by scientists at Genentech, meibomianitis

California. Inflammation of the meibomian glands,
the sebaceous (oil-secreting) glands
1986 Zidovudine (originally called AZT) Introduced to treat AIDS after development by within the eyelids. The condition is
scientists at Burroughs Wellcome Research Laboratories, North Carolina. caused by excessive or unusually thick
glandular secretions, which result in an
1998 Viagra (sildenafil) Introduced as a treatment for erectile dysfunction after overgrowth of bacteria on the eyelids.
development by the Pfizer Corporation, US. Conditions that can increase the secre-
tions include skin disorders affecting
the face (such as acne or rosacea), aller-
may lead to weight loss. Diarrhoea may megalomania gic reactions, and the hormonal changes
occur if semi-liquid faeces leak around An exaggerated sense of one’s importance that occur in adolescence.
the obstructing hard faeces. or ability that often occurs in mania. Mega- Symptoms of meibomianitis include
DIAGNOSIS AND TREATMENT lomania may take the form of a delusion of swelling of the eyelid edges, brief blur-
The diagnosis is made by proctoscopy grandeur, or may manifest itself as a desire ring of the vision due to oily tears, and
(viewing of the rectum with an endo- to organize large-scale activities that are frequent styes. Careful cleansing of the
scope), barium X-ray examination, and expensive and involve many people. eyelids may relieve the symptoms.
tests to assess the functioning of the Antibiotic eye ointment may be pre-
intestinal muscles. If Hirschsprung’s dis- -megaly scribed to clear up infection.
ease is suspected, biopsy of the large A suffix meaning “enlargement”, as in
intestine may be performed. acromegaly, a disorder in which the jaw, Meig’s syndrome
Impacted faeces are often removed skull, hands, and feet are enlarged. A rare condition in which a tumour of
using enemas. In severe cases, the faeces an ovary is accompanied by ascites (an
must be removed manually. megaureter accumulation of fluid in the abdomen)
Gross distension (widening) of a ureter, and a pleural effusion (fluid around one
megaloblastic anaemia the tube that carries urine from each of the lungs). The fluid usually disap-
See anaemia, megaloblastic. kidney to the bladder. One possible pears when the tumour is removed.

495
 MEIOSIS

meiosis
A type of cell division that occurs in the MECHANISM OF MEIOSIS
ovaries and testes during the production
In meiosis, a cell in the testis or ovary containing 46 chromosomes divides to form
of egg and sperm cells. During meiosis
four germ cells (sperm or eggs), each with 23 chromosomes. Germ cells have only
in humans, a cell containing 23 pairs of half the usual chromosome content because a child can receive only half the genes
chromosomes (46 in total) divides to of each parent.
form four sperm or egg cells, each with
23 single chromosomes. Original Key The 46 chromosomes in the original cell
First, each chromosome is duplicated cell
Maternal 1chromosomes
duplicate themselves, then the doubled
form 23 pairs. (Only 10 pairs
(making a total of 92); the doubled chromosomes
chromosomes are joined at a point are shown in this box.) There is an exchange
Paternal of genetic material between the members in
called the centromere. Matching pairs chromosomes each pair, so that each of the germ cells will
of doubled chromosomes line up and receive a unique mix of the parental genes.
exchange genetic material. The cell then
divides twice to form four daughter
cells, with each taking one copy of each
chromosome.
Egg and sperm cells therefore have 23
single chromosomes, which is only half
the usual chromosome content of a
body cell, so each parent contributes
half of the offspring’s genetic material. Exchange occurs
The exchange between chromosomes between pair
members.
means that each daughter cell has a uni-
que genetic make-up. (See also mitosis). The chromosomes
first double up,
then they form
melaena into pairs.
Black, tarry faeces caused by bleeding,
usually in the upper gastrointestinal
M tract. The blood is blackened by the 2pairAfter exchange, the cell divides, the
two members of each chromosome
going into separate daughter cells.
action of secretions during digestion.
Melaena is usually caused by a peptic First
division
ulcer but may indicate cancer.

melancholia
Former term for depression.
melanin
The brown or black pigment that gives Each cell now has one
skin, hair, and the iris of the eyes their doubled-up chromosome
colouring. Melanin is produced by cells from each of the pairs.
called melanocytes. Second division
Exposure to sunlight increases the
production of melanin, which protects
3cells.Each daughter cell now
divides into two germ
The doubled-up
the skin from the harmful effects of chromosomes are pulled
ultraviolet rays and causes the skin to apart so that each germ cell
darken. Localized overproduction of receives a single copy of
each chromosome.
melanin in the skin can result in a pig-
mented spot, most commonly a freckle
or mole (see naevus).
melanocyte
A specialized skin cell that produces the
pigment melanin. The cells can be dam-
aged by overexposure to the sun; this
damage may result in skin cancer (see
melanoma, malignant).

melanoma, juvenile Separate germ cells

receive chromosomes
A raised, reddish-brown skin blemish, containing different Germ cells (sperm or eggs)
genetic mixes.
also called a Spitz naevus, which some-
times appears on the face or legs in

496
 MEMORY

early childhood (see naevus). Despite Diagnosis is by a skin biopsy, in which ovary, cancer of). Possible adverse effects
the name, it is noncancerous. Although tissue from the growth, together with include nausea, vomiting, sore throat,
it is harmless, an unsightly growth, or some of the surrounding skin, is loss of appetite, reduced numbers of red
one that is suspected of being skin can- removed for microscopic examination. and other blood cells (see anaemia,
cer, may be removed surgically. Samples from nearby lymph nodes may aplastic), abnormal bleeding, and in-
also be examined; the presence of any creased susceptibility to infection.
melanoma, malignant cancerous cells in these samples would
The most serious of the three types of indicate that the cancer has spread. membrane
skin cancer. (The other two forms of the The melanoma will be removed surgi- A layer of tissue that covers or lines a
disorder are basal cell carcinoma and cally. If the cancer has spread from the body surface or forms a barrier.
squamous cell carcinoma.) If left untreat- primary site, radiotherapy or anticancer drugs
ed, the cancer may be fatal. may also be necessary. Immunotherapy may memory
CAUSE AND INCIDENCE be used to help the body fight the cancer; The ability to remember. Memory is
Malignant melanoma is a tumour of this treatment involves the use of sub- usually regarded as comprising three
melanocytes, the cells that produce the stances such as interferon or interleukin-2. stages: registration, retention, and recall.
pigment melanin, and is due to long- In registration, information is perceived,
term exposure to strong sunlight. It is melanonychia is understood, and is then held in the
most common in middle-aged and Black or dark coloration of a fingernail short-term memory. In retention, more
elderly people with pale skin and fair or toenail, due to an excess of the pig- important information is transferred
hair who have spent many years in ment melanin. The colour often forms a into the long-term memory and stored.
sunny climates. Severe sunburn during vertical streak down the nail. Recall involves bringing information
childhood doubles the risk of develop- Melanonychia is a normal occurrence into the conscious mind at will. There
ing melanoma in later life. in some black and Asian people. In are a number of factors that determine
There is an increasing number of white people, it may be due to a naevus how well information is remembered,
new cases and deaths in the UK each (pigmented blemish) beneath the nail; including its familiarity and how much
year from this skin cancer, probably due melanoma (see melanoma, malignant); a attention has been paid to it.
to people sunbathing and taking holi- reaction to a drug; or HIV infection. Where in the brain the memory
days in sunny countries. process takes place is not known. How-
SYMPTOMS melanosis coli ever, the temporal lobe and limbic system
Tumours usually develop on areas of ex- Black or brown discoloration of the may be involved. The mechanisms for
posed skin but may occur anywhere on colon lining. Melanosis coli is associated storing memory are also unknown. M
the body, including in the eye. A mela- with chronic constipation and prolonged
noma usually grows from an existing use of certain laxative drugs, such as
mole. An affected mole may change senna, rhubarb, and cascara. THE STAGES OF MEMORY
colour, increase in size, or develop an The discoloration is most common in
irregular edge. Other signs include a elderly people and is usually symptom- Stage 1: Registration
mole becoming lumpy, bleeding or less. It clears up when the laxatives are Information is perceived and understood,
crusting, forming a scab, or becoming no longer used. Rarely, it is associated then held in a short-term memory system.
This system seems to be very limited in
itchy or inflamed. Such changes should with colon cancer (see colon, cancer of). the amount of material that it can store at
be reported to a doctor. Occasionally, a one time. Unless refreshed by constant
melanoma develops in normal skin. If melasma repetition, the contents of short-term
left untreated, the cancer can grow down See chloasma. memory are lost within minutes, to be
replaced by other material.
through the layers of skin and rapidly
spread to other parts of the body. melatonin
DIAGNOSIS AND TREATMENT A hormone secreted by the pineal gland in
Early diagnosis is vital to help prevent the brain that is thought to play a part in Stage 2: Retention
life-threatening spread of the cancer. controlling daily body rhythms and regu- If information is sufficiently important, it
lating the sleep–wake cycle. Levels of is transferred into long-term memory for
storage. The process of storage involves
melatonin rise in response to decreasing association of the information with
light, preparing the body for sleep. Some certain words or meanings, with visual
people believe that taking supplements of imagery evoked by it, or with other
melatonin can help to minimize the effects experiences, such as smell or sound.
of jet-lag, but this has not been proved.
Melleril Stage 3: Recall
A brand name for the antipsychotic Information that has been stored at
drug thioridazine. an unconscious level, in long-term
memory, is brought into the conscious
mind by an act of will. The reliability of
Development of malignant melanoma melphalan the recall process depends on how well
Only one mole in a million becomes malignant.
However, change of shape, darkening, tenderness,
An anticancer drug used to treat multiple the information was encoded in stage 2.
pain, itching, or ulceration are warning signs of a myeloma as well as certain types of
malignant melanoma. breast cancer and ovarian cancer (see

497
 MEMORY B-CELL

DISORDERS during reproduction the genes in each meninges

Most memory disturbances are due to pair separate, with only one allele (gene The three membranes that cover and
failure at the retention or recall stage from a pair) being carried in a gamete protect the brain and the spinal cord.
(see amnesia). In some cases, the prob- (egg or sperm cell) and passed on to an The outermost membrane, the dura
lem occurs at the registration stage. offspring (see meiosis). Mendel’s second mater, is tough and fibrous; it lines the
Some people with temporal lobe epilepsy law, or the law of independent assort- inside of the skull and forms a loose
have uncontrollable flashbacks of dis- ment, states that each gene in a pair can sheath around the spinal cord. The
tant past events. The most common be combined with either of the genes middle membrane, the arachnoid mater,
memory disorder is the normal diffi- from any other pair, so that gametes can is elastic and weblike. The innermost
culty in recall that develops with age. show all possible combinations of non- membrane, the pia mater, lies next to
More severe loss of memory may be an paired genes. the surface of the brain.
early symptom of dementia. The pia mater is separated from the
Mendelson’s syndrome arachnoid mater by the subarachnoid
memory B-cell Inhalation of regurgitated stomach con- space, which contains cerebrospinal fluid.
A type of white blood cell, also known as tents by someone who is under general Another space, called the subdural
a memory B-lymphocyte (see lympho- anaesthesia; also called pulmonary acid space, separates the arachnoid mater
cyte), that is involved in the immune aspiration syndrome. Stomach acid can from the dura mater.
system response to invading bacteria. damage the mucous membranes lining
Memory B-cells recognize bacteria that the airways; it can also cause broncho- meningioma
the body has previously encountered. spasm (sudden constriction of the A rare, noncancerous tumour of the
They promptly produce huge quantities airways leading to each lung), and pul- meninges (the membranes surrounding
of antibodies that inactivate the bacteria, monary oedema (a buildup of fluid in the brain). A meningioma arises from
thus preventing or shortening the organ- the lungs). Breathing may be severely the arachnoid mater (the middle mem-
isms’ effects. (See also memory T-cell.) impaired and the person may die. brane) and, in most cases, it then
The problem is particularly associated becomes attached to the dura mater
memory, loss of with general anaesthesia for emergency (the outer membrane).
See amnesia. obstetric procedures during labour. It can The meningioma slowly expands and
be prevented by giving drugs to inhibit may become very large before any
memory T-cell stomach acid secretion before operating. symptoms appear. The symptoms may
A type of white blood cell, also known include headache, vomiting, and im-
M as a memory T-lymphocyte (see lympho- Ménière’s disease paired mental function. There may also
cyte), that is involved in the immune An inner ear disorder characterized by be speech loss or visual disturbance. If
system response to viruses, parasites, recurrent vertigo (a spinning sensation), the tumour invades the overlying skull
and cancer cells. Memory T-cells recog- deafness, and tinnitus (ringing in the ears). bone, there may be thickening and
nize viruses, parasites, or cancer cells It is uncommon before the age of 40. bulging of the skull.
that the body has previously encoun- CAUSE
tered. Some belong to the class of killer The cause of the disorder is an accumu-
T-cells, which attach themselves to lation of fluid in the labyrinth. The
infected cells and then release toxic pro- buildup may damage the labyrinth and
teins to destroy the cells. (See also sometimes the adjacent cochlea.
memory B-cell.) SYMPTOMS
There is a sudden attack of vertigo, last-
menarche ing from a few minutes to several
The onset of menstruation. Menarche hours. This is usually accompanied by
usually occurs around the age of 12 or nausea, vomiting, nystagmus (abnormal
13, two years after puberty starts. jerky eye movements), and deafness,
tinnitus, and a feeling of pressure or Eardrum
Mendelian inheritance pain in the affected ear. Ossicles
A form of inheritance first described by DIAGNOSIS AND TREATMENT
the Austrian monk Gregor Mendel. He Diagnosis is usually made with audiom- Excess fluid in
discovered that certain distinct, un- etry (see hearing tests) or other hearing inner ear
changing physical characteristics are tests, and a caloric test.
controlled by factors that are now called Treatment with certain antihistamine Cochlea
genes, which are transmitted through drugs, such as cinnarizine, or with beta-
many generations. He also revealed the histine usually relieves the symptoms.
existence of dominant and recessive Prochlorperazine may be given, either
genetic characteristics. rectally or by injection, for severe
Mendel formulated two laws con- attacks. Ménière’s disease can also be
Eustachian tube
cerning inheritance. Mendel’s first law, treated by surgery to the inner ear if
The cause of Ménière’s disease
or the law of segregation, states that the symptoms are not controlled by drugs. This condition is caused by excessive fluid in the
characteristics of an organism are deter- If deafness eventually becomes total, the labyrinth and cochlea, in the inner ear. These
mined by pairs of genes, and that other symptoms usually disappear. structures may become damaged as a result.

498
 MENISCUS

consciousness. In about half the cases of meningococcal meningitis

ANATOMY OF THE MENINGES meningococcal meningitis, there is also One of the most common forms of bac-
meningococcaemia (a potentially life- terial meningitis. Most cases occur in
The pia mater lies on the brain. It is
separated from the arachnoid mater threatening condition in which bacteria children or young adults. The disease is
by the subarachnoid space. The multiply rapidly in the blood). This transmitted by exhaled droplets; it can
outermost membrane, the dura condition causes a reddish-purple rash spread rapidly through groups of peo-
mater, lines the inside of the skull. under the skin, which does not fade ple who are in close contact with each
with pressure (see glass test). The rash other, such as children in boarding
Scalp Skull Subdural space Dura starts as pin-prick spots that can expand schools. If not treated promptly, it may
mater
to give a bruiselike appearance. progress to the life-threatening disorder
DIAGNOSIS AND TREATMENT meningococcaemia.
To make a diagnosis, a lumbar puncture is
performed to remove a small sample of meningococcal rash
cerebrospinal fluid. A rash that occurs in about half of all cases
Viral meningitis needs no treatment of meningococcal meningitis and meningo-
and usually clears up in a week or two coccal septicaemia. The rash arises as
with no after-effects. Bacterial meningitis pin-prick spots beneath the skin that join
is a medical emergency. It is treated with together to give the appearance of a bruise
intravenous antibiotic drugs. With prompt (see purpura). The rash associated with
Brain treatment, a full recovery is usually made; meningococcal infection does not fade
the earlier treatment is given, the better when pressure is applied (see glass test).
the outlook. In some cases, however,
Subarachnoid
space deafness or brain damage may occur, or meningoencephalitis
Arachnoid the person may lose an area of skin, or Inflammation of the brain and the men-
Pia
mater fingers or toes, as a result of the rash. inges (the membranes surrounding the
PREVENTION brain), usually as a result of a viral
Vaccines are now given to protect chil- infection. See encephalitis.
dren and teenagers against two of the
major types of bacterial meningitis: meningomyelocele
those caused by HAEMOPHILUS INFLUENZAE and Another name for myelomeningocele.
Meningiomas can be detected by X-ray or by MENINGOCOCCUS type C (see immuniza- M
CT scanning, or by MRI. The tumours can tion). Antibiotic drugs may be given as a meniscectomy
often be completely removed by surgery. protective measure to people who have A surgical procedure in which all or
Otherwise, treatment is by radiotherapy. come into contact with these infections. part of a damaged meniscus (cartilage
Immunization against some forms of disc) is removed from a joint, almost
meningitis meningitis is recommended for Mus- always from the knee.
Inflammation of the meninges (memb- lims travelling to Saudi Arabia for the WHY IT IS DONE
ranes covering the brain and spinal Hajj and Umrah pilgrimages, and for Meniscectomy may be performed when
cord), usually due to infection. people travelling to Nepal and some damage to the meniscus causes the knee
CAUSES parts of sub-Saharan Africa. to lock or to give way repeatedly. It cures
Viral meningitis tends to occur in epi- these symptoms and reduces the risk of
demics in winter; it is usually relatively meningocele premature osteoarthritis in the joint.
mild. Bacterial meningitis, however, is A protrusion of the spinal cord’s men- HOW IT IS DONE
life-threatening. It is mainly caused by inges (protective coverings) under the Arthroscopy (in which a viewing instru-
HAEMOPHILUS INFLUENZAE, STREPTOCOCCUS PNEU- skin. It is caused by a congenital defect ment is inserted into the joint through a
MONIAE, or M ENINGOCOCCUS types B and C. in the spine (see spina bifida). small incision) may be carried out to
The infection usually reaches the confirm and locate the damage. The
meninges via the bloodstream from an meningococcaemia damaged area may then be removed by
infection elsewhere in the body, often An acute, life-threatening infection of the instruments passed through the arthro-
in the nose or throat. Less commonly, it bloodstream caused by MENINGOCOCCUS scope. Alternatively, the meniscus may
passes through skull cavities from an bacteria; also called meningococcal sep- be removed through an incision at the
infected ear or sinus, or from the air fol- ticaemia. It may occur with uncontrolled side of the patella (kneecap).
lowing a skull fracture. meningococcal meningitis and produces OUTLOOK
SYMPTOMS the characteristic, reddish-purple rash In either case, there may be an increased
The main symptoms are fever, severe often seen in this condition. risk of osteoarthritis in later life, but
headache, nausea and vomiting, dislike Meningococcaemia can cause shock; this is less than if the damaged menis-
of light, and a stiff neck. In viral menin- kidney failure; and the loss of areas of cus had been left in place.
gitis, the symptoms are mild and may skin, or fingers and toes, due to blood
resemble influenza. In bacterial menin- vessel damage. It can be fatal. Affected meniscus
gitis, the main symptoms may develop people need to be admitted to hospital A crescent-shaped disc of cartilaginous
over only a few hours, followed by immediately. Treatment is with antibiotic tissue found in several joints. The knee
drowsiness and, occasionally, loss of drugs followed by intensive care. joint has two menisci, and the wrist

499
 MENOPAUSE

urethra also become thinner, which can certain types of male and female infertil-
MENISCI cause a feeling of needing to urinate ity, asit prepares the ovary for ovulation
frequently. In addition, the breasts tend and may help stimulate sperm produc-
The diagram (right) to decrease in size. Some women expe- tion. It is used along with human
shows the sites of the
rience psychological symptoms, such as chorionic gonadotrophin (see gonado-
menisci. The menisci of
the knee are shown in poor concentration, tearfulness, loss of trophin, human chorionic).
detail below. interest in sex, and depression. In women, menotrophin may cause
Changes in metabolism occur during multiple pregnancy, abdominal pain,
the menopause but they may not cause bloating, and weight gain. In men, it
symptoms until later. In all women, the may cause enlargement of the breasts.
bones become thinner; this process
happens most rapidly in the years menses
immediately after the menopause. The Another name for a menstrual period.
loss of bone density may result in osteo- The word “menses” may also mean the
porosis. The risk of heart disease also blood, tissue, and fluid that is dis-
increases, gradually approaching that charged from the uterus during a
for men of a similar age, due to the menstrual period (see menstruation).
drastic reduction in oestrogen hor-
mones (which protect premenopausal menstruation
women against heart disease). The periodic shedding of endometrium
TREATMENT (the lining of the uterus), accompanied
Women going through the menopause by bleeding, that takes place in women
Femur Lateral Medial can protect themselves from losing bone who are not pregnant. Menstruation
meniscus meniscus
density by regularly taking weight- usually begins at puberty and continues
bearing exercise, such as walking, and until the menopause.
by eating foods that are rich in calcium, The loss of the endometrium occurs
joints, and the temporomandibular joints such as dairy products and green, leafy at the end of the menstrual cycle, which
of the jaw, have one meniscus each. The vegetables. Measures such as avoiding usually lasts for 28 days (with the nor-
menisci are held in position by liga- fatty foods, stopping smoking, and lim- mal range being between 21 and 35
ments and help to reduce friction iting alcohol intake can help to protect days). At the beginning of the cycle, a
M during joint movement. women against heart disease. hormone from the pituitary gland,
Hormone replacement therapy (HRT) may known as follicle-stimulating hormone
menopause relieve menopausal symptoms and re- (FSH), prompts several follicles (collec-
The cessation of ovulation (egg produc- duce the risk of fractures associated with tions of cells containing eggs) within
tion) and of menstruation (discharge of osteoporosis. However, it is not usually the ovaries to mature. The egg follicles
blood and tissue from the uterus). This recommended as the first line of treat- secrete oestrogen hormones, which cause
process usually occurs between the ages ment because it may increase the risk of the endometrium to thicken.
of 45 and 55, the average age being 52 abnormal blood clotting and is associa- Ovulation (the release of a mature egg
years. The term “menopause” usually ted with an increased risk of breast cancer. from a follicle) usually occurs in the
refers to a period of physical and psy- middle of the cycle. The empty follicle
chological changes that occur as a result menorrhagia (called the corpus luteum) produces
of reduced oestrogen production. Excessive loss of blood during menstru- progesterone hormone. This hormone
The menopause usually occurs grad- ation. Menorrhagia may be caused by an causes the endometrium to retain fluid
ually; it is signalled by a change in imbalance of oestrogen hormones and and grow thicker, so that a fertilized egg
menstrual patterns (see perimenopause) progesterone hormone, which control can implant in the tissue. If pregnancy
followed by amenorrhoea (the cessation menstruation. The imbalance leads to an does not occur, production of oestro-
of menstrual periods). It can also be excessive buildup of endometrium (the gens and progesterone diminishes. The
brought on by medical procedures that uterine lining). Disorders affecting the endometrium is shed about 14 days after
halt the activity of the ovaries, such as uterus, such as fibroids, polyps, or a pel- ovulation. Uterine contractions force the
oophorectomy (surgical removal of the vic infection, can also cause menorrhagia. tissue, together with fluid and blood, to
ovaries), radiotherapy, or chemotherapy. Treatment may include nonsteroidal be expelled via the vagina; this process
In a few women, the menopause may anti-inflammatory drugs, drugs that affect lasts for one to eight days.
occur abnormally early, usually before blood clotting, hormones, or the fitting
age 40 (see premature menopause). of an IUD (intrauterine device) that menstruation, anovular
SYMPTOMS releases small amounts of progestogen. The occurrence of a menstrual period
Some women have few difficulties with Menorrhagia may also be treated by when ovulation (the release of an egg
the menopause. Other women may have endometrial ablation. from an ovary) has not occurred (see
symptoms including hot flushes and menstruation). Anovular menstruation is
night sweats; vaginal dryness caused by menotrophin common in girls who have just started
thinning of the vaginal lining; and a A gonadotrophin hormone given as a drug to menstruate, and in women who are
decrease in vaginal secretions. The tis- to stimulate cell activity in the ovaries approaching the menopause. It may
sues in the neck of the bladder and the and testes. It is used as a treatment for produce irregular menstrual cycles.

500
 MENTAL RETARDATION

THE MENSTRUAL CYCLE

During menstruation, the endometrium (the lining of the them to release a mature egg. The empty follicle produces
uterus) is shed. Following menstruation, a pituitary hormone progesterone, which, along with oestrogen, prepares the
called follicle-stimulating hormone (FSH) triggers the growth endometrium to receive the egg. If the egg is unfertilized,
of follicles containing eggs. The follicles secrete oestrogen. then levels of oestrogen and progesterone fall and a new
Another hormone, luteinizing hormone (LH), causes one of menstrual cycle begins.
Phase Menstruation Proliferative Secretory
Oestrogen Progesterone

Egg
release and
endometrial
changes

Endometrium New egg ripens Egg released Endometrium Unfertilized egg

is shed and endometrium thickens further degenerates
begins to thicken

Day b c d e f g h i j ba bb bc bd be bf bg bh bi bj ca cb cc cd ce cf cg ch ci

menstruation, disorders of tubes instead of the vagina. Retrograde When individuals are endangering their
Abnormalities in menstrual bleeding. menstruation is thought to be a possible own or other people’s health or safety
Menstrual disorders may indicate a cause of endometriosis. (for example, threatening harm or sui-
problem in the pelvic area, such as fib- cide) because of a recognized mental
roids, endometriosis, or pelvic inflammatory menstruation, suppressed illness, they may be compulsorily
disease, but the cause is often unknown. The failure of menstrual (monthly) taken into hospital to be given treat-
Dysmenorrhoea (painful periods) is bleeding (see menstruation) to occur. ment. If people break the law because M
the most common type of menstrual (See also amenorrhoea). of a mental disorder, the courts may
disorder. Other types are amenorrhoea remand them to hospital.
(absence of menstruation), polymenor- mental
rhoea (overly frequent menstruation), A word meaning “relating to the mind”. mental hospital
oligomenorrhoea (infrequent periods A type of hospital, formerly known as
or scanty blood loss), and menorrhagia mental age an asylum, that specializes in the treat-
(excessive bleeding). A measurement of the intellectual ment of psychiatric illness.
Some women have extreme variations development of a person, with regard Patients who have psychiatric illnes-
in the length of menstrual cycles or to the normal age at which that level of ses are increasingly being integrated into
periods, or in the amount of blood lost achievement is attained. For example, a mainstream hospitals for their care.
(see menstruation, irregular). 13 year-old child with learning difficulties Admission to a mental hospital occurs
may have a mental age of five years. when a patient is sectioned under the
menstruation, irregular Mental Health Act.
A variation in the normal pattern of mental handicap
menstruation. Irregular menstruation in- Impaired intellectual development. This mental illness
cludes variations in the interval between condition is also known as general A general term that describes any form
periods, the duration of bleeding, or learning difficulties or disability. of disorder affecting mental functions
the amount of blood that is lost. such as thought, emotion, perception,
The most common cause is a distur- Mental Health Act or memory. Such illnesses are distinct
bance in the balance between oestrogen The Mental Health Act (1983) details from learning difficulties.
hormones and progesterone hormone. Other the rights of people with mental illness Mental illnesses include forms of psy-
causes include stress, travel, a change in and the grounds for admitting people chosis, in which a person loses contact
contraception, unsuspected pregnancy, or to psychiatric hospitals against their with reality, and disorders such as anxi-
early miscarriage. Menstruation is often will. It also outlines forms of legal ety, obsessive–compulsive disorder, and
irregular for the first few years, and for guardianship for such patients. The Act post-traumatic stress disorder, in which
several years before the menopause. applies in England and Wales. mental processes are abnormal but the
The Act is divided into several sec- affected person is fully aware of his or
menstruation, retrograde tions for different situations. (These her condition.
The backward flow of tiny amounts of divisions have given rise to the term
menstrual discharge (see menstruation) “being sectioned” to describe compul- mental retardation
from the uterus through the fallopian sory admission to a mental hospital.) See learning difficulties.

501
 MENTHOL

menthol of industrial exposure. Also, mercury The main symptoms are pain and ten-
An alcohol prepared from mint oils. compounds may be absorbed through derness in the abdomen, which may
Menthol is an ingredient of several over- the intestines (producing symptoms mimic appendicitis. There may also be
the-counter inhalation preparations used such as nausea, vomiting, diarrhoea, mild fever. Mesenteric lymphadenitis
to treat a blocked or stuffy nose. and abdominal pain) or through the usually clears up rapidly, needing only
skin (causing severe inflammation). analgesic drugs to reduce pain and fever.
mentum SYMPTOMS
The medical term for the chin. After entering the body, mercury accu- mesentery
mulates in organs, principally the brain A membrane that attaches organs to the
meprobamate and kidneys. Mercury deposits in the abdominal wall. The term particularly
An antianxiety drug occasionally used in brain cause tiredness, incoordination, refers to the membranous fold that enclos-
the treatment of anxiety and stress. It excitability, tremors, and numbness in es the small intestine, attaching it to the
also acts as a muscle relaxant. Meproba- the limbs. In severe cases, there may back of the abdominal wall.The mesentery
mate can, however, induce dependence be impaired vision and dementia. De- contains the blood vessels, nerves, and
(see drug dependence). posits of mercury in the kidneys may lymphatic vessels for the intestines.
lead to kidney failure.
meptazinol TREATMENT mesial
An opioid analgesic drug used for the Treatment of mercury poisoning may A word meaning the same as “medial”
short-term relief of moderate to severe involve the use of chelating agents, which (relating to, or situated at, the centre of
pain, such as after surgery and during help the body to excrete the mercury an organ, tissue, or the body). The term
childbirth. Possible side effects include quickly; haemodialysis (see dialysis); “mesial” is often used in dentistry, to
nausea, vomiting, and dizziness. and induced vomiting or pumping out refer to a tooth surface or position.
the stomach, if mercury has been swal-
meralgia paraesthetica lowed within the previous few hours. mesomorph
Abnormal sensations such as burning A term used for an individual whose
pain, numbness, and tingling, in the Merkel cell tumour body is characterized by a square head;
outer surface of the thigh. The condi- A rare form of cancerous skin tumour a large heart; broad and muscular chest
tion occurs in the area supplied by the that occurs in people over 60 years old, and shoulders; powerful arms and legs;
lateral femoral cutaneous nerve, and is on areas of skin that have been exposed and little body fat. The term has no clin-
due to the nerve being trapped at the to the sun. The tumour arises from ical significance, however. (See also
M point where it passes under the in- Merkel cells, which are found deep in ectomorph; endomorph.)
guinal ligament, in the groin. (See also the skin, close to nerve endings; these
lateral cutaneous nerve entrapment). cells are thought to be part of the neu- mesothelioma
roendocrine system, which produces A cancerous tumour of the pleura (the
mercaptopurine hormones that trigger nerve signals. membrane that lines the chest cavity and
An anticancer drug used to treat certain The cancer is initially treated by covers the lungs). Exposure to asbestos
types of leukaemia. Adverse effects in- surgery, but metastasis (migration of dust is a risk factor (see asbestos-related
clude nausea, mouth ulcers, and loss of cancer cells to other parts of the body) diseases). Symptoms do not always
appetite. Rarely, it may cause liver dam- may occur. In this case, radiotherapy or occur. Those that do include cough,
age, anaemia, and abnormal bleeding. chemotherapy may be given, but these chest pain, and breathing difficulty,
treatments rarely produce a cure. especially if a pleural effusion (a collec-
Mercilon tion of fluid around the lung) develops.
A brand-named oral contraceptive con- mesalazine Diagnosis is made with a chest X-ray
taining the synthetic female hormones A drug that is used to reduce intestinal followed by pleural biopsy or examin-
ethinylestradiol (an oestrogen drug) and inflammation in ulcerative colitis. It may ation of a sample of fluid from any
desogestrel (a progestogen). be prescribed to relieve symptoms in effusion. If the tumour is small, surgery
acute attacks or given as a preventive is often successful. There is no effective
mercury measure. Adverse effects of mesalazine treatment for large tumours, although
The only metal that is liquid at room include nausea, diarrhoea, abdominal radiotherapy may alleviate symptoms.
temperature. Mercury is used in certain pain, and headache.
instruments, such as thermometers and mesothelium
sphygmomanometers (instruments for mescaline A type of epithelium (surface cell layer)
measuring blood pressure). It is also A hallucinogenic drug obtained from the covering the peritoneum (the membrane
included in compounds used as fillings crowns of the Mexican peyote cactus lining the abdominal cavity), the pleura
for teeth (see amalgam, dental). (LOPHOPHORA WILLIAMSII). (the membrane lining the chest cavity
and surrounding the lungs), and the
mercury poisoning mesenteric lymphadenitis pericardium (the covering of the heart).
Toxic effects of mercury on the body. An acute abdominal disorder, mainly
CAUSES affecting children, in which lymph nodes messenger RNA
The most common cause of mercury in the mesentery (a membrane that An RNA chain (see nucleic acids), also
poisoning is breathing in vapour given anchors organs to the abdominal wall) called mRNA, involved in protein synthe-
off by liquid mercury, usually as a result become inflamed. sis within cells. The mRNA is made

502
 METAPLASIA

from free nucleotide bases (of which overproduction of a hormone that con- SYMPTOMS
three types are the same as those of trols metabolic activity, as occurs in Symptoms of these disorders are usually
DNA, and one is unique to mRNA); diabetes mellitus and hypothyroidism. present at or soon after birth. They may
these attach themselves to correspond- include unexplained illness or failure to
ing bases on a single strand of DNA. By metabolism thrive, developmental delay, floppiness,
following the sequence of bases in a A collective term for all of the chemical persistent vomiting, or seizures.
length of DNA, the mRNA copies in- processes that take place in the body. It DIAGNOSIS AND TREATMENT
structions for making a protein. It then is divided into catabolism (in which Routine tests are performed on new-
passes from the cell’s nucleus to its complex substances are broken down born babies for some genetic disorders,
cytoplasm, where the sequence of bases into simpler ones) and anabolism (in such as phenylketonuria.
is decoded to form the protein. which complex substances are built up For some inborn errors of metabo-
from simpler ones). Usually, catabolism lism, no treatment is needed. For others,
mesterolone releases energy, while anabolism uses it. avoidance of a specific environmental
An androgen hormone (male sex hor- These chemical processes are regulated factor, such as certain foods, may be
mone) used as replacement therapy in by proteins called enzymes. sufficient. In some cases, the missing
hypogonadism. Adverse effects of mes- METABOLIC RATE enzyme or the protein that it produces
terolone can include prostate problems, The energy needed to keep the body can be manufactured with the use of
headache, and depression. functioning at rest is called the basal genetic engineering techniques, or a vita-
metabolic rate (BMR). It is measured in min supplement can help to compensate
mestranol kilojoules (or kilocalories) per square for the defective enzyme. If the enzyme
An oestrogen drug that is used in some metre of body surface per hour. The is made in blood cells, a bone marrow
oral contraceptives. BMR increases in response to factors transplant may provide a cure.
such as stress, fear, exertion, and illness. PREVENTION
metabolic acidosis It is chiefly controlled by hormones People with a child or a close relative
Increased acidity of the blood and tis- such as thyroxine, adrenaline (epinephrine), who is affected may wish to consider
sues due to chemical processes in the and insulin. (See also metabolism, inborn having genetic counselling before plan-
body. It may result from uncontrolled or errors of; metabolic disorders.) ning a new pregnancy.
abnormal processes, as in diabetic keto-
acidosis and lactic acidosis, or from a metabolism, inborn errors of metabolite
failure to remove waste from normal Inherited defects of body chemistry. Any substance involved in a metabolic
processes, as in kidney disease (see renal CAUSE AND TYPES reaction (a chemical reaction in the M
tubular acidosis). Alternatively, it may be Inborn errors of metabolism are caused body). The term “metabolite” is some-
due to loss of alkali in conditions such by single gene defects, which lead to times used only for the products of
as diarrhoea. Acidosis may also be the abnormal functioning of an enzyme. such a reaction. (See also metabolism.)
due to poisoning with antifreeze (ethyl- Some defects are harmless, but others are
ene glycol) or aspirin. If untreated, it severe enough to cause death or physi- metacarpal bone
can be fatal. Treatment involves giving cal or mental disability. Examples are One of five long, cylindrical bones in
sodium bicarbonate to correct the acid- Tay–Sachs disease, phenylketonuria, Hurler’s the hand. The bones run from the wrist
osis, and measures to relieve the syndrome, and Lesch–Nyhan syndrome. to the base of each digit, with the heads
underlying cause. (See also acidosis; of the bones forming the knuckles.
acid–base balance.)
LOCATION OF THE metaphysis
metabolic alkalosis METACARPAL BONES
The part of a long bone that forms new
Increased alkalinity of the blood and The five metacarpals lie between
tissue to lengthen the bone during nor-
body tissues, due to chemical processes the carpal (wrist) bones and the mal childhood growth. The metaphysis
in the body. One possible cause is loss phalanges of the fingers. is situated between the diaphysis (bone
of stomach acids through prolonged shaft) and epiphysis (bone end). In chil-
vomiting. Metabolic alkalosis can also Carpals dren the area consists of spongy bone,
result from excessive consumption of but in adults it has become hard and
alkaline substances, such as sodium Metacarpals fused with the epiphysis.
bicarbonate in antacid drugs.
Treatment is for the underlying cause. metaplasia
(See also alkalosis; acid–base balance.) A change in tissue that results from the
transformation of one type of cell into
metabolic disorders Phalanges
another. Metaplasia is usually harmless
A group of disorders in which some but is occasionally precancerous. It can
aspect of body chemistry is disturbed. affect the lining of various organs, such
Some metabolic disorders result from as the bronchi (airways) and the blad-
an inherited malfunction or deficiency der. Metaplasia of the cervix (the neck
of an enzyme involved in a particular of the uterus), which occurs in cervical
chemical reaction (see metabolism, inborn erosion, can be detected by means of a
errors of). Others result from under- or cervical smear test.

503
 METASTASIS

metastasis metformin methicillin-resistant

A secondary cancerous tumour (one An oral hypoglycaemic drug (see hypogly- staphylococcus aureus
formed from cells that have spread from caemics, oral) that lowers blood glucose See MRSA.
a primary cancer to another part of the levels and is used to treat type 2 diabetes
body). The term metastasis also applies mellitus. Possible adverse effects include methotrexate
to the process by which such migration loss of appetite, a metallic taste in the An anticancer drug used to treat lymph-
occurs. Metastases can spread through mouth, nausea, vomiting, and diarrhoea. oma (cancer of the lymph nodes) and
the lymphatic system, in the blood- some forms of leukaemia. Methotrexate
stream, or across a body cavity. methadone is also used for cancers of the uterus,
A synthetic opioid analgesic drug that breast, ovary, lung, bladder, and testis,
metastatic abscess resembles morphine. Methadone is ad- and severe psoriasis when other treat-
An abscess (localized collection of pus) ministered, under supervision, in grad- ments are ineffective. It may cause nau-
formed by bacteria that have spread ually decreasing doses, to people who sea, vomiting, diarrhoea, mouth ulcers,
from another site via the blood or are undergoing a heroin or morphine anaemia, increased susceptibility to
lymph. The bacteria may come from an withdrawal programme. It may also be infection, and abnormal bleeding.
existing (primary) abscess or from an used to treat severe pain in people who
infected wound. One example of this cannot tolerate morphine. Side effects methyl alcohol
process is the spread of bacteria from may include nausea, vomiting, consti- An alternative name for methanol.
the heart valves (see endocarditis) to pation, dizziness, and dry mouth.
form an abscess in the brain. methylcellulose
methaemoglobin A bulk-forming laxative drug that is used
metatarsal bone An abnormal substance formed by oxi- in the treatment of constipation, irritable
One of five long, cylindrical bones in dation of the iron in haemoglobin (the bowel syndrome (IBS), and diverticular dis-
the foot. The metatarsal bones make up pigment in red blood cells). Unlike oxy- ease. It increases the firmness of faeces
the central skeleton of the foot, con- haemoglobin, this compound cannot in chronic watery diarrhoea and regu-
necting the phalanges (the bones of take up and transport oxygen. lates their consistency in people who
each toe) to the tarsal bones (which Normal blood usually carries a small have a colostomy or ileostomy.
form the ankle). The bones are held amount of methaemoglobin. Excessive The drug causes a feeling of fullness, so
together in an arch by the ligaments that blood levels (methaemoglobinaemia) it is sometimes used to help treat obesity.
surround them. may result from poisoning with sub-
M stances such as nitrates and chlorates. In methyldopa
some cases, the excess is due to a con- An antihypertensive drug that controls
LOCATION OF THE genital defect in haemoglobin. The high blood pressure by acting on the
METATARSAL BONES
resulting symptoms include cyanosis part of the brain that regulates the
The five metatarsals lie between
(blue-grey colouring of the extremities diameter of blood vessels.
the tarsal bones (which form the and lips), headache; drowsiness; and Methyldopa does not affect unborn
ankle and the back of the foot) shortness of breath. Very high levels babies, so may be prescribed for women
and the phalanges of the toes. of methaemoglobin lead to coma and who have high blood pressure during
death. Treatment is with a substance pregnancy. It may also be used for people
called methylene blue. with kidney disorders, because it does
Tarsals
not impair the blood flow to the kidneys.
Metatarsals methane Side effects include drowsiness, depres-
A colourless, odourless, highly inflam- sion, and nasal congestion.The drug may
mable gas that occurs naturally in oil also cause premature destruction of red
wells and coal mines. Methane is also blood cells (see anaemia, haemolytic).
produced by the decomposition of
organic matter; it is one of the gases methylenedioxy-
Phalanges
present in intestinal gas (see flatus). methamfetamine
See Ecstasy.
methanol
metatarsalgia A poisonous type of alcohol that is used methylphenidate
Pain in the foot. Causes include fracture as a solvent or paint remover and in A central nervous system stimulant drug
of a metatarsal bone, flat-feet, or neuroma some types of antifreeze. Methanol poi- used, under specialist supervision, to
of a nerve in the foot. soning usually occurs as a result of treat attention deficit hyperactivity disorder
drinking it as a substitute for ordinary (ADHD) in children. Possible adverse
metatarsophalangeal joint alcohol. Symptoms of poisoning include effects include loss of appetite, tremors,
The joint between each metatarsal bone headache, dizziness, nausea, vomiting, sleeplessness, and rashes.
and its adjoining toe bone (see pha- and unconsciousness. Damage may also
langes). The metatarsophalangeal joint occur to the retina and the optic nerve, methylprednisolone
at the base of the big toe is commonly causing blurred vision. Repeated or A corticosteroid drug used to treat severe
affected by gout and by hallux rigidus large doses of methanol may result in asthma, skin inflammation, inflammatory
(immobility due to osteoarthritis). permanent blindness. bowel disease, and certain types of arthri-

504
 MICROCYTIC ANAEMIA

tis.Adverse effects are the same as for idazole is also used to treat protozoan is a very early sign of kidney disease in
other corticosteroid drugs; they are more infections such as trichomoniasis and people with diabetes mellitus. (See also
likely to occur if the drug is taken over amoebiasis. In addition, it may be albuminuria.) If left untreated, it may
long periods of time. applied topically as a gel to treat skin lead to diabetic kidney disease (see dia-
conditions such as acne and rosacea, and betic nephropathy) in people with type 1
methysergide it is used to treat gum disease. diabetes, or may increase the risk of car-
A drug that is used to prevent migraine Adverse effects include nausea and diovascular disorders in those who have
and cluster headaches. Methysergide is vomiting, loss of appetite, abdominal type 2 diabetes.
usually administered only under hospi- pain, and dark-coloured urine. Alcohol The increase is too small to be mea-
tal supervision, when other treatments should be avoided during treatment, sured by routine dipstick tests on urine,
have been ineffective. because it frequently interacts with the but can be confirmed by testing urine
Adverse effects of the drug can in- drug to cause vomiting. over 24 hours or with a special kit.
clude dizziness, drowsiness, and nausea. Treatment with ACE inhibitor drugs is
Long-term treatment may cause chest metropathia haemorrhagica usually advised, even if the affected per-
pain, kidney failure, or leg cramps. Abnormal, excessive, sometimes contin- son’s blood pressure is normal.
uous menstrual bleeding (see menstrual
metoclopramide cycle) due to excessive production of microaneurysm
An antiemetic drug that is used to prevent oestrogen hormones. The high oestrogen A tiny, localized swelling in a capillary
and treat nausea and vomiting, including levels cause hyperplasia (overgrowth) (the smallest form of blood vessel).
that which is associated with migraine or of the endometrium (uterus lining). Microaneurysms in the vessels of the
caused by anticancer drugs, radiotherapy, retina are a characteristic sign of diabetic
or anaesthetic drugs. Metoclopramide mexiletine retinopathy in diabetes mellitus; they may
may be given with a premedication to An antiarrhythmic drug that is used to also be due to blockage of a retinal ves-
reduce the risk of a person inhaling treat certain heart-rhythm disorders, sel. The swellings can be seen as small
vomit when he or she is under general usually after a myocardial infarction (heart red dots when the retina is examined
anaesthesia (see anaesthesia, general). attack). Possible adverse effects include with an ophthalmoscope.
Adverse effects of the drug include nausea, vomiting, dizziness, and tremor.
dry mouth, sedation, or diarrhoea. Large microangiopathy
doses may cause uncontrollable move- mianserin Any disease or disorder of the smallest
ments of the face, mouth, and tongue. An antidepressant drug that is used to blood vessels. It may be a feature of
treat severe depression, especially if the conditions such as diabetes mellitus, septi- M
metolazone illness is accompanied by anxiety or caemia, eclampsia, glomerulonephritis, and
A diuretic drug used to treat hypertension insomnia. Mianserin usually takes several advanced cancer. When microangiopa-
(high blood pressure). Metolazone is also weeks to become fully effective. Possi- thy occurs with these conditions, the
given to reduce oedema in people who ble adverse effects include dry mouth, small blood vessels become distorted
have heart failure, kidney disorders, or cir- blurred vision, constipation, dizziness, and the red blood cells are damaged,
rhosis. In addition, it is used to treat and drowsiness. Rarely, the drug may leading to microangiopathic haemolytic
certain types of kidney stone (see calcu- cause reduced blood cell production; anaemia (see anaemia, haemolytic).
lus, urinary tract). Adverse effects can regular blood counts are therefore car-
include weakness, lethargy, and dizziness. ried out during treatment. microbe
A popular term for a microorganism,
metoprolol miconazole particularly a type that causes disease.
A cardioselective beta-blocker drug that An antifungal drug that is used topically
acts mainly on nerve endings in the (applied directly to the skin), in the microbiology
heart and blood vessels. It is used to form of creams, ointments, or powder, The study of microorganisms, partic-
prevent the heart from beating too fast, to treat tinea skin infections such as ath- ularly of pathogenic types (organisms
in angina pectoris (chest pain due to lete’s foot, or as vaginal suppositories for that cause disease).
insufficient blood supply to the heart), vaginal candidiasis (thrush). Miconazole
and for hypertension (high blood pres- in the form of a cream or vaginal sup- microcephaly
sure). It is also given after a myocardial pository may, in rare cases, cause a An abnormally small head. Microceph-
infarction (heart attack) to reduce the burning sensation or a rash. Prepara- aly is associated with learning difficulties.
risk of further damage to the heart. In tions used in the vagina may damage It may be the result of certain chromoso-
addition, metoprolol is used to relieve diaphragms or latex condoms. mal abnormalities; in addition, it may
symptoms of hyperthyroidism (overactiv- occur if the brain is damaged before or
ity of the thyroid gland). Adverse effects micro- during birth, or if it is injured or dis-
include lethargy, cold hands and feet, A prefix meaning “small”, as in microor- eased in early infancy.
nightmares, and rash. ganisms (tiny organisms).
microcytic anaemia
metronidazole microalbuminuria Any form of anaemia in which there is a
An antibiotic drug used to treat infections A slight increase in the level of the pro- defect in the production of haemoglobin
caused by anaerobic bacteria, such as tein albumin in the urine, usually due to (the oxygen-carrying pigment in the
dental abscess and peritonitis. Metron- early kidney damage. Microalbuminuria blood), causing a reduction in size of

505
 MICRODISCECTOMY

the red blood cells. An example of micro- nation of a tissue sample. This is a tran- microsurgery
cytic anaemia is iron-deficiency anaemia. sitional stage between carcinoma in situ Surgery on minute, delicate, or not easi-
(See also normocytic anaemia.) and invasion (see staging). ly accessible tissues in the body. In
procedures involving microsurgery, the
microdiscectomy Micronor surgeon views the operation site using
Surgery to relieve pressure on the spinal A brand-named oral contraceptive that a special binocular microscope with
cord, or on a nerve root emerging from contains the female hormone norethis- pedal-operated magnification, focusing,
it, due to protrusion of the core of an terone (a progestogen). and movement. He or she carries out
intervertebral disc (see disc prolapse). the procedure using tiny, specially
The procedure is performed under gen- microorganism adapted surgical instruments, such as
eral anaesthesia and involves removing A single-celled living organism. Most forceps, clamps, and very fine suturing
the protruding tissue via a small inci- microorganisms are too small to be needles and thread.
sion in the outer coat of the disc. seen by the naked eye. The main groups The technique of microsurgery is
of disease-causing microorganisms are applied to a variety of procedures. It is
microfilaria bacteria, viruses, protozoa, and fungi. used for eye operations such as repair-
The immature forms of certain types of ing a detached retina or replacing a
worm. Microfilaria are produced by adult microphthalmos diseased lens. Microsurgery may be
worms that have infected a human being A rare congenital eye disorder. Affected carried out to fit a prosthesis to replace
or an animal (see filariasis), and circulate children are born with an abnormally a diseased bone in the inner ear (see
in the blood or lymph. They complete small eye on one or both sides. stapedectomy). After serious injuries, it
their life cycle when they are ingested by may be performed to rejoin the sev-
mosquitoes or other insects that bite microscope ered ends of blood vessels or nerves.
infected people or animals; they turn into An instrument for producing a magni- Microsurgery may also be used to
larvae within the insect, and are then fied image of a very small object. reverse female or male sterilization
passed on when it bites another victim. Microscopes are used to examine the (see sterilization, female; vasectomy), by
The presence of microfilaria in the structure and chemical composition of rejoining structures that have been sur-
body can be determined by microscopic cells and tissues, and to investigate gically severed.
examination of blood samples. microorganisms and diseased tissues. In
the operating theatre, microscopes are microvillus
microglioma used in microsurgery. One of the many microscopically small,
M An obsolete term for a primary central LIGHT MICROSCOPES hairlike structures covering the surface
nervous system lymphoma (PCNSL). Compound microscopes are the most of a villus (a tiny projection from the
widely used type. They have two lens wall of the small intestine).
microglossia systems (the objective and the eye-
An abnormally small tongue.The condi- piece), mounted at opposite ends of a microwave therapy
tion is often due to a genetic disorder tube called the body tube. There is a A form of diathermy that uses micro-
and associated with micrognathia (an stage to hold the specimen, a light waves (electromagnetic waves of very
abnormally small jaw). source, and an optical condenser which short wavelength). One form of micro-
concentrates the light. The maximum wave therapy in which the waves are
micrognathia magnification is about 1,500 times. directed through probes into tumours,
An abnormally small jaw (usually the Phase-contrast and interference mic- to kill or shrink the abnormal tissue, is
lower jaw). Micrognathia is congenital roscopes are modified light microscopes currently being investigated as a possi-
(present at birth), and may stop a baby that allow unstained transparent speci- ble treatment for breast cancer and
from feeding properly. It is a feature of mens to be seen. They are used for prostate cancer. Microwave therapy is
various chromosomal abnormalities. In examining living cells and tissues. also used to treat benign prostatic hyper-
many cases, the problem disappears as Fluorescence microscopes use ultra- trophy, although it is less effective than
the child’s skull grows. violet light to study specimens stained other treatments.
with fluorescent dyes.
micrograph ELECTRON MICROSCOPES micturition
A photographic image of a tiny object Electron microscopes give much higher A medical term for passing urine.
seen through a microscope. magnifications than light microscopes
by using a beam of electrons instead of micturition syncope
Microgynon 30 light. There are two types: transmission A brief loss of consciousness (see syn-
A brand-named oral contraceptive that electron microscopes (TEMs) and scan- cope) that occurs during or just after
contains the female hormones ethinyl- ning electron microscopes (SEMs). TEMs micturition (passing
urine), usually when
estradiol (an oestrogen drug) and levonor- can magnify objects up to about a person has got out of bed to urinate at
gestrel (a progestogen). 5,000,000 times, enabling tiny viruses night. The condition is more common
and molecules to be seen. SEMs have a in older men. It is thought to result
microinvasion lower maximum magnification (100,000 from a drop in blood pressure as the
The spread of cancerous cells into nor- times), but produce three-dimensional person gets up (see orthostatic hypoten-
mal tissue adjacent to the tumour. It is images, so are useful for studying sur- sion), combined with changes in blood
detectable only by microscopic exami- face structures of cells and tissues. flow as the bladder empties.

506
 MIGRALEVE

TECHNIQUES OF MICROSURGERY

Microsurgery started with ophthalmic surgeons, whose demands for more delicate
operating instruments led to the adoption of the operating microscope. The results
were so favourable that surgeons working in other specialties began to use the
technique for intricate operations.

The operating microscope Surgeon

This surgeon is performing microsurgery
with the aid of an operating microscope.
The photograph below shows a blood
vessel as seen through the microscope.
Eyepiece
Forceps

Scalpel Speculum
Replantation microsurgery
A major application of microsurgery is the
replantation of severed fingers, toes, hands, feet,
Site of or even entire limbs. This is successful only if the
surgery severed blood vessels and nerves are accurately
Blood vessel rejoined so that regeneration occurs.

midazolam Possible adverse effects include malaise, DIAGNOSIS AND TREATMENT

A benzodiazepine drug that is used as pre- faintness, nausea, rash, and, rarely, uter- Diagnosis is usually made from the
medication. Adverse effects of midazolam ine bleeding. Women over 35 who history and a normal outcome from
include confusion, drowsiness, and diz- smoke should not be given the drug. any physical examinations between
ziness. If benzodiazepines are taken for attacks. Treatment for an attack is an
a long time, dependence may result. migraine analgesic drug such as aspirin, paraceta-
A severe headache, typically lasting mol, or a nonsteroidal anti-inflammatory M
midbrain from four to 72 hours, accompanied by drug, with an antiemetic drug, if needed.
The top part of the brainstem, situated light and noise sensitivity and/or nau- If this is not effective, drugs called
above the pons. The midbrain is also sea and vomiting. Migraine attacks are 5HT1 agonists (see serotonin agonists),
called the mesencephalon. due to spasm, followed by excessive such as sumatriptan, may be prescribed.
dilation, of blood vessels in the brain. These drugs are taken as early as possi-
middle ear CAUSES ble at the start of an attack, and may
See ear. There is no single cause of migraine, prevent the development of a full-
although it tends to run in families. blown attack. Sleeping in a darkened
middle-ear effusion, persistent Stress-related, food-related, or sensory- room may hasten recovery.
See glue ear. related factors (such as eating cheese For frequent attacks, preventive treat-
or chocolate, or drinking red wine) ment may be required. Keeping a diary
middle-ear infection may trigger attacks. In women, men- can help people to identify trigger fac-
See otitis media. struation, oral contraceptives, and HRT tors, and prophylactic drugs may be
may also be triggers. prescribed. Drugs that contain ergota-
mid-life crisis TYPES AND SYMPTOMS mine may prevent an attack if taken
A popular term for the feelings of dis- There are two types: migraine with aura before the headache begins, but are
tress that affect some people in early (an impression of flashing lights and/or now rarely used; they have largely been
middle age when they realize that they other neurological symptoms such as replaced by serotonin antagonists such as
are no longer young. Counselling and numbness and tingling) and migraine pizotifen. Beta-blocker drugs, or low doses
support are usually effective in helping without aura. In migraine without aura, of tricyclic antidepressant drugs, may
people to come to terms with aging. there is a slowly worsening headache, also be used to prevent attacks. (See also
often on one side of the head, with cluster headaches.)
midwifery nausea and sometimes vomiting and/or
The profession concerned with assisting light and noise sensitivity. migrainous neuralgia
women in pregnancy and childbirth, In migraine with aura, there may be See cluster headaches.
and in the weeks just after a birth. visual disturbances for up to an hour, fol-
lowed by a severe, one-sided headache, Migraleve
mifepristone nausea, vomiting, and sensitivity to A brand-named drug for migraine relief
A sex hormone drug that is used to light and noise. Other temporary neu- that contains the analgesic drugs (pain-
induce medical termination of a very rological symptoms, such as weakness killers) paracetamol and codeine and the
early pregnancy (see abortion, induced). in one half of the body, may occur. antiemetic drug buclizine.

507
 MIGRIL

Migril mins, and minerals. The composition of lymphatic vessels that prevents the free
A brand-named drug for migraine relief milk varies between species; for example, flow of lymph. The disease is a genetic
containing caffeine, ergotamine (to relieve human breast milk contains more sugar disorder inherited in an autosomal dom-
migraine symptoms), and the antihista- (lactose) and less protein than cows’ milk. inant manner and is congenital (present
mine drug cyclizine (to relieve nausea). from birth). The condition usually
milk–alkali syndrome affects the legs.
milia A rare type of hypercalcaemia (abnormal-
Tiny, harmless, hard, white spots that ly high level of calcium in the blood) Minamata disease
usually occur in clusters around the nose together with alkalosis (reduced acidity The name given to a severe form of
and on the upper cheeks in newborn of the blood) and kidney failure. The syn- mercury poisoning that occurred in the
babies and also in young adults. drome is caused by excessive, long-term mid-1950s, in people who had eaten
intake of antacid drugs containing calci- polluted fish taken from Minamata Bay,
miliary tuberculosis um and of milk. It is most common in Japan. Many affected people suffered
A potentially life-threatening form of people with a peptic ulcer. Symptoms severe nerve damage, and some died.
tuberculosis in which bacteria from the include weakness, muscle pains, irrita-
original site of infection enter the bility, and apathy. Treatment is to reduce mineral
bloodstream and spread throughout the the intake of milk and antacids. A chemical element that is defined in
body to form millions of tiny tubercles nutrition as being essential in the diet
(nodular masses) in other organs and Milk of Magnesia for the maintenance of health. At least
tissues. The condition occurs in only a A magnesium preparation used as an 20 minerals, including calcium, iron,
small minority of people with tubercu- antacid and laxative drug. potassium, and sodium, are vital for
losis; it is most common in immuno- health. Some, such as zinc, are needed
compromised people such as those with milk teeth in only tiny amounts (see trace ele-
AIDS or those taking corticosteroid drugs. See primary teeth. ments). A well-balanced diet that has
sufficient amounts of nutrients should
milk Milroy’s disease provide all the minerals that the body
A nutrient fluid produced by the mam- An inherited form of lymphoedema (the needs. (See also Minerals and main food
mary glands of female mammals. Milk accumulation of lymph in the tissues) sources table, opposite; Reference nutrient
contains fat, carbohydrate, protein, vita- that is caused by a malformation of the intake (RNI) table, below.)

M
REFERENCE NUTRIENT INTAKE (RNI) FOR SELECTED MINERALS
The table below gives the reference nutrient intake (RNI) of breast-feeding are approximately the same as those
the minerals for which amounts have been established; when for nonpregnant women, but additional iron may be
different, the RNI for males and females is denoted by the recommended for two to three months after the birth
letters M and F. Iron requirements during pregnancy and to replenish iron stores depleted by pregnancy.

0–6 6 months 1–3 4–6 7 –10 11–14 15–18 19–50 51+ Extra needed:
months –1 year years years years years years years years Pregnancy Breast-feeding
Calcium 525 525 350 450 550 M 1000 M 1000 M 700 M 700 0 +550
(mg/day) F 800 F 800 F 700 F 700

Iodine 50 60 70 100 110 130 140 140 140 0 0

(mcg/day)

Iron 4.3 7.8 6.9 6.1 8.7 M 11.3 M 11.3 M 8.7 8.7 0 0
(mg/day) F 14.8* F 14.8* F 14.8*

Magnesium 60 80 85 120 200 M 280 M 300 M 300 M 300 0 +50

(mg/day) F 280 F 300 F 270 F 270

Phosphorus 400 400 270 350 450 M 775 M 775 M 550 550 0 +440
(mg/day) F 625 F 625 F 550

Selenium 13 10 15 20 30 45 M 70 M 75 M 75 0 +15
(mcg/day) F 60 F 60 F 60

Sodium 280 350 500 700 1200 1600 1600 1600 1600 0 0
(mg/day)

Zinc 4 5 5 6.5 7 9 M 9.5 M 9.5 M 9.5 0 +6

(mg/day) F7 F7 F7

Units: mg = milligrams (thousandths of a gram)

* Insufficient for women with heavy menstrual periods, who should take iron supplements. mcg = micrograms (millionths of a gram)

508
 MIOSIS

mineralization, dental occur in women who have heavy men- sible cause of some learning difficulties,
The deposition of calcium crystals and strual periods or are pregnant or difficulty in concentrating, impulsive-
other mineral salts in developing teeth. breast-feeding, vegans (people who eat ness, and hyperactivity.
(See calcification, dental.) no meat, eggs, or dairy products), and
people with persistent internal bleeding minimally invasive surgery
mineralocorticoid (for example, from a peptic ulcer). Surgery using a rigid endoscope passed
The term used for a corticosteroid hor- into the body through a small incision.
mone that controls the amount of salts miner’s lung Further small openings are made for
that are excreted in urine. See pneumoconiosis. instruments so that the operation can
be performed without a long incision.
mineral supplements minilaparotomy Minimally invasive surgery may be
Dietary supplements containing one or A procedure for female sterilization (see used for a range of operations on the
more minerals in tablet or liquid form. sterilization, female). abdomen (see laparoscopy), including
Most people obtain sufficient amounts appendicectomy, cholecystectomy, hernia
from their diet; supplements are only minimal access surgery repair, and many gynaecological proce-
necessary for those with a recognized See minimally invasive surgery. dures. Operations on the knee (see
deficiency. Some mineral supplements arthroscopy) are also often performed by
may even be harmful if taken in excess. minimal brain dysfunction minimally invasive surgery.
(See also entries for individual minerals.) A hypothetical condition that is thought
Iron, the most commonly taken min- to account for behavioural and other minipill
eral supplement, is used to treat people problems in children for which no Also known as the progestogen-only
with iron-deficiency anaemia, which may physical cause is found. It may be a pos- pill (POP), an oral contraceptive that con-
tains only a progestogen drug. The mini-
pill makes the mucus that lines the
MINERALS AND MAIN FOOD SOURCES cervix so thick that sperm cannot pass
Mineral Sources and has other effects that impede con-
ception. Possible adverse effects include
Calcium Milk, cheese, calcium-fortified bread, butter and margarine, green
menstrual irregularities, bleeding bet-
vegetables, pulses, nuts, soya bean products, hard water ween periods, and ovarian cysts.

Chromium Red meat, cheese, butter and margarine, whole-grain cereals and
minocycline M
breads, green vegetables A tetracycline antibiotic drug used to
treat acne, respiratory-tract infections
Copper Red meat, poultry, liver, fish, seafood, whole-grain cereals and breads, such as pneumonia, and some genitouri-
green vegetables, pulses, nuts, raisins, mushrooms nary infections, such as gonorrhoea and
nongonococcal urethritis. It is also used to
Fluorine Fish, fluoridated water, tea prevent meningococcal meningitis.
The most common side effects are
Iodine Milk, cheese, butter and margarine, fish, whole-grain cereals and nausea, dizziness, and diarrhoea. The
breads, iodized table salt drug may also interfere with the bal-
ance mechanism within the inner ear,
Iron Red meat, poultry, liver, eggs, fish, whole-grain cereals and breads, causing dizziness or vertigo, but these
dried fruit problems usually disappear once the
drug is no longer being used.
Magnesium Milk, fish, whole-grain cereals and breads, green vegetables, pulses,
nuts, hard water minoxidil
A vasodilator drug used to treat severe
Phosphorus Red meat, poultry, liver, milk, cheese, butter and margarine, eggs, fish, hypertension (high blood pressure) when
whole-grain cereals and breads, green vegetables, root vegetables, other drugs have been ineffective.
pulses, nuts, fruit Prolonged use can stimulate hair
growth, especially on the face.This effect
Potassium Whole-grain cereals and breads, green vegetables, pulses, fruit may be a problem for people using the
drug to control high blood pressure. It
Selenium Red meat, liver, milk, fish, seafood, whole-grain cereals and breads can, however, be beneficial for male-pat-
tern baldness (see alopecia); preparations
Sodium Red meat, poultry, liver, milk, cheese, butter and margarine, eggs, fish, containing minoxidil are applied topi-
whole-grain cereals and breads, green vegetables, root vegetables, cally to stimulate hair regrowth.
pulses, nuts, fruit, table salt, processed foods
miosis
Zinc Red meat, fish, seafood, eggs, milk, whole-grain cereals and breads, Constriction of the pupil of the eye.
pulses
Miosis may be caused by drugs such
as pilocarpine or opium, by a disease

509
 MIOTIC DRUGS

affecting the autonomic nervous system, TYPES inner one is highly folded to provide a
or by bright light. A degree of miosis is Miscarriages are classified medically as surface for respiration reactions. Cells
normal in older people. different types of abortion. In a threat- that use a lot of energy, such as muscle
ened abortion, the fetus remains alive in cells, contain many mitochondria.
miotic drugs the uterus. In an inevitable abortion, the
Drugs used in the treatment of glaucoma fetus dies and is expelled from the mitochondrial DNA
to reduce pressure in the eye. When uterus. In a missed abortion, the fetus A particular form of DNA existing in
applied to the eye, miotic drugs cause dies but remains in the uterus. mitochondria. In human mitochondria,
the pupil to contract, which opens up INVESTIGATION AND TREATMENT the DNA is a double-helical circle that
the drainage channels and drains fluid A pelvic examination and ultrasound codes for 13 proteins. Mitochondria
from the front of the eye. Side effects scanning may be performed in order to have a distinctive genetic code, and
include headache, particularly over the assess the pregnancy. If all of the con- their genomes are not changed by mei-
eye, and blurred vision. Common miot- tents of the uterus are expelled, no osis during reproduction; these features
ics include carbachol and pilocarpine. further treatment may be necessary. make the DNA useful in genetic studies.
(See also mydriatic drugs.) Otherwise, a D and C may be per- The significance of mitochondria hav-
formed. Missed abortion requires a D ing their own DNA is that diseases can
Mirena and C or induction of labour depending be inherited via abnormalities of mito-
A brand-named intrauterine contracep- on the duration of the pregnancy. Rh- chondrial DNA, and inheritance of the
tive device (see IUD) containing the negative women are given anti-D (Rho) DNA is maternal, directly from the egg.
female hormone levonorgestrel (a pro- immunoglobulin to prevent complica-
gestogen). The Mirena device is fitted tions related to Rhesus incompatibility mitosis
inside the uterus, then releases a low from occurring in any future pregnan- A type of cell division in which the
dose of the drug continually. It will cies. (See also abortion.) chromosomes in a cell nucleus are dupli-
need to be replaced after five years. cated into each of two daughter cells.
The device may cause irregular bleed- misoprostol Before cell division, the chromosomes
ing or slightly heavier menstrual periods A synthetic prostaglandin drug that in- duplicate themselves and coil up with
(see menstrual cycle) just after being fit- hibits the secretion of stomach acid. the two copies joined together. The dou-
ted, but the periods usually become Misoprostol may be used alone to treat bled chromosomes line up in the centre
much lighter after about three months. peptic ulcers, or it may be combined of the cell and are pulled apart to oppo-
Some women cease to have periods at with a nonsteroidal anti-inflammatory drug site ends of the cell, which then divides.
M all, although most continue to ovulate. (NSAID), such as diclofenac, to prevent Each daughter cell therefore has the same
The device is particularly useful for the development of peptic ulcers that chromosome content as the original cell.
those women who need to use an IUD may be associated with the use of these (Egg and sperm cells, in contrast, divide
but have heavy periods. drugs. The most likely side effects of by means of a process called meiosis.)
misoprostol are diarrhoea and indiges-
miscarriage tion. If severe, or if problems such as mitral incompetence
Loss of the fetus before the 24th week vomiting, abnormal vaginal bleeding, Failure of the mitral valve of the heart to
of pregnancy or viability (the ability to abdominal pain, or rash occur, a doctor close properly, allowing blood to leak
survive outside the uterus without arti- should be consulted promptly. back into the left atrium (upper cham-
ficial support). The medical term is ber) when it has been pumped out of
“spontaneous abortion”. The majority mites and disease the left ventricle (lower chamber). The
of miscarriages occur in the first 12 Mites are very small animals, usually disorder, also known as mitral regurgi-
weeks of pregnancy, and may be mis- less than about 1 mm long, with eight tation, may occur in conjunction with
taken for a late menstrual period. legs. Many species of mites have pierc- mitral stenosis (narrowing of the valve).
CAUSES ing and blood-sucking mouthparts. SYMPTOMS
Miscarriages may occur because of Species that may cause disorders Symptoms include increasing breath-
chromosomal abnormalities or develop- include the scabies mite, which bur- lessness and fatigue, sometimes with
mental defects in the fetus, or because rows in human skin causing intense palpitations. Later, as heart failure devel-
of severe illness, exposure to toxins, or itching; the house-dust mite, which can ops, the ankles may swell.
an autoimmune disorder in the mother. cause asthma when inhaled; and chig- DIAGNOSIS AND TREATMENT
Miscarriages that occur later in preg- gers (American harvest mites), which Diagnosis may be made by hearing a
nancy may be due to genetic disorders, are found in grass and cause an itchy characteristic heart murmur; from X-rays;
cervical incompetence, a defect in the rash when they bite. Mites in grain or ECG; and echocardiography. The heart’s
uterus, or large uterine fibroids (non- fruit may cause skin irritation – some- interior may also be investigated with a
cancerous growths). times called grocers’ or bakers’ itch. catheter (see catheterization, cardiac).
SYMPTOMS Certain mites transmit diseases, particu- Treatment may include diuretic drugs,
The symptoms are heavy vaginal bleed- larly scrub typhus and rickettsial pox. ACE inhibitor drugs, and anticoagulant
ing with cramping. Slight blood loss drugs. If symptoms are disabling, heart-
accompanied by severe pain can be a mitochondria valve surgery may be considered.
symptom of either a threatened miscar- Small organelles found inside cells in Before dental or other surgery, people
riage or ectopic pregnancy (development which cell respiration occurs. The mito- with mitral incompetence are given anti-
of the embryo outside the uterus). chondrial wall has two membranes. The biotic drugs to prevent endocarditis.

510
 MMR VACCINATION

THE MECHANISM OF MITOSIS

Mitosis is the simplest type of cell division. It provides new body cells to replace The two identical
those that have died. Each of the new cells receives an identical copy of the 3chromosomes
groups of single
now
chromosomes from the original cell.
gather at opposite
ends of the cell, and
Nucleus a nuclear membrane
The doubled chromosomes line up
Cell
membrane 2nucleus
in the centre of the cell. The cell
breaks down, and threads
forms around each
group. The rest of the
appear in the cell. The two copies of cell then divides.
Doubled-up each chromosome then move apart
chromosomes along the threads.
Nuclear membrane

Threads

1the Chromosomes in a cell nucleus are

invisible, long threads. Before cell division,
threads replicate, coil up, and shorten, Chromosome
When division has finished and new
4daughter
nuclei have fully formed in the two
copies
appearing as dark rods. The two copies of each cells, the chromosomes uncoil to
chromosome are joined at a point called the resume their invisible, threadlike form.
centromere, so they appear X-shaped. Mitosis is now complete.

mitral stenosis mitral valve mixed connective tissue

Narrowing of the opening of the mitral A valve in the left side of the heart. The disorder
valve in the heart. The left atrium (upper mitral (or bicuspid) valve is made up of An autoimmune disease that affects the M
chamber) has to work harder to force two flaps, allowing one-way blood flow connective tissue (which supports body
blood through the narrowed valve. from the left atrium (upper chamber) structures) throughout the body. It
Mitral stenosis is more common in into the left ventricle (lower chamber). combines features of systemic sclerosis,
women and may be accompanied by systemic lupus erythematosus, polymyo-
mitral incompetence (failure of the valve mitral valve prolapse sitis, and rheumatoid arthritis.
to close properly). It is usually due to A common, slight deformity of the mitral Mixed connective tissue disorder is
damage caused by rheumatic fever. valve, in the left side of the heart, that can diagnosed by blood tests that reveal
SYMPTOMS produce a degree of mitral incompetence antibodies to a cellular protein called
The main symptom is breathlessness on (failure of the valve to close properly).The ribonucleic protein (RNP). Treatment is
exertion. As mitral stenosis worsens, prolapse is most common in women and similar to that for systemic lupus eryth-
breathing difficulty eventually occurs causes a heart murmur. It may be inherit- ematosus, with corticosteroid drugs and
when the person is at rest. Other signs ed, but the cause is often unknown. immunosuppressant drugs.
include palpitations, atrial fibrillation (a Usually, there are no symptoms. Occa-
rapid, uncoordinated, irregular heart- sionally, however, the condition may MMR vaccination
beat), and flushed cheeks. The person produce chest pain, arrhythmia (irregu- Administration of a combined vaccine
may also cough up blood and feel lar heartbeat), or, rarely, heart failure. that gives protection against measles,
fatigued. Possible complications are as Often, no treatment is required for mumps, and rubella. The vaccination is
for mitral incompetence. mitral valve prolapse, but some people offered to all children between 12 and
DIAGNOSIS AND TREATMENT may be treated with beta-blocker drugs, 15 months of age, with a booster shot
A diagnosis is made from the patient’s diuretic drugs, antiarrhythmic drugs, or, at three to five years.Vaccination is post-
history, listening to heart sounds, and rarely, heart-valve surgery. poned if a child is feverish, and it is not
by various investigations such as an given to children with untreated cancer
ECG, chest X-rays, echocardiography, and mittelschmerz or allergies to aminoglycoside antibiotic
cardiac catheterization. Drug treatment Lower abdominal pain experienced by drugs such as neomycin.
is broadly the same as for mitral some women at the time of ovulation. Mild fever, rash, and malaise may
incompetence. The pain usually occurs on one side of occur after vaccination. In a minority
If symptoms persist, balloon valvu- the abdomen and lasts for only a few of cases, mild, noninfectious swelling of
loplasty may be carried out in order to hours. It may be accompanied by slight the parotid glands develops three to four
stretch the valve. Alternatively, heart- vaginal blood loss. In cases of severe weeks after vaccination. There is no evi-
valve surgery may be performed to mittelschmerz, oral contraceptives may be dence for a link between MMR and
replace the valve. prescribed to suppress ovulation. Crohn’s disease or autism.

511
 MOBILIZATION

mobilization mole as cheese and red wine. Moclobemide,

The process of making a part of the A type of pigmented naevus. (See also however, is a type called a reversible
body capable of movement. Mobiliza- molar pregnancy.) MAOI, or RIMA, which makes the ad-
tion is treatment that is designed to verse reactions less likely to occur.
increase mobility in a part of the body molecule
that is recovering from injury or The smallest complete unit of a sub- monoarthritis
affected by disease. stance that can exist independently and Inflammation that affects a single joint,
Surgeons use the term to refer to the still retain the characteristic properties causing pain and stiffness. Common
freeing of an organ or structure from of that substance. Almost all molecules causes of monoarthritis include osteo-
surrounding connective tissue or fibrous consist of two or more atoms bonded arthritis, gout, and infection.
adhesions (bands of tissue joining nor- together. Those that consist of only one
mally unconnected parts of the body). atom are called monatomic molecules. monoclonal antibody
See antibody, monoclonal.
Möbius’ syndrome molluscum contagiosum
A rare genetic disorder characterized by A harmless viral infection characterized monocyte
paralysis of both sides of the face, due to by shiny, pearly white papules (tiny One of the main types of white blood
absence or underdevelopment of the lumps) on the skin surface. Each papule cell. Monocytes are phagocytes (cells
sixth and seventh cranial nerves. The has a central depression, and releases a that surround and engulf invading
condition is congenital (present from cheesy fluid when it is squeezed. A microorganisms) and play an important
birth). An affected child has a mask-like crust forms before healing occurs. role in the immune system.
facial expression and cannot move the The papules often appear on the gen-
eyes fully from side to side. Newborn itals, the insides of the thighs, or the mononucleosis, infectious
babies are unable to feed properly. In face. Children are more commonly An acute viral infection, commonly
some cases, the syndrome is associated affected than adults. The infection is called glandular fever, that is character-
with abnormalities of the limbs or with transmitted by direct skin contact or ized by a high temperature, sore throat,
learning difficulties. There is no specific during sexual intercourse; it usually and swollen lymph nodes.
treatment, but surgery may restore clears up within a few months, but may CAUSE
some facial expression. last for up to 18 months. The infection is caused by the Epstein–
Barr virus. It is transmitted via saliva,
moclobemide Mongolian blue spot through close personal contact (including
M An antidepressant drug that is used to Blue-black pigmented spots found on kissing), or possibly on cups or cutlery.
treat severe resistant depression and the lower back and buttocks at birth. SYMPTOMS
social phobia. Moclobemide is a revers- The spots are a type of naevus, caused In the body, the virus multiplies in the
ible monoamine oxidase inhibitor and is by a concentration of melanocytes (cells lymphocytes (also called mononuclear
less likely than other MAOIs to cause that produce pigment). Mongolian blue cells). If the infection occurs in early
high blood pressure. As with all MAOIs, spots are commonly found in black or childhood, it may cause no symptoms.
however, interactions occur with some Asian children. They usually disappear However, symptoms are common in
foods, and dietary restrictions still apply: by the age of three to four years. adolescence or early adulthood; and the
people taking the drug should not con- first to appear are a fever and headache,
sume foods such as cheese, meat, or Mongolism followed by swollen lymph nodes (par-
yeast extracts, or drink red wine or beer. An outdated name for Down’s syndrome. ticularly in the neck) and a severe sore
throat. In rare cases, enlargement of the
Mogadon moniliasis tonsils may obstruct breathing. The
A brand name for the benzodiazepine See candidiasis. spleen may become enlarged. In addi-
drug nitrazepam. tion, the liver may become inflamed,
monitor sometimes causing jaundice.
molar To maintain a constant watch on the DIAGNOSIS AND TREATMENT
See teeth. condition of a patient.The word “moni- Diagnosis of the condition is often
tor” is also used to refer to any device made from the symptoms and from a
molar pregnancy used to carry out monitoring. blood test (see monospot test); affected
A pregnancy in which a tumour devel- lymphocytes have an atypical appear-
ops from the placental tissue and the monoamine oxidase inhibitors ance. Recovery usually takes four to six
embryo does not develop normally. A Also known as MAOIs, one of the three weeks, with rest the only treatment
molar pregnancy may be noncancerous main types of antidepressant drug. They needed. In rare cases, corticosteroid drugs
(a hydatidiform mole) or may invade the work by preventing the breakdown of are given to reduce severe inflammation
wall of the uterus (an invasive mole). A certain neurotransmitters by the enzyme of the tonsils, particularly if the breath-
molar pregnancy that becomes cancer- monoamine oxidase. The increased lev- ing is obstructed. Contact sports should
ous is called a choriocarcinoma. els of neurotransmitters that result are be avoided until the spleen has returned
If the dead embryo and placenta are associated with improved mood. to its normal size. For two to three
not expelled from the uterus after a mis- Common drugs include phenelzine months after recovery, people often feel
carriage, the dead tissue forms a mass and isocarboxazid. All MAOIs interact depressed, lacking in energy, and sleepy
called a carneous mole. with certain other drugs and foods such during the day.

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 MORTALITY

Monteggia’s fracture morbidity

Fracture of the ulna (the bone on the The state of being diseased. In medical
inner side of the forearm) just below statistics, the morbidity ratio is the pro-
the elbow, together with dislocation of portion of diseased people to healthy
the radius (the outer forearm bone) people in a particular community.
from the elbow joint.
morbilli
montelukast Another name for measles.
A specific leukotriene receptor antagonist
drug used in the management of morning-after pill
Blood smear in mononucleosis asthma. It is not, however, used to treat See contraception, emergency.
The large cell with a three-lobed nucleus,
surrounded by many red blood cells, is an atypical
acute attacks.
lymphocyte (it is bigger than normal). Such cells
morning sickness
are a feature of mononucleosis. Montgomery’s tubercles See vomiting in pregnancy.
Raised sebaceous glands on the areola
monorchism (the pigmented area around the nip- Moro reflex
The presence of only one testis. The ple). The glands tend to become more An automatic movement in infants (see
most probable causes of monorchism obvious during pregnancy. reflex, primitive) in which the arms are
are surgery (see orchidectomy) and con- flung outwards before coming together
genital absence of the testis. mood in an embracing movement, the head
See affect; affective disorders. jerks backwards, and the legs extend.
monosaccharide The Moro reflex occurs in response to a
An alternative term for a simple sugar mood swings stimulus such as the head being allowed
(see carbohydrates). Rapid changes in mood. Milder forms to fall back momentarily.
of mood swings, such as changes from
monosodium glutamate a calm state to a state of anxiety, irri- morphine
A food additive that is used as a flavour tability, or tearfulness, may occur in An opioid analgesic drug derived from
enhancer and seasoning in food. Mono- women suffering from premenstrual syn- the opium poppy. Morphine is given to
sodium glutamate (MSG) is the sodium drome or those who are going through relieve severe pain caused by myocardial
salt of an amino acid. the menopause. Extreme mood swings, infarction (heart attack), major surgery,
Some individuals who eat foods that from mania (abnormal overactivity and serious injury, and cancer. It blocks the M
contain MSG develop a short-lived ill- elation) to depression, are associated transmission of pain signals at sites
ness, which involves pain in the neck with bipolar affective disorder (see called opiate receptors in the brain and
and chest, palpitations, feeling hot, and manic–depressive illness). spinal cord. The drug also induces a
a headache. sense of wellbeing or euphoria.
moon face Side effects include drowsiness, dizzi-
monospot test Rounding of the face that is due to ness, constipation, nausea, vomiting,
A blood test that is used in the diagno- abnormally high levels of natural corti- and confusion. Long-term use of mor-
sis of infectious mononucleosis (see costeroid hormones in the body, as in phine may lead to drug dependence, with
mononucleosis, infectious). It is designed Cushing’s syndrome, or to prolonged severe flulike symptoms when the drug
to detect certain antibodies (proteins courses of corticosteroid drugs. is withdrawn (see withdrawal syndrome).
produced by the immune system to
fight infection) that are associated with Moraxella morphoea
this disorder. A group of bacteria that exist in a var- A condition in which one or more
iety of mammals, including humans. hard, flat patches develop on the skin. It
monounsaturated The bacteria can cause a wide range of is a type of scleroderma but is confined
A term that is used to describe a form disorders; for example, the bacterium to the skin. Although harmless, the con-
of unsaturated fatty acid that is found MORAXELLA LACUNATA may cause conjunct- dition can be disfiguring.
in certain oils that are used for food, ivitis and infections of the cornea (the
such as olive oil and groundnut oil. transparent covering over the front of mortality
(See fats and oils.) the eye), and M. CATARRHALIS occasionally The death rate – the number of deaths per
causes otitis media (infection of the mid- 100,000 (or 10,000 or 1,000) of the
monozygotic twins dle ear) and certain infections of the population per year. Mortality is often cal-
The medical term for identical twins. upper respiratory tract, such as sinusitis culated for specific groups. For example,
(See twins.) and bronchitis. infant mortality measures the deaths of live-
born infants during the first year of life.
mons pubis morbid anatomy Standardized mortality is a measure
The rounded area over the front of the Also called pathological anatomy, the that allows comparison of the death rate
pubic bone. The mons pubis is formed study of the structural changes that in, for example, a particular occupa-
by a pad of fatty tissue underneath the occur in body tissues as a result of dis- tional or socioeconomic group with
skin. It becomes covered with pubic ease, especially the changes that are that for the entire population. (See also
hair at puberty. visible to the naked eye. life expectancy; maternal mortality.)

513
 MORULA

morula
A stage in the development of an embryo DANGEROUS MOSQUITOES
following fertilization. The fertilized egg Mosquito Appearance Habits Diseases
divides repeatedly as it travels down the transmitted
fallopian tube towards the uterus. Once it
has developed into a ball of cells, it is ANOPHELES Head and body in Mainly rural; Malaria; filariasis.
called a morula. species straight line and at an bite at night.
angle to surface.
mosaicism
The presence of two or more groups of
cells containing different genetic mater- CULEX Body parallel to Urban or rural; Viral encephalitis;
species surface; head bent bite in evening filariasis.
ial within one person. down; whining sound or at night.
Some people who have syndromes in flight; brown colour.
that are caused by chromosomal abnor-
malities (such as Down’s syndrome and
AEDES Body shape as for Urban or rural; Dengue; yellow
Turner’s syndrome) also have mosaicism. species CULEX, but tropical bite during day. fever; viral
Depending on the proportion of the species are black encephalitis.
abnormal cells and the type of abnor- and white.
mality, they range from appearing
physically normal to having features
typical of the syndrome. motion sickness called ALS, or Lou Gehrig’s disease). It
A problem that some people experience usually affects people over the age of 50
mosquito bites during road, sea, or air travel. Symptoms and is more common in men. Some
Mosquitoes are flying insects found range from uneasiness and headache to cases run in families. Usually, symptoms
throughout the world. The females bite distress, excessive sweating and saliva- start with weakness in the hands and
humans or animals to obtain blood, tion, pallor, nausea, and vomiting. arms or legs, and muscle wasting. There
which they need to produce eggs. The Motion sickness is caused by the may be irregular muscle contractions,
males do not bite. A doctor should be effect of repetitive movement on the and muscle cramps or stiffness. Soon, all
consulted if there is a severe skin reac- organ of balance in the inner ear. Factors four extremities are affected.
tion to a mosquito bite. such as anxiety, a fume-laden atmos- Progressive muscular atrophy and
M DISEASE TRANSMISSION phere, or the sight of food may make progressive bulbar palsy are conditions
In addition to causing skin irritation, the condition worse. So, too, can focus- that both start with patterns of muscle
mosquito bites are also capable of trans- ing on nearby objects; sufferers should weakness different from ALS but usually
mitting diseases. The main types of look at a point on the horizon. The sick- develop into ALS.
disease-transmitting mosquitoes belong ness may be prevented or controlled by There are two types of motor neu-
to three different groups: ANOPHELES antiemetic drugs or by wearing acupres- ron disease that first appear in child-
(which transmits malaria), AEDES (which sure bands on the wrist. hood or adolescence. In most cases,
carries yellow fever), and CULEX (which these disorders are inherited. Werd-
transmits filariasis). motor nig–Hoffman disease affects infants at
PREVENTION A term used to describe any body struc- birth or soon afterwards. In almost all
Preventive measures should be taken in ture that brings about movement, such cases, progressive muscle weakness
any area where mosquitoes are ram- as a muscle or a nerve. leads to death within only a few
pant. The most effective measures are years. Chronic spinal muscular atrophy
wearing long-sleeved shirts and socks, motor nerve begins in childhood or adolescence,
fitting mosquito screens over win- A bundle of nerve fibres that carry elec- causing progressive weakness but not
dows, and using insect-repellent sprays trical impulses from the central nervous always serious disability.
or slow-burning impregnated coils system (the brain and spinal cord) to a DIAGNOSIS
that release insecticidal smoke. In addi- muscle to bring about activity. (See also There are no specific tests for motor
tion, mosquito nets should be placed sensory nerve.) A group of muscle fibres neuron disease. Diagnosis is based on
over beds. (See also insect bites; insects that are activated by a single motor careful clinical examination by a neu-
and disease.) nerve fibre is called a motor unit. rologist. Tests including EMG, muscle
biopsy, blood tests, myelography, CT scan-
motility stimulant drugs motor neuron disease ning, or MRI may be performed.
Drugs that stimulate movement through A group of disorders in which there is TREATMENT AND OUTLOOK
the gastrointestinal tract. There are two degeneration of the nerves in the central The disease typically progresses to affect
main types of motility stimulant: those nervous system that control muscular the muscles involved in breathing and
that work as antiemetic drugs and affect activity. This nerve degeneration causes swallowing, leading to death within
the upper gastrointestinal tract (metoclo- weakness and wasting of the muscles. two to four years.
pramide and domperidone, for example); The cause is unknown. The nerve degeneration cannot be
and intestinal stimulant laxative drugs, TYPES AND SYMPTOMS slowed down, but physiotherapy and the
such as dantron and senna, which are The most common type of the disease use of various aids may help to reduce
used to treat constipation. is amyotrophic lateral sclerosis (also disability. The drug riluzole is used to

514
 MOUTH ULCER

extend life (or the time until mechani- sinusitis) or by enlarged tonsils or ade- implants in the area (brachytherapy);
cal ventilation is required) in people noids. Noisy mouth breathing that however, it sometimes damages the sali-
who have ALS. occurs during sleep is called snoring. vary glands (see mouth, dry).
When mouth cancer is detected and
mould mouth cancer treated early, the outlook is good. Any
Any of a large group of fungi that exist Forms of cancerous tumour that devel- nonhealing ulcer or lump in the mouth
as many-celled, filamentous colonies. op in the lips, tongue, and oral cavity. should be assessed by a doctor or den-
Some moulds are the source of antibiotic Lip cancer and tongue cancer are the tist within two weeks, to maximize the
drugs. Others, however, can cause dis- most common types. chance of effective treatment.
eases such as aspergillosis. CAUSES AND INCIDENCE
Predisposing causes of mouth cancer mouth, dry
mountain sickness are smoking, poor oral hygiene, drinking A condition caused by inadequate pro-
An illness that can affect people who alcoholic spirits, chewing tobacco, and duction of saliva. Dry mouth is usually a
have ascended rapidly to heights above inhaling snuff. Irritation from ill-fitting temporary problem resulting from fear,
2,400–3,000 m. Mountain sickness, also dentures or jagged teeth are other risk infection of a salivary gland, or the
called altitude sickness, is caused by the factors. Men are affected twice as com- action of anticholinergic drugs.
reduced atmospheric pressure and oxy- monly as women; most cases occur in Rarely, permanent dry mouth may
gen levels that exist at high altitude. men over the age of 40. result from Sjögren’s syndrome or radio-
SYMPTOMS AND SIGNS SYMPTOMS therapy for mouth cancer. The dryness
Affected people breathe abnormally fast In the majority of cases, the cancer causes swallowing and speaking diffi-
and deeply (see hyperventilation) to com- begins with a whitish patch, called culty, impaired taste, and tooth decay
pensate for the lack of oxygen; as a leukoplakia, or a small lump. These (see caries, dental). Spraying the inside
result, the level of carbon dioxide in lesions may cause a burning sensation, of the mouth with artificial saliva or
the blood falls abnormally low. Other but are usually painless. As a tumour taking pilocarpine tablets may help.
symptoms include nausea, headache, grows, it may develop into an ulcer or a
anxiety, and exhaustion. In severe cases, deep fissure, which may bleed and mouth-to-mouth resuscitation
pulmonary oedema (the accumulation of erode surrounding tissue. See artificial respiration.
fluid in the lungs) may occur, leading DIAGNOSIS AND TREATMENT
to acute shortness of breath (see respira- Diagnosis is based on a biopsy. Treat- mouth ulcer
tory distress syndrome). Fluid may also ment consists of surgery, radiotherapy, An open sore that is caused by a break
accumulate in the brain (see cerebral or both. Surgical treatment may cause in the mucous membrane that lines the M
oedema), causing confusion, loss of facial disfigurement and problems with mouth. Mouth ulcers are white, grey, or
consciousness, or coma. eating and speaking, which may then yellow spots with an inflamed border.
TREATMENT necessitate plastic surgery to restore The most common types are aphthous
An affected person should be returned appearance and function. Radiotherapy ulcers (see ulcer, aphthous) and ulcers
to a lower altitude as rapidly and safely may be given either externally or with caused by the herpes simplex virus.
as possible. He or she may need extra
oxygen. Pulmonary or cerebral oedema
will need treatment in hospital. ANATOMY OF THE MOUTH
PREVENTION
The mouth has a complex structure, which reflects its various functions. For
Mountain sickness can be prevented or
example, the tongue, lips, teeth, and palate play an essential role in speech
minimized if the affected person ascends production. The same parts of the mouth, with the salivary glands, also begin
gradually, stopping for one or two days the process of digestion by taking in and swallowing food and drink.
of rest for every 600 m above 2,400 m.
Hard palate Soft palate
He or she should drink plenty of fluids,
have regular high-carbohydrate meals,
and avoid drinking alcohol. Those with
existing heart or lung disorders should
avoid ascending to high altitudes.
Lips Lips
mouth Uvula
The oral cavity. The mouth breaks down
Tonsil Teeth
food for swallowing (see mastication)
and is used in breathing. In addition, it Teeth
helps to convert sound vibrations from Gums
the larynx into speech.
mouth breathing Gums
Breathing through the open mouth,
rather than through the nose. It may be
Tongue
due to obstruction of the nasal passages
by thick secretions (as in a heavy cold or

515
 MOUTHWASH

A mouth ulcer may be an early stage of

mouth cancer. Those that fail to heal
MOVEMENT
within a month may need to be investi-
Various movements occur constantly
gated with a biopsy. throughout the body. All movement is EYE MOVEMENT
either voluntary (willed) or involuntary
mouthwash (automatic). Visible movements are A group of six muscles act together
A solution for rinsing the mouth. Many caused by the contraction of skeletal on each eyeball to give a range of
only leave the mouth feeling fresh and muscles or eye muscles, usually for smooth, precise movements. The
remove loose food debris from the only brief periods at a time. eyeball can move through an arc of
teeth. Some, such as those containing about 100° horizontally and about
hydrogen peroxide, can help to clean the 80° vertically.
SKELETAL MOVEMENT
teeth if the gums are too tender for prop- Oblique muscle Optic nerve
er toothbrushing, as in some types of This action involves the
movement of bones relative to Rectus
gingivitis. Those containing chlorhexidine muscle
are effective against plaque when routine one another, often at the joints.
dental hygiene is impossible. Many muscles are involved. Some
Fluoride mouthwashes help to prevent act to brace certain bones, while
others move adjacent bones.
tooth decay (see caries, dental), and a
mouthwash of warm salt water can help Humerus
to ease painful inflammation caused by Scapula
tooth disorders. Antiseptic mouthwashes Rectus
muscles
intended to combat halitosis are usually
ineffective because they do not treat the Oblique muscle
cause of the problem. Eye muscles
The four rectus eye muscles run directly
movement from the eyeball to a tendon at the back of
the eye socket. The oblique muscles are
Any motion of limbs or other areas of
Arm movements attached to the eyeball at an angle.
the body, or any motion within soft tis- A ball-and-socket joint, the shoulder
sues and body organs. All movements allows combined rotation and
are caused by the actions of muscles. displacement movements in all directions.
M They may be either voluntary (willed) or Looking from
Patella Tibia side to side
involuntary (automatic). Certain move-
ments occur as reflex actions.
SKELETAL MOVEMENTS
These movements involve the bones,
the joints, and the skeletal muscles. Femur Fibula
Looking up
Most of them are voluntary. They are and down
initiated in a part of the cerebrum (the
main mass of the brain) called the 130° arc
motor cortex. Signals are sent down the Actions of the eye muscles
Knee movement Two rectus muscles control side-to-side
spinal cord along some nerve fibres, and, A hinge joint, the knee allows movement movements. The other rectus muscles,
from there, along separate nerve fibres (through an arc of about 130°) in only one with the oblique muscles, control up-and-
to the appropriate muscles. Control plane: forwards or backwards. down and rotational movements.
relies on information supplied by sen-
sory nerve receptors, in the muscles and
elsewhere, that record the position of INVOLUNTARY MOVEMENT
different body parts and the degree of
contraction in each muscle. This infor- Many movements in the body Food Contraction
mation is integrated in specific regions are involuntary (automatic), and
of the brain (including the cerebellum are regulated by the autonomic
and basal ganglia) that control the nervous system. One example
coordination, initiation, and cessation of involuntary movement is the
of movement. beating of the heart, which
Skeletal movements can also occur as automatically speeds up in
simple reflexes in response to certain response to increased demands
sensory warning signals. These move- for oxygenated blood by body
Peristalsis
ments are automatic and less controlled, tissues and slows down again This is an example of movement caused by
when these demands decrease. involuntary muscle action. Waves of contraction
involving far fewer nerve connections. Another example is peristalsis pass along muscles in the intestinal wall, forcing
OTHER MOVEMENTS (see right). the contents forwards and preventing obstruction.
Some body movements do not involve
the skeleton. For example, eye and
tongue movements result from the con-

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 MRI

tractions of muscles attached to other

soft tissues. These movements may be MAGNETIC RESONANCE IMAGING (MRI)
voluntary or reflex.
A valuable diagnostic technique, MRI has been in use since the early 1980s. The
The movements of the internal org- patient lies down and is surrounded by a massive electromagnet and is exposed to
ans are involuntary; they include the short bursts of powerful magnetic fields and radio-waves. The bursts stimulate protons
heartbeat and peristalsis. (hydrogen nuclei) in the patient’s tissues to emit radio signals, which are detected and
analysed by computer to create an image of a “slice” of the patient’s body.
movement, loss of
See akinesia. Femur

moxibustion Patella
A form of treatment, often used with
acupuncture, in which a cone of worm- Cartilage
wood leaves (moxa) or certain other Fat
plant materials is burned just above the Tibia
skin to relieve internal pain.
MRI of the knee
moxisylyte On this MRI of the knee joint,
A vasodilator drug used to treat Raynaud’s the tissues, including bones
disease. Side effects include nausea, diar- and cartilage, are clearly visible.
rhoea, hot flushes, headache, and dizziness.
MRI
The abbreviation for magnetic reso-
nance imaging. MRI is a diagnostic
technique that produces cross-sectional
or three-dimensional images of organs
and other body structures.
HOW IT IS DONE
The patient lies inside a scanner sur-
rounded by a large, powerful magnet. A M
THE SCANNING PROCESS
receiving magnet is placed around the
part of the body to be investigated. If An MRI scanner consists of a Magnet
large areas, such as the abdomen, are to powerful electromagnet, a radio-
be imaged, the receiving magnet is fit- wave emitter, and a radio-wave
ted inside the scanner; for a smaller detector. A plane of the body is
area, such as a joint, a magnet may be selected for imaging and the
placed around the part to be scanned. electromagnet is turned on.
The scanner generates a strong mag-
netic field, which causes the atoms in Radio-wave Radio-wave detector Proton
source
the body to line up parallel to each Normally, the protons (nuclei) of
other. Short pulses of radio waves from Magnet 1 the body’s hydrogen atoms point
randomly in different directions, but under
a radiofrequency source briefly knock
the influence of the scanner’s powerful
the atoms out of alignment. As the magnetic field they align themselves in
atoms realign they emit tiny signals, the same direction.
which are detected by the receiving
magnet. Information about these signals Scanning
plane Radio-wave
is passed to a computer, which builds detector
up an image based on the signals’ Radio-wave source
strength and location.
MRI images can be enhanced by use
of a contrast medium to highlight partic-
ular body structures, such as tumours
and blood vessels.
WHY IT IS DONE
Images from MRI are similar to those Radio-wave emissions
Radio-wave stimulation
produced by CT scanning, but they give However, milliseconds later, the protons
greater contrast between normal and
abnormal tissues. MRI is useful for 2knocksNext, the radio-wave source emits a
powerful pulse of radio-waves, which
3 realign themselves. As they do so, they
emit faint radio signals, which are picked up
studying the brain and spinal cord, the the protons out of alignment. by the scanner’s radio-wave detector.
internal structure of the eye and ear,
the internal organs, and blood flow.

517
 MRSA

RISKS mucopolysaccharidosis multi-infarct dementia

There are no known risks or side effects. A group of rare inherited metabolic A deterioration in brain function (see
The scans do not use ionizing radiation disorders (see metabolism, inborn errors dementia) resulting from the death of
and can be performed repeatedly. The of) of which Hurler’s syndrome is the small areas of brain tissue. It is the sec-
scanner may, however, interfere with the most well known. Mucopolysaccharidos- ond most common cause of dementia
functioning of pacemakers, hearing es are genetic disorders in which there is after Alzheimer’s disease. The disorder
aids, and other electrical devices. an abnormality of a specific enzyme, caus- occurs when clots block small blood
ing the accumulation of substances called vessels within the brain, preventing the
MRSA mucopolysaccharides in body cells. flow of blood to particular areas and
The abbreviation for methicillin-resistant SYMPTOMS thereby starving the tissue of oxygen.
STAPHYLOCOCCUS AUREUS, a bacterium that is Features may include abnormalities of The risk of developing multi-infarct
resistant to methicillin and many other the skeleton and/or the central nervous dementia is increased in people with
antibiotic drugs. It is responsible for the system, with learning difficulties and, in hypertension (high blood pressure) and
emergence of difficult-to-treat infections some cases, a characteristic facial ap- atherosclerosis (narrowing of the arteries
in hospitals and can sometimes be fatal. pearance. There may also be clouding of by fatty deposits on the artery walls).
the cornea, enlargement of the liver, and Symptoms vary depending on the
MS stiffness in the joints. part of the brain that is affected, but they
The abbreviation for multiple sclerosis. TREATMENT AND OUTLOOK become progressively worse, in distinct
No specific treatment is available; how- steps, after each attack. Symptoms in-
MSG ever, a bone marrow transplant may be clude disruption of memory, so that the
The abbreviation for the food additive used to treat Hurler’s syndrome. person cannot recall recent events or
monosodium glutamate. Mild forms of mucopolysaccharidoses gets lost in familiar surroundings; diffi-
allow a child to have a relatively normal culty in making decisions or carrying
MST Continus life. More severe types usually cause out simple tasks; and changes in mood,
A brand name for a modified-release death in childhood or adolescence. such as depression or agitation. Affected
preparation of the opioid analgesic people often experience repeated tran-
(painkilling) drug morphine. mucosa sient ischaemic attacks or strokes.
A term for mucous membrane. Diagnosis is based on the symptoms
MSU and, if necessary, confirmed by MRI or
The abbreviation for midstream speci- mucous membrane CT scanning of the brain. Antihypertensive
M men of urine: a sample to be examined The soft, pink, skinlike layer that lines drugs may be prescribed to control
for microorganisms in the urinary tract. many of the cavities and tubes in the blood pressure, and aspirin is often pre-
Allowing the first part of the stream to body, including the respiratory tract and scribed to reduce the risk of the
flow into the toilet helps clear contami- the digestive tract. Mucous membranes condition progressing. People can also
nants from the skin or urethral lining. contain cells called goblet cells, which help to protect themselves from any
secrete a fluid containing mucus. further infarcts by following a low-fat
Muckle–Wells syndrome diet and exercising regularly.
An autosomal dominant genetic disorder mucoviscidosis
that leads to amyloidosis (the formation See cystic fibrosis. multiparous
of protein deposits) in the kidneys. It A term for a woman who has had two
causes nephritis (inflammation of the mucus or more pregnancies resulting in birth
kidneys), deafness, pain in the extremi- The thick, slimy fluid that is secreted by (whether or not the fetuses were alive
ties, and recurrent urticaria with fever. mucous membranes. Mucus moistens, at the time of birth).
lubricates, and protects parts of the body
mucocele lined by mucous membranes, such as the multiple endocrine neoplasia
A sac or cavity in the body that is filled digestive and respiratory tracts. (MEN)
with mucus secreted by its inner lining. The name for a group of rare, autoso-
mucus method of contraception mal dominant genetic disorders that
mucolipidoses See contraception, natural methods of. cause tumours to develop in several of
A group of rare metabolic disorders (see the endocrine glands. Each disorder is
metabolism, inborn errors of) in which a MUGA scan caused by a different abnormal gene.
particular enzyme deficiency causes an A method of investigating how much One form of MEN causes tumours in
abnormal accumulation of lipids and blood the heart can pump with each the pancreas, parathyroid glands, and pitu-
substances called mucopolysaccharides heartbeat and whether different parts of itary gland, and sometimes also in the
in cells. The disorders appear in child- the heart wall are contracting properly. adrenal gland and the thyroid gland.
hood; they may cause learning difficulties The patient’s red blood cells are injected Another, less common form produces
and a variety of physical abnormalities. with a radioactive isotope to enable an tumours in the adrenal, thyroid, and
image to be formed of the blood pool parathyroid glands. Tumours may arise
mucolytic drugs within the heart at different times dur- simultaneously or at different times
Drugs that make sputum (phlegm) less ing the heart cycle. A MUGA scan, or over several years. The affected glands
sticky and easier to cough up. An exam- multiple-gated acquisition scan, uses may produce excess hormones. One
ple is acetylcysteine. ECG, a gamma camera, and a computer. type of thyroid tumour, which secretes

518
 MUMPS

the hormone calcitonin, is usually can- multiple organ failure relapse occurs. Most people have mild
cerous, but most tumours in other Loss of function in several organs at relapses and long periods of remission
endocrine glands are not. once. This life-threatening condition (relapsing–remitting MS), with few per-
Tumours are usually removed by affects the lungs (see respiratory distress manent effects. Others have a form
surgery, and the person will be moni- syndrome), kidneys and other organs, called chronic–progressive MS, becom-
tored afterwards so that any further and the circulation. It is most often trig- ing gradually more disabled from the
endocrine abnormalities can be detect- gered by overwhelming infection, but first attack. A few have a form called ful-
ed. The person’s relatives may be may also be due to shock following minant MS, which progresses rapidly in
offered screening for the abnormal severe injury. the first year of illness.
gene or the effects of the disorder (see DIAGNOSIS
familial screening). multiple personality disorder There is no single diagnostic test, but MRI
A rare disorder in which a person has may show damage to white matter in the
multiple-gated acquisition scan two or more distinct personalities, each brain, and a lumbar puncture may show
See MUGA scan. of which dominates at different times. abnormal proteins in the fluid around
Each personality may be unaware that the spinal cord. Evoked response tests on
multiple myeloma the others exist. The transition from one the eyes may reveal disruption of the
A rare, cancerous disorder, also called personality to another is often sudden, nerve pathways from the optic nerves.
myelomatosis, in which plasma cells in and may be triggered by stress.The con- TREATMENT
the bone marrow proliferate uncontrol- dition is thought to result from severe There is no specific treatment. A short
lably and function incorrectly. It is more emotional trauma, such as violent sexual course of corticosteroid drugs may reduce
common in elderly people. abuse, during childhood. the severity of relapses, while beta inter-
CAUSE feron can lengthen the time between
Plasma cells are a type of B-lymphocyte multiple pregnancy attacks; however, these drugs do not
that produce immunoglobulins, which See pregnancy, multiple. improve the outlook.The use of rehabili-
help protect against infection. In multi- tation, physiotherapy, and occupational
ple myeloma, the proliferating plasma multiple sclerosis therapy is essential so that people can
cells produce excessive amounts of one A progressive disease of the central ner- carry out daily activities more easily.
type of immunoglobulin while the pro- vous system, in which patches of myelin Some people try remedies such as
duction of other types is impaired. This (the protective covering of nerve fibres) taking sunflower seed oil, following a
makes infection more likely. in the brain and the spinal cord are dis- gluten-free diet, hyperbaric oxygen ther-
SYMPTOMS rupted. The damaged patches are called apy, or having various vaccines. To date, M
Proliferation of the abnormal cells plaques. The nerves cannot conduct however, there is no evidence that any
in the bone marrow causes pain and electrical impulses, so functions such as of these measures are beneficial.
destroys the bone tissue. Affected verte- movement and sensation may be lost.
brae may collapse and compress the Any part of the central nervous system multivitamins
spinal cord or spinal nerves, causing may be affected. Over-the-counter preparations, contain-
numbness or paralysis. As bone is des- CAUSES AND INCIDENCE ing a combination of vitamins, that are
troyed, levels of calcium in the blood There may be a genetic predisposition, used as a dietary supplement. (See vita-
increase, as may the levels of one or because MS sometimes runs in families. min supplements.)
more immunoglobulins. These changes There may also be an environmental
in the blood may lead to damage of the cause. It is more common in temperate mumps
kidneys, resulting in kidney failure. There zones than in the tropics. An acute viral illness usually occurring
may also be anaemia and a tendency for SYMPTOMS in childhood. The main symptom is in-
abnormal bleeding. MS usually develops between the ages of flammation and swelling of one or both
DIAGNOSIS AND TREATMENT 20 and 45, and is more common in
The disease is diagnosed by a bone mar- women. Symptoms depend on the area
row biopsy, blood tests or urinalysis, and of the brain or spinal cord that is
X-rays. Treatment includes radiotherapy involved in an attack. Spinal cord dam-
for localized bone deposits, to relieve age may cause tingling, numbness,
pain and reduce the risk of fractures; weakness in the extremities, spasticity,
anticancer drugs to slow the course of paralysis, and incontinence. Damage to
the disease; correction of associated white matter (myelinated nerves) in the
problems, such as kidney failure; and brain may cause fatigue, vertigo, clumsi-
supportive measures, including blood ness, muscle weakness, slurred speech,
transfusions, antibiotic drugs, and anal- blurred vision, facial numbness, or
gesic drugs (painkillers). No treatment facial pain. For further information see
provides a cure, however. Features of multiple sclerosis box, overleaf.
The outlook for multiple myeloma An attack may last for several weeks
varies depending on the severity of the or months. It is followed by a variable
Appearance of mumps
illness. Some people remain well for period of remission, in which dramatic The swelling may be present on either or both
months or years, and then the progres- improvements may be made. After a sides and can give the affected child’s face a
sion of the disease accelerates. remission period, a further attack or a bloated appearance.

519
 MUNCHAUSEN’S SYNDROME

FEATURES OF MULTIPLE SCLEROSIS

The disease can affect any area of the white matter of the brain destroyed. The affected fibres cannot conduct nerve impulses,
and spinal cord. The plaques of demyelination are areas in so functions such as movement and sensation may be lost.
which the fatty myelin sheaths of the nerve fibres have been The patchy distribution of plaques causes very varied effects.

AFFECTED AREAS

The brain and spinal cord control Vision

all parts of the body, so damage The optic nerves may be
involved, causing severe
to these parts by multiple (but usually temporary)
sclerosis may affect any loss of the centre of the
Multiple sclerosis function or any organ. visual field.
and the spine
Multiple sclerosis
often affects nerve Strength
fibres in the spinal Coordination Damage to the
cord, thus blocking When the nerve fibres in the nerve fibres in the
brainstem are involved, there spinal cord can
impulses to and from may be incoordination, loss of cause weakness
the brain. balance, and double vision. and heaviness in
the arms.

Cell body Nerve fibre

Sensation Bladder
The nerve tracts that carry In people severely
impulses for sensation are affected by multiple
often involved. This causes sclerosis, spinal cord
areas of numbness, or a damage often leads to
feeling of pins-and-needles incontinence due to loss
in the skin. of sphincter control in
Myelin Demyelinated the bladder.
sheath area
M
Movement
Plaques on the long
motor nerve tracts in
the brain or spinal cord
may affect walking,
sometimes causing
Balance dragging of one leg or
Normal Abnormal Damage to nerves in a feeling of weakness.
the brain stem may
Effects of multiple sclerosis affect balance.
The fibre of the nerve tract is not usually
destroyed, but the loss of insulating myelin
alters normal ion movements, so that the fibre
can no longer conduct impulses.

parotid glands,
which are situated inside glands then become swollen and tender. Munchausen’s syndrome
the angle of the jaw. One attack of A fever and headache may develop. The A chronic factitious disorder in which a
mumps confers lifelong immunity. Since swelling subsides within a week to ten person complains of physical symptoms
routine MMR vaccination, epidemics of days. When only one gland is affected, that are pretended or self-induced in
mumps no longer occur. the second gland often swells as the order to play the role of patient.
CAUSE swelling in the first subsides. The usual complaints are abdominal
The mumps virus is spread in airborne COMPLICATIONS pain, bleeding, neurological symptoms,
droplets. The incubation period is two to Mumps may lead to a number of other rashes, and fever. People typically
three weeks; an affected person is in- conditions including viral meningitis (in- invent dramatic histories. Most suffer-
fectious for about a week before and up flammation of the membranes covering ers are repeatedly admitted to hospital,
to two weeks after symptoms appear. the brain and spinal cord), pancreatitis and many have detailed medical knowl-
SYMPTOMS (inflammation of the pancreas), or, in edge and scars from self-injury or
Infected children often have no symp- adolescent or adult males, epididymo- previous treatment. In Munchausen’s
toms, or they may feel slightly unwell orchitis (inflammation of the testes). syndrome by proxy, parents simulate
and have some discomfort around the DIAGNOSIS AND TREATMENT disorders in children.
parotid glands. In more serious cases, Diagnosis is usually made from the Treatment consists of protecting the
there is pain around the glands and symptoms.There is usually no treatment; sufferers from unnecessary operations
chewing becomes difficult; one or both rest and painkillers may ease symptoms. and drug treatments.

520
 MUSCLE ENZYMES

mupirocin muscular system). They are called volun- blood vessels, airways, and bladder. It is
An antibacterial cream or ointment used tary muscles because they are under also called involuntary muscle, because
to treat skin infections such as impetigo. conscious control (see The body’s mus- it is not under conscious control.
cles box, overleaf). The muscle is made of long, spindle-
mural aneurysm Skeletal muscles comprise groups of shaped cells, and contracts by the same
A dilated, weakened area in the wall of muscle fibres arranged in bundles called action of actin and myosin as skeletal
the left ventricle in the heart; also called fascicles. A fibre is made up of longi- muscle. It is stimulated by the autonomic
a ventricular aneurysm. tudinal units called myofibrils, the nervous system; it also responds to hor-
working units of which are filaments of mones and to levels of chemicals in the
mural thrombus actin and myosin (two proteins that fluid around the muscle.
A thrombus (blood clot) on the inner wall control contraction). Impulses from the CARDIAC MUSCLE
of a heart chamber, usually a ventricle brain cause the myosin filaments to Cardiac muscle (also called myocardium)
(lower chamber).The clot develops on an slide over the actin, making the muscle is found only in the heart. It is able to
area of tissue that has been damaged by fibres contract and move the body. Con- contract continually and rhythmically,
a myocardial infarction (heart attack). versely, nerve fibres in the muscle about 100,000 times a day. Contraction is
register the force of contraction (while stimulated by the autonomic nervous
murmur nerves in the tendon register how much system, by hormones, and by the stretch-
A sound caused by turbulent blood flow it has stretched) and transmit this infor- ing of muscle fibres. The initial electrical
through the heart, as heard through a mation back to the brain, which limits stimulus comes from the sinoatrial node;
stethoscope. Heart murmurs are regarded the strength of the contraction. The it spreads through specialized conduction
as an indication of possible abnormal- muscle activity is affected by changes in cells that form a network throughout the
ities in the blood flow. Apart from the chemical composition of the fluid muscle fibres.The fibres are joined end to
innocent murmurs, the most common that surrounds the muscle cells. A fall in end by areas of extensive folds that enable
cause of extra blood turbulence is a dis- the level of potassium ions causes mus- contractions to be transmitted rapidly
order of the heart valves. Murmurs can cle weakness; a decrease in calcium ions from one fibre to another.
also be caused by some types of con- causes muscle spasm. DISORDERS
genital heart disease (see heart disease, A state of partial contraction is con- The most common disorders are injury
congenital) or by rarer conditions such stantly maintained, even when the and lack of blood supply to a muscle.
as a myxoma in a heart chamber. (See muscles are not moving; this is called (See also Disorders of muscle, overleaf.)
also systolic murmur.) muscle tone (see tone, muscle). Some dis-
orders may cause abnormalities in muscle enzymes M
muscle muscle tone, such as excessive rigidity Proteins that regulate the rate of chemi-
A structure composed of bundles of (spasticity) or floppiness (hypotonia). cal reactions in muscle cells. Measuring
specialized cells, which are capable of SMOOTH MUSCLE the blood levels of muscle enzymes (see
contraction and relaxation to create This type of muscle exists in the walls of blood tests) can help doctors to diagnose
movement. There are three types of internal organs. It produces movements certain disorders. One such disorder is
muscle: skeletal, smooth, and cardiac. such as peristalsis in the intestine and myocardial infarction (heart attack), in
SKELETAL MUSCLE contractions of the uterus in childbirth. which damaged heart muscle leaks high-
The skeletal muscles are the most prom- Smooth muscle also forms part of the er than normal levels of enzymes into
inent muscle group in the body (see lining of hollow structures such as the the blood. Another is muscular dystrophy,

MUSCLE TYPES

In each main muscle type, the fibres form Cardiac muscle Large intestine
a distinctive structure that enables the
muscle to fulfil a specific function. Myofibril
Small intestine

Muscle fibre Muscle

Skeletal muscle Muscle
Cell cell
fibres Myofibril Cell nucleus
nucleus
Cell
nucleus

Skeletal muscle Cardiac muscle Smooth muscle

Long bundles of muscle fibres, each containing This muscle comprises short, branching cells In smooth muscle, loosely woven, tapering cells
myofibrils (contractile elements), allow skeletal that interconnect, so that nerve signals can form flat sheets of tissue. Contraction is slower
muscle to contract briefly but powerfully. spread instantly throughout the heart. than in other muscle types.

521
 MUSCLE ENZYMES

THE BODY’S MUSCLES

The most prominent muscles in the body are the skeletal are indicated on the illustration below. In contrast, many
muscles, which account for 40 to 45 per cent of body weight. of the internal organs, such as the heart and the intestines,
These muscles are defined as voluntary because they are consist partly or entirely of involuntary muscle, which is
under conscious control; some important voluntary muscles not under conscious control.

Portion of rhomboideus
Cranial muscles
Facial muscles
Sternocleidomastoid
Trapezius
Trapezius Pectoralis major

Infraspinatus
Deltoid
Rectus abdominis
Teres minor
Deltoid
Serratus anterior
Teres major

Biceps Triceps

Latissimus
dorsi

Obliquus
M externus Extensors
of wrist and
Tensor fingers
fasciae latae
Gluteus
maximus
Adductors
of thigh Adductor
magnus
Sartorius
Semimembranosus
Flexors of
wrist and Semitendinosus
Rectus femoris
fingers

Biceps femoris
Vastus medialis Gracilis

Plantaris

Peroneus longus Vastus lateralis

Tibialis anterior Gastrocnemius

Gastrocnemius Soleus
Extensor digitorum
longus
Peroneus brevis

Achilles tendon
(calcaneal tendon)

Front view (male) Back view (female)

522
 MUSCLE SPASM

in which the raised levels of muscle such as multiple sclerosis and painful The drugs may cause muscle weakness
enzyme are due to the death of muscle muscular conditions such as torticollis. and drowsiness. In rare cases, dantro-
cells. Enzymes leaked from the heart They are occasionally used to relieve lene causes liver damage.
muscle differ from those from skeletal muscle rigidity due to injury. Some
muscle; this distinction helps doctors to types of muscle-relaxant drugs are used muscle spasm
identify the site of the muscle damage. to cause temporary paralysis during Sudden and involuntary contraction of a
surgery under general anaesthesia. muscle. Spasm is a reaction to pain and
muscle-relaxant drugs Most muscle-relaxant drugs partially inflammation around a joint. Common
A group of drugs that are used to relieve block nerve signals that stimulate mus- causes are strain, disc prolapse (slipped
muscle spasm and spasticity. Muscle- cle contraction. Dantrolene, in contrast, disc), and stress. Usually, the underlying
relaxant drugs are used mainly in the interferes with the chemical activity in cause is treated. Muscle-relaxant drugs
treatment of nervous-system disorders muscle cells needed for contraction. may also be needed. (See also spasticity.)

DISORDERS OF MUSCLE

The most common muscle disorder is way; it causes widespread muscle spasm that move the eyes, causing a bulging
injury, followed by symptoms caused through the release of a powerful toxin. eyeball (see exophthalmos). Adrenal
by a lack of blood supply to a muscle Viruses (especially influenza B) may failure (see Addison’s disease) causes
(including the heart muscle). There are also infect muscles (causing myalgia), as general muscle weakness.
also various other, rare disorders that may the organism causing toxoplasmosis.
can affect the muscles. Lastly, a parasitic disease called trichinosis Poisons and drugs
can occur in muscle tissue. This disease Several toxic substances can damage
Injury results from infestation with the worm muscle tissue. Alcohol can cause
Muscle injuries, such as tears and TRICHINELLA SPIRALIS, which is acquired by damage following a prolonged drinking
strains, are very common. They cause eating undercooked meat (usually pork). bout. Other substances that may cause
bleeding into the muscle tissue. Healing muscle damage include the drugs
may lead to the formation of a scar in Tumours chloroquine and vincristine.
the muscle, which shortens its natural Various forms of tumour may originate
length. Blunt injury may result in the in the muscles. Such tumours, called Genetic disorders
formation of a haematoma (a localized
collection of blood) from bleeding into
primary muscle tumours, may or may not
be cancerous. Noncancerous tumours are
These disorders include the various
forms of muscular dystrophy, which
M
the muscle. Rarely, bone may form in a called myomas; those affecting smooth cause progressive weakness and
blood clot, causing myositis ossificans. muscle are called leiomyomas, and those disability. Some types appear at birth,
developing in skeletal muscle are called some in infancy, and some develop as
Impaired blood supply rhabdomyomas. Myomas of the uterus (see late as the fifth or sixth decade.
Muscles depend on a good blood fibroids) are among the most common of Cardiomyopathy (disease of the heart
supply in order to function normally. all tumours. Cancerous tumours, called muscle) is also inherited in some cases.
A temporary lack of blood flow, which myosarcomas, are very rare; they include
is sometimes associated with severe rhabdomyosarcomas, which are cancers of Autoimmune disorders
exertion, may cause cramp. Peripheral the skeletal muscle. Myasthenia gravis is a disorder involving
vascular disease, in which blood vessels Secondary tumours, which spread from the transmission of nerve impulses to
in the legs (and sometimes the arms) a primary site of cancer elsewhere in the muscles; it usually begins with
are narrowed, restricts the blood supply, body, very rarely involve muscle. drooping of the eyelids and double
causing claudication (muscle pain on vision. Other autoimmune diseases that
exercise). Angina pectoris (chest pain Hormonal and metabolic disorders may affect the muscles are lupus
caused by lack of blood supply to heart Muscle contraction depends on the erythematosus, rheumatoid arthritis,
muscle) may occur in people with maintenance of proper levels of sodium, systemic sclerosis, sarcoidosis, and
coronary artery disease. potassium, and calcium in and around dermatomyositis.
The compartment syndrome is pain in muscle cells. Any alteration in the
muscles as a result of pressure that concentration of these substances affects
limits their blood supply. It may be muscle function. For example, a severe INVESTIGATION
brought on by injury or exercise, and drop in the level of potassium Muscle disorders are investigated by
occurs most often in athletes who have (hypokalaemia) causes profound muscle EMG (electromyography), which
well-developed muscles. weakness and may stop the heart. A drop measures the response of muscles to
in blood calcium (hypocalcaemia) causes electrical impulses, and by biopsy
Infection increased excitability of muscles and, (removal of a sample of tissue for
The most serious infection of muscle is occasionally, muscle spasms. analysis). In addition, blood tests may
gangrene, which may complicate deep Thyroid disease is often associated with be used to detect abnormal levels of
wounds (especially those contaminated muscle disorders, the most common of muscle enzymes.
by soil). Tetanus is acquired in a similar which is swelling of the small muscles

523
 MUSCLE WASTING

muscle wasting
See muscular atrophy. DUCHENNE MUSCULAR DYSTROPHY: A TYPICAL FAMILY TREE

muscular atrophy Affected males always inherit the gene for the disorder from their mothers, who
are carriers of the gene but are themselves unaffected. About half the sons of
Weakness and shrinking of muscle tis- carriers are affected; the other sons are neither affected nor carriers. The daughters
sue. Muscular atrophy may have many of carriers have a 50 per cent chance of being carriers themselves. Complex blood
possible causes, including injury, starva- tests provide the only means of knowing whether or not a certain daughter (or
tion, loss of function in a body part, granddaughter) is a muscular dystrophy carrier.
degeneration of muscle cells, and disor-
ders of the nerves supplying muscles.
Muscles can atrophy rapidly if a body Key
part is not used and if no measures are Unaffected
taken to prevent the problem. In a bro- male
ken leg, for example, muscle loss may Affected
be visible after only a week. The muscle male
fibres are not lost, however; they can
Carrier
return to normal if the muscle is stimu- female
lated and used.
Possible
muscular dystrophy carrier female
A group of rare inherited muscle disor- Unaffected
ders that cause slow, progressive wasting female
of muscle fibres. This degeneration may
lead to disability and death.
TYPES AND SYMPTOMS
The most common and severe form of
muscular dystrophy is Duchenne muscu-
lar dystrophy.This is caused by a recessive TYPES OF MUSCULAR DYSTROPHY
gene carried on the X chromosome (see Duchenne muscular In this type, the child is slow in Sometimes there is curvature
sex-linked inheritance). Boys only have one dystrophy
M X chromosome, so if they inherit a copy
learning to sit up and walk, and
does so much later than normal.
of the spine. Despite their
weakness, the muscles
of the defective gene from their mother The condition is rarely (especially those in the calves)
diagnosed before the age of appear bulky; this is because
they develop the disorder. Girls (with two three, but progresses rapidly. wasted muscle is replaced by fat.
X chromosomes) are not affected but Affected children tend to walk By about the age of 12, affected
become carriers of the defective gene. with a waddle and have children are no longer able to
Affected boys walk with a waddle, difficulty climbing stairs. In walk, few survive beyond their
find climbing difficult, and may have getting up from the floor, the teenage years, usually dying
child “climbs up his legs”, from a chest infection or heart
curvature of the spine. The disorder pushing his hands against his failure. Affected boys often have
progresses rapidly: the ability to walk is ankles, knees, and thighs. below-average intelligence.
lost by the age of 12, and few boys sur-
vive beyond the teenage years. Becker’s muscular This type produces the same more slowly. Patients often
Becker’s muscular dystrophy starts dystrophy symptoms as the Duchenne reach the age of 50. Both types
later in childhood and progresses at a type, but starts later in of dystrophy have sex-linked
slower rate. Myotonic dystrophy affects childhood and progresses much inheritance.
the muscles of the hands, face, neck,
and feet, and causes learning difficulties. Myotonic dystrophy This form affects muscles of the dystrophy is associated with
Limb-girdle muscular dystrophy mainly face, hands, and feet. Infants cataracts in middle age,
are floppy and slow to develop. baldness, mental retardation,
affects muscles in the hips and shoul- The main feature is that the and endocrine problems. The
ders, and facioscapulohumeral muscular muscles contract strongly but do condition has an autosomal
dystrophy affects muscles in the upper not relax easily. Myotonic dominant pattern of inheritance.
arms, shoulder girdle, and face. In this
last form, severe disability is rare. Limb-girdle muscular This type takes different forms. It affected. Other nerve and
DIAGNOSIS dystrophy starts in late childhood or early muscle conditions must be
A diagnosis for Duchenne muscular adult life, and progression is eliminated before this form of
slow. The muscles of the hips dystrophy can be diagnosed
dystrophy can be made with gene test- and shoulders are mainly confidently.
ing before symptoms develop. Once
muscle weakness has developed, other
Facioscapulohumeral This form usually appears first autosomal dominant pattern.
tests may be used, including measure- muscular dystrophy between the ages of 10 and 40; In this form of muscular
ment of muscle enzymes and an EMG. it affects only the muscle so the dystrophy, progression of the
TREATMENT upper arms, shoulder girdle, and weakness is slow, and severe
There is no cure, and physiotherapy is face. It is inherited in an disability is rare.
the main treatment. Remaining as active

524
 MUTATION

as possible keeps healthy muscles in poisoning appear within 20 minutes to

good condition. Surgery to the heel ten- MUSCLE MOVEMENT two hours and may include drowsiness,
dons may aid walking in some cases. visual disturbances, delirium, muscle tre-
To move a particular part of the
OUTLOOK mors, nausea, and vomiting. This type
body, a skeletal muscle contracts.
The long-term outlook depends on the It shortens and draws together the of poisoning (and other types that have
particular form. Families in which a bones to which it is attached. rapidly developing symptoms) is treated
child or adult has developed any form with gastric lavage (see lavage, gastric)
of muscular dystrophy may wish to Opposing muscles and activated charcoal. Recovery usually
consider genetic counselling. Two or more muscles, such occurs within 24 hours.
as the biceps and the
MAGIC MUSHROOMS
muscular system triceps, may oppose each
other’s actions in order to “Magic” mushrooms contain the hallu-
The muscles of the body that are move a joint. cinogen psilocybin. They may also cause
attached to the skeleton. These muscles Biceps muscle
high fever in children. The effects usual-
are responsible for voluntary move- Triceps muscle
ly last for four to six hours.
ment, and also support and stabilize the Elbow joint
skeleton. In most cases, a muscle attach- mutagen
es to a bone (usually by means of a Any agent that increases the rate of
tendon) and crosses over a joint to attach mutation (genetic changes) in cells. The
to another bone. main mutagens are ionizing radiation
FUNCTION (see radiation hazards), some chemicals,
Muscles produce movement by con- and certain illnesses.
tracting and shortening to pull on the
bone to which they are attached. They Triceps relaxes mutation
can only pull, not push, and are there- Biceps contracts A change in a cell’s DNA. Many muta-
fore arranged so that the pull of one tions are harmless; however, some are
muscle or group of muscles is opposed harmful, giving rise to cancers, birth
to another, enabling a movement to be defects, and hereditary diseases. Very
reversed. Although most actions of the rarely, a mutation may be beneficial.
skeletal muscles are under conscious CAUSES
control, reflex movements can occur in A mutation results from a fault in the
response to certain stimuli. replication of DNA when a cell divides. M
TYPES OF MUSCLE A daughter cell inherits some faulty
There are more than 600 muscles in the Moving the elbow DNA, and the fault is copied each time
body, classified according to the type of Elbow movement relies on relaxation and the new cell divides, creating a cell pop-
movement they produce. An extensor contraction of the biceps, which bends the ulation containing the altered DNA.
elbow, and the triceps, which straightens it.
opens out a joint, a flexor closes it; an Some mutations occur by chance. Any
adductor draws a part of the body agent that makes mutations more likely
inwards, an abductor moves it out- is called a mutagen.
wards; a levator raises it, a depressor DEATH CAP TYPES
lowers it; and constrictor or sphincter Most fatal cases of mushroom poison- There are several types of mutation.
muscles surround and close orifices. ing in the UK are caused by AMANITA Point mutations affect only one gene and
PHALLOIDES (death cap). This mushroom may lead to the production of defective
musculoskeletal can be confused with the edible field enzymes or other proteins. In other
Relating to muscle and/or bone. The mushroom, although it has white gills mutations, chromosomes (or parts of
musculoskeletal system is the skeleton instead of pinkish-brown ones. them) are deleted, added, or rearranged.
and the muscles attached to it. The death cap and some related spec- This type may produce greater disrup-
ies, such as AMANITA VIROSA (destroying tive effects than point mutations.
musculoskeletal pain angel), contain poisons called amanitins, EFFECTS
Pain in the bones, joints, muscles, or which attack cells in the liver, kidneys, If a mutated cell is a somatic (body)
other parts of the musculoskeletal sys- and small intestine. Symptoms such as cell, it can, at worst, multiply to form a
tem. Such pain may have a wide variety severe abdominal pain, vomiting, and group of abnormal cells. These cells
of causes, from fever and temporary diarrhoea usually develop 8 to 14 hours often die out, are destroyed by the
injuries to soft tissues (such as muscle after eating the mushrooms. Later, there body’s immune system, or have only a
or tendon strains and ligament sprains) may be liver enlargement and jaundice, minor effect. Sometimes, however, they
to severe diseases such as arthritis. which may lead to death from liver fail- may become a tumour.
ure. There is no antidote; treatment A mutation in a germ cell (immature
mushroom poisoning consists of supportive measures only. egg or sperm) may be passed on to a
There are numerous species of poiso- For people who survive, recovery usual- child, who then has the mutation in all
nous mushrooms and toadstools in the ly occurs after about a week. of his or her cells. This may cause an
UK, but many have an unpleasant taste FLY AGARIC obvious birth defect or an abnormality
and are therefore unlikely to be eaten in AMANITA MUSCARIA(fly agaric) has a red in body chemistry. The mutation may
sufficient amounts to cause problems. cap flecked with white. Symptoms of also be passed down to the child’s

525
 MUTISM

descendants. Genetic disorders (such as Blood testsand EMG are also sometimes produces a non-itchy, red, scaly rash,
haemophilia and achondroplasia) stem used. In some cases, CT scanning or MRI which may spread slowly or remain
from point mutations that occurred in may be performed to detect a thymoma. unaltered for many years. In more severe
the germ cell of a parent, grandparent, TREATMENT AND OUTLOOK forms, thickened patches of skin, ulcers,
or more distant ancestor. Chromosomal Drugs that facilitate the transmission of and enlarged lymph nodes may develop.
abnormalities (such as Down’s syndrome) nerve impulses can often restore a per- Diagnosis is confirmed with a skin
are generally due to mutations in the son’s condition to near normal. In some biopsy.Treatment may include PUVA, rad-
formation of parental eggs or sperm. people, the condition may improve, and iotherapy, nitrogen mustard, anticancer
is sometimes cured, with thymectomy drugs, and corticosteroid drugs.
mutism (removal of the thymus gland). In more
Refusal or inability to speak. Mutism severe cases, regular plasmapheresis may mydriasis
may be a symptom of profound con- be carried out. Corticosteroid drugs may Dilation (widening) of the pupil of the
genital deafness, severe manic–depressive also be given to suppress immune sys- eye. Mydriasis occurs in the dark; with
illness, catatonic schizophrenia, or a rare tem activity. In a few people, however, emotional arousal; after the use of
form of conversion disorder. The term paralysis of the throat and respiratory certain eye-drops (for example those
“mutism” may also be used of a reli- muscles may lead to death. containing atropine); and also after
gious vow of silence. drinking alcohol.
Elective mutism is a rare childhood mycetoma
disorder (usually starting before age five) An uncommon tropical infection affect- mydriatic drugs
in which a child can speak properly but ing skin and bone. Mycetoma is caused A group of drugs used to treat uveitis
refuses to do so most of the time. by fungi or by bacteria called actino- and to dilate the pupil during examina-
Akinetic mutism is a state of passivity mycetes. It usually occurs on one limb, tion of the inside of the eye and for
caused by some brain tumours or by causing a hard swelling and a discharge surgery. Mydriatics work by relaxing the
hydrocephalus (fluid surrounding the of pus. Infections caused by actinomy- circular muscles of the iris, causing the
brain). Affected people are incontinent, cetes are treated with antibiotic drugs. pupil to dilate. Common mydriatic
require feeding, and respond at most Surgical removal of diseased tissue may drugs include tropicamide, cyclopento-
with a whispered “yes” or “no”. be necessary for a fungal infection. late, homatropine, and phenylephrine.
(See also cycloplegia; miotic drugs.)
myalgia mycobacterial infections
Medical term for muscle pain. Diseases caused by bacteria from the myectomy
M MYCOBACTERIUM group (see tuberculosis; Surgical removal of part or all of a mus-
myalgic encephalomyelitis Hansen’s disease). An increasing range cle. Myectomy may be performed to
Also known as ME, an alternative name of mycobacterial infections is recog- treat severely injured and infected mus-
for chronic fatigue syndrome. nized in immunocompromised people, cles or to remove a fibroid (an operation
such as those with AIDS. called a myomectomy) from the muscular
myasthenia gravis wall of the uterus.
A rare disorder in which the muscles mycology
become weak and tire easily. The mus- The study of fungi. myel-
cles of the eyes, face, throat, and limbs A prefix denoting a relationship to bone
are most commonly affected. mycophenolate mofetil marrow (as in multiple myeloma) or to
CAUSE An immunosuppressant drug used after the spinal cord (as in myelitis). The pre-
Myasthenia gravis is an autoimmune dis- organ transplants to reduce the risk of fix “myelo-” has the same meaning.
order. In many cases, abnormalities in the body rejecting the organ.
the thymus gland are present, and in myelin
some cases a thymoma (tumour of the mycoplasma The fatty material made of lipid (fat)
thymus gland) is found. Women are af- Any of a group of bacteria that are the and protein that forms a protective
fected more often than men. smallest type capable of free existence. sheath around some nerve fibres and
SYMPTOMS Mycoplasmas are about the same size as increases the efficiency of nerve impulse
The disease is extremely variable in its viruses but, unlike viruses, are capable transmission. (See also demyelination).
effects. In most cases, it causes drooping of reproducing outside living cells. One
eyelids, double vision, a blank facial species, MYCOPLASMA PNEUMONIAE, causes myelitis
expression, and a weak, hoarse, nasal primary atypical pneumonia. Inflammation of the spinal cord. It is
voice that is hesitant and becomes slur- often caused by a viral infection. In
red during extended conversation. The mycosis transverse myelitis, the spinal cord be-
arm and leg muscles may also be affec- Any disease caused by a fungus. (See comes inflamed around the middle of
ted. In severe cases, the respiratory fungal infection; fungi.) the back. Common symptoms are back
muscles may become weakened, caus- pain and gradual paralysis of the legs; in
ing breathing difficulty. mycosis fungoides some cases, the paralysis becomes per-
DIAGNOSIS A rare type of lymphoma that primarily manent. (See also poliomyelitis).
One common test is injection of the drug affects the skin of the buttocks, back,
edrophonium into a vein, which tempor- or shoulders. The cause is unknown. In myelocele
arily restores power to the weak muscles. its mildest form, mycosis fungoides Another name for myelomeningocele.

526
 MYOCARDIAL INFARCTION

marrow to produce blood cells. Myelo- risk factors include increased age, an
sclerosis may be primary (with no unhealthy diet, obesity, and disorders
Nerve cell body obvious cause) or secondary (resulting such as hypertension (high blood pres-
from another bone marrow disease). sure) and diabetes mellitus.
The main symptoms of myelo- SYMPTOMS
sclerosis are those of anaemia. In addi- There is a sudden, crushing pain that
tion, enlargement of the spleen, night starts in the centre of the chest and may
sweats, loss of appetite, and weight spread into the arms or up to the jaw.
loss commonly occur. In secondary Breathlessness, restlessness, clammy skin,
Myelin sheath myelosclerosis, the underlying disease and nausea and/or vomiting may also
may cause other symptoms. occur. In some cases, the first symptom
Treatment of primary myelosclerosis is sudden collapse and loss of con-
includes blood transfusions to relieve the sciousness. A few people have only mild
Axon symptoms. A few people, however, may symptoms or have none at all; this type
Muscle fibre develop acute leukaemia. Treatment of of heart attack is known as a silent
secondary myelosclerosis depends on myocardial infarct.
the underlying cause. The damage to the heart tissue may
cause immediate heart failure (reduced
The myelin nerve sheath
The axon is the conducting fibre of a nerve. To
myiasis pumping efficiency) or arrhythmias
transmit impulses more efficiently, some nerve Infestation by fly larvae; the condition is (irregular heartbeat). Ventricular fibrilla-
axons have a myelin sheath. primarily restricted to tropical areas. In tion is the most dangerous form of
Africa, the tumbu fly lays eggs on wet arrhythmia; it prevents the heart from
myelofibrosis clothing left outside; the larvae hatch pumping effectively and, if untreated, is
An alternative term for myelosclerosis. and penetrate the skin to cause swel- fatal within a few minutes.
lings like boils. Other flies lay eggs in DIAGNOSIS
myelography open wounds, on the skin, or in the Diagnosis is made from the patient’s
X-ray examination of the spinal cord, ears or nose. Sometimes, larvae pene- history, together with an ECG. Tests are
nerves, and other tissues within the trate deeply into the tissues. Intestinal also carried out to measure levels of
spinal canal after injection of a contrast infestation can occur after eating food certain enzymes, and of a protein called
medium (a substance that is opaque to that has been contaminated. troponin, which are released into the
X-rays). The procedure has now been Myiasis of the skin is treated by blood from damaged heart muscle. M
replaced by CT scanning and MRI. applying drops of oil to the swelling. TREATMENT
The larva comes to the surface, where it A myocardial infarction is a medical
myeloid leukaemia can be carefully removed. In deeper tis- emergency. A person who suspects that
See leukaemia, chronic myeloid. sues, surgery may be required. Intestinal he or she is having a heart attack should
myiasis is treated with a laxative. Preven- chew an aspirin tablet, which will help
myeloma, multiple tive measures include keeping flies away to dissolve the clot in the artery. He or
See multiple myeloma. from food, keeping open wounds cov- she should then be taken to hospital as
ered, and ironing clothes that have been soon as possible.
myelomatosis dried outdoors. Initially, oxygen and diamorphine are
See multiple myeloma. given in order to relieve the pain and
myo- intravenous thrombolytic drugs may be
myelomeningocele A prefix denoting a relationship to mus- given to dissolve the blood clot (unless
A congenital abnormality seen in spina cle (as in myocarditis). there is a risk that the drugs will cause
bifida. An affected baby has a raw swelling excessive bleeding).
over the spine, containing an exposed, myocardial infarction Afterwards, patients are monitored in
malformed section of the spinal cord and Sudden death of part of the heart mus- an intensive care or coronary care unit
its meninges (protective membranes). cle due to a blockage in the blood so that any complications, such as heart
supply to that area of the heart. The dis- failure, arrhythmias (see arrhythmia, car-
myelopathy order is popularly known as a heart diac), or rupture of a heart valve can be
A disease or disorder of the spinal cord. attack. Myocardial infarction is the most detected and treated as early as possible.
common cause of death in the UK. If thrombolytic drugs have failed to re-
myeloproliferative disorders CAUSES store blood flow in the affected artery,
Conditions characterized by the abnor- The usual cause is atherosclerosis of the surgery may be considered (see angio-
mal proliferation of one or more blood coronary arteries. In this condition, plasty, balloon; coronary artery bypass graft).
cell groups within the bone marrow. (See plaques (fatty deposits) develop on the On leaving hospital, patients may be
leukaemia; polycythaemia.) artery walls; a clot may then form over advised to take aspirin, beta-blocker
a plaque and block an artery (see Features drugs to protect the heart muscle, and
myelosclerosis of myocardial infarction box, overleaf). statin drugs to lower blood cholesterol.
An increase of fibrous tissue within the Men are more likely to have a heart ACE inhibitors are also given to treat
bone marrow (also called myelofibrosis), attack than women, and smokers are at heart failure or impaired function of the
which interferes with the ability of the greater risk than nonsmokers. Other left ventricle. In addition, people will

527
 MYOCARDIAL ISCHAEMIA

FEATURES OF MYOCARDIAL INFARCTION

Myocardial infarction (heart attack), in which an area of heart muscle is

deprived of blood and suffers tissue death as a result, causes severe pain and RISK FACTORS
can be fatal. Most cases result from atherosclerosis of the coronary arteries, a
condition in which plaques (patches of fatty deposits) collect inside the arteries.
• Uncontrollable factors include family history of
heart disease, increasing age, and being male.
Aorta
• Cigarette smokers have a substantially
increased risk of dying of myocardial infarction.

Left pulmonary artery • High blood pressure is a major risk factor, and
the risk increases the higher the pressure.

• The risk of atherosclerosis and coronary artery

Right coronary artery disease increases dramatically in those who
are more than 30 per cent overweight.
Left coronary artery

• A raised blood cholesterol level (for which

Blood clot there may be a genetic tendency) increases
the risk. A high-fat diet is also a factor.

Left ventricle • Physical inactivity is also a major risk factor.

PAIN

Heart muscle Some people who suffer myocardial infarction have a history of angina pectoris,
in which blood flow through the coronary arteries is impaired but the resulting
chest pain is relieved by rest. The pain of infarction usually comes on suddenly,
M Outer layer and ranges from a tight ache to intense, crushing agony. It lasts for longer than
10 minutes, and is not relieved by rest.
Blood clot
Central chest Jaw to back
A feeling of In some cases,
pressure in the pain radiates
Fatty deposit central chest, up into the
(atheroma)
ranging from mild jaw and through
to severe, occurs to the back.
in almost every Sometimes, it
myocardial occurs only in
infarction that is these places.
due to coronary
Inner obstruction.
lining
Chest to arm Upper abdomen
Atherosclerosis
In many cases, More rarely, pain
Plaques of atheroma develop on the inner lining
pain radiates from may be felt in the
of the arteries, restricting the blood flow. The
the chest down upper abdomen.
plaques develop a fibrous covering, which may
the left arm; it may If it occurs only
rupture or become roughened. Platelets (tiny
cause a feeling of here, it may be
blood cells) may then stick to the plaque and
weakness in the mistaken for
trigger the formation of a blood clot. The clot may
arm muscles. another disorder.
completely block the artery, causing a sudden
stoppage of blood flow to the heart.

undergo a rehabilitation programme to deposits on the walls of arteries). Myocar- SYMPTOMS

help them return to full activity and to dial ischaemia causes the heart muscle to There are often no symptoms. Rarely,
increase awareness of risk factors. be deprived of oxygen, and may give rise there may be a serious disturbance of
to problems such as angina pectoris and the heartbeat, breathlessness, chest pain,
myocardial ischaemia myocardial infarction (heart attack). and heart failure. In severe cases of
An insufficient blood supply to the heart myocarditis, death may result from
muscle. It is usually caused by narrowing myocarditis cardiac arrest.
or blockage of the coronary blood vessels Inflammation of heart muscle, usually DIAGNOSIS AND TREATMENT
(which supply the heart muscle), due to due to coxsackievirus infection. It is also Myocarditis may be suspected from the
atherosclerosis (an accumulation of fatty a characteristic feature of rheumatic fever. patient’s history and from a physical

528
 MYXOVIRUS

examination. An ECG will show charac- myopathy feature of myotonic dystrophy, a form
teristic abnormalities of the heartbeat. A disease of muscle that is not caused by of muscular dystrophy.
Diagnosis also involves echocardiography disease of the nervous system. A myopa-
and blood tests. thy may be an inherited disorder, such myringitis
There is no specific treatment. Bed as muscular dystrophy; it may also be Inflammation of the eardrum. Myringi-
rest is usually recommended and cortico- caused by chemical poisoning, a chronic tis occurs in otitis media.
steroid drugs may be prescribed. disorder of the immune system, or a
metabolic disorder. myringoplasty
myocardium Surgical closure of a perforation (hole)
The middle of the three layers of mus- myopia in the eardrum (see eardrum, perforated)
cle that make up the wall of the heart. An error of refraction, commonly called by means of a tissue graft (see grafting).
The myocardium is composed of car- shortsightedness, in which distant ob-
diac muscle. (See also cardiomyopathy; jects appear blurred. It is caused by the myringotomy
myocardial infarction; myocardial isch- eye being too long from front to back. A surgical opening made through the
aemia; myocarditis.) As a result, images of distant objects are eardrum to allow drainage of the mid-
focused in front of the retina. dle-ear cavity. It is usually performed to
myoclonus Myopia, which tends to be inherited, treat persistent glue ear in children. A
Rapid, uncontrollable jerking or spasm usually appears around puberty, increas- grommet may be inserted into the
of one or more muscles, either at rest ing until the early 20s. If it starts in eardrum at the same time.
or during movement. Myoclonus may early childhood it may become severe.
be associated with a muscular or ner- The condition is detected during a myxoedema
vous disorder, but it also occurs in vision test. Treatment is with concave A condition in which the skin and other
healthy people; for example, when the glasses (or contact lenses) or by photo- body tissues (most noticeably in the
limbs twitch before sleep. refractive keratectomy or LASIK. face) thicken and coarsen. Myxoedema
is usually due to hypothyroidism.The term
myofascial pain syndrome myosin “myxoedema” is sometimes used of
See temporomandibular joint syndrome. A major protein component of muscle adult hypothyroidism.
fibres. Together with actin, it provides
myoglobin the mechanism for muscles to contract. myxoma
An oxygen-carrying pigment found in The myosin molecules slide along the A noncancerous, jellylike tumour com-
muscles. Myoglobin consists of a com- actin filaments in order to make the posed of soft mucous material and loose M
bination of iron and protein. It stores muscle fibres shorten. fibrous strands. Myxomas usually occur
oxygen, releasing it when it is needed singly, and may sometimes grow very
by the muscles. myositis large. They may develop under the skin,
Myoglobin may be released into the Inflammation of muscle tissue, causing in the abdomen, or, very rarely, in the
urine, causing myoglobinuria. Slight pain, tenderness, and weakness. Types heart chambers. In this last case, thrombi
myoglobinuria may result from pro- include myositis ossificans, polymyositis, (blood clots) may form, and the blood
longed exercise. Severe myoglobinuria and dermatomyositis. flow through the heart may be obstruct-
is usually due to the release of myo- ed. Myxomas can usually be successfully
globin from a large area of damaged myositis ossificans removed by surgery.
muscle, and may cause kidney failure. A congenital (present from birth) or ac-
quired condition in which bone is myxovirus
myoma deposited in muscles. The congenital One of a group of RNA-containing viruses
A noncancerous muscle tumour. (See form is rare. The first symptoms are that are responsible for various human
also fibroid.) painful swellings in the muscles, which and animal diseases.There are two fami-
gradually harden and extend until the lies of myxovirus: the paramyxovirus and
myomectomy affected child is encased in a rigid sheet. the orthomyxovirus.
Surgical removal of a myoma. The term There is no treatment, and death results.
is also used to describe the surgical The acquired form may develop after
removal of fibroids from the uterus. a bone injury, especially around the
elbow; it causes severe pain and a
myometrium swelling that hardens. Treatment with
The muscular wall of the uterus. It is diathermy, and gentle, active move-
composed of smooth muscle and lined ments, may be helpful.
with endometrium. The myometrium
contracts strongly during childbirth in myotomy
order to dilate the cervix and push the A surgical procedure that involves cut-
fetus (and the placenta) out of the ting into a muscle.
uterus. It also undergoes much smaller
contractions during menstrual periods, myotonia
which help to expel blood and tissue Inability of a muscle to relax after the
(see menstruation). need for contraction has passed. It is a

529
 NABILONE

N
has an autosomal dominant pattern of A spider naevus is another example of a
inheritance (see genetic disorders) and vascular naevus. These are common in
affects both males and females. children and pregnant women.
TREATMENT
naevus Most naevi are harmless. If, however, a
A type of blemish on the skin. There are naevus suddenly appears, grows, bleeds,
two main groups of naevus: pigmented or changes colour, medical advice should
naevi, which are caused by an abnormal- be sought immediately to exclude skin
ity in or overactivity of melanocytes cancer. Permanent birthmarks can be
(skin cells that produce the brown pig- treated with laser treatment.
ment melanin); and vascular naevi, which
nabilone result from an abnormal collection of nail
An antiemetic drug derived from mariju- blood vessels near the surface of the skin. A hard, curved plate, found on each of
ana. Nabilone is used to treat patients PIGMENTED NAEVI the fingers and toes, composed of keratin
suffering from the nausea and vomiting The most common type of pigmented (a tough protein that is also the main
caused by anticancer drugs that have not naevus is a freckle, which is a small, flat, constituent of skin and hair). Nails grow
responded to other treatments. light-brown to dark-brown area that may from an area called the nail bed. At the
occur on any part of the body exposed to base of each nail, a half-moon shape (the
nabothian cyst the sun.The tendency to develop freckles lunula) is crossed by a flap of skin known
A cyst (a small fluid-filled swelling or on exposure to the sun is inherited; they as the cuticle.The surrounding skin is the
lump) that develops on the cervix (the are more common in people with fair nail fold. A fingernail takes about six
neck) of the uterus when the ducts of skin and red hair. A lentigo, sometimes months to grow from its base to its tip,
a mucous gland become obstructed. A called an age spot or liver spot, is a light- although there are seasonal growth varia-
nabothian cyst, which is also known as brown spot similar to a freckle. These tions; and toenails take twice as long.
a nabothian follicle, is harmless and spots most commonly affect people over DISORDERS
requires no treatment. the age of 40 and appear both on cov- The nails are susceptible to damage
ered and on sun-exposed areas of the through injury, usually as a result of
NAD body. Café au lait spots are another type of crushing or pressure on the nail. Nails
The abbreviation for nicotinamide ade- light-brown pigmented naevus. may also be damaged by bacterial or
nine dinucleotide, which is a coenzyme Another common type of pigmented fungal infections, especially tinea and
(an organic compound that plays an naevus is a mole, which is sometimes candidiasis (thrush). In paronychia, it is
essential role in a reaction catalyzed by called a melanocytic naevus. Moles are the nail folds that are infected. Some-
N an enzyme) derived from nicotinic acid. brown to dark-brown in colour and usu- times the nails can become abnormally
NAD acts as a hydrogen acceptor (form- ally measure less than 1 cm in diameter.
ing NADH) in the chemical process that Moles can form anywhere on the body
produces energy within cells. and a tendency to develop them some- ANATOMY OF A NAIL
times runs in families. Moles may appear
nadolol soon after birth (see birthmark) or during
The nail bed is the area from which
the nail grows. At the base of each
A beta-blocker drug used to treat hyper- childhood and early adolescence; almost nail, a half-moon shape, the lunula,
tension (high blood pressure), angina all adults have between ten and 20 moles is crossed by a flap of skin, the
pectoris (chest pain due to impaired by the time they are 30. Most moles are cuticle. The skin that surrounds
blood supply to the heart muscle), and noncancerous, but, rarely, a mole may the nail is the nail fold. The nail
certain types of arrhythmia (irregularity undergo changes that make it cancerous is composed of keratin, a tough
of the heartbeat). Nadolol is also used (see melanoma, malignant). Red-brown protein also found in skin and hair.
to control symptoms of hyperthyroidism naevi that occur in childhood are juve- Growing area
(overactivity of the thyroid gland). nile melanomas (see melanoma, juvenile).
Possible side effects are typical of Some naevi have a bluish coloration. Cuticle
other beta-blocker drugs; they include a Many black and Asian infants are born Lunula
reduction in the patient’s capacity for with blue-black spots on their lower
strenuous exercise and aggravation of backs (see Mongolian blue spot). Nail bed
any existing symptoms of lung disease VASCULAR NAEVI Nail plate
and peripheral vascular disease. Port-wine stains and strawberry marks
(see haemangioma) are vascular naevi.
Naegeli syndrome These types of naevi are usually present
A rare inherited condition that has its at birth. A port-wine stain is visible as
onset in the first few years of life. Symp- an irregularly shaped red patch and may
toms include weblike skin pigmentation, be distressing, especially if it affects the
diminished function of the sweat glands, individual’s face. The mark is usually
hypodontia (fewer teeth than normal), permanent. Strawberry marks are com- Bone
hyperkeratosis (thickening of the outer mon birthmarks and appear as raised,
layer of skin) affecting the palms and red swellings; they usually disappear by Fingertip
soles, and blistering. Naegeli syndrome the time a child is about five years old.

530
 NARCOLEPSY

thick and curved, a condition known as overdose of an opioid drug. Naloxone TREATMENT
onychogryphosis. This mainly affects the may be given to newborn babies who are If nappies are changed frequently and
big toes of elderly people. affected by opioid drugs used to relieve the affected area is regularly cleaned
The nails may also be affected by skin the mother’s pain during childbirth. and covered in a barrier cream (such as
diseases. Examples of the effects of skin Possible side effects of naloxone zinc and castor oil cream), nappy rash
disease on the nails include pitting of include nausea, vomiting, abdominal generally clears up within a few days. In
the nails in alopecia areata; pitting and cramps, diarrhoea, and tremors. more severe cases, an ointment contain-
separation of the nail from its bed in pso- ing a mild corticosteroid drug may be
riasis; and scarring of the nails in lichen naltrexone prescribed to suppress the inflamma-
planus. Certain nail abnormalities may An opioid antagonist (a drug that tion. If the area has become infected,
be signs of more generalized illness. counteracts the effects of opioid anal- oral or topical antibiotic drugs or antifun-
Brittle, ridged, concave nails are a sign gesic drugs) that is used in the treatment gal drugs may also be given.
of iron-deficiency anaemia (see anaemia, of opioid addiction. Naltrexone works
iron-deficiency) and fibrous growths on by blocking the action of opioid drugs naproxen
the nail are a sign of tuberous sclerosis. and precipitating withdrawal symptoms A nonsteroidal anti-inflammatory drug
Splinterlike black marks develop beneath in opioid-dependent people. The drug (NSAID) that is used to relieve pain in
the nails in particular bleeding disorders, may be given to former addicts to help the joints and stiffness in arthritis
indicating bleeding into the nail bed. to prevent relapse. (See also drug abuse; (including juvenile arthritis). Naproxen
Abnormalities of nail colour may also drug dependence.) is also prescribed to speed recovery
indicate disease. A greenish discolora- following injury to soft tissues, such as
tion may be caused by a bacterial nandrolone muscles or ligaments.
infection under the nail; blue nails may An anabolic steroid (see steroids, anabol- Side effects of naproxen may include
be a sign of respiratory or heart disease; ic) sometimes used in the treatment of nausea, abdominal pain, and peptic ulcer.
and yellow nails that are hard and certain types of aplastic anaemia (see
curved develop in the lung disorder anaemia, aplastic). Nandrolone is also naratriptan
bronchiectasis and in lymphoedema (an used illegally by some body builders A serotonin agonist drug used in the
accumulation of lymph in the tissues). and athletes to increase their protein treatment of acute attacks of migraine.
Nails may also become discoloured by production and, therefore, muscle bulk.
smoking (due to nicotine) and by the Possible side effects of nandrolone narcissism
use of nail polish. include swollen ankles, nausea and vom- Intense self-love. A narcissistic person-
Treatment of nail disorders can be iting, and jaundice (yellowing of the skin ality disorder is characterized by an
difficult. Creams and lotions seldom and the whites of the eyes). Nandrolone exaggerated sense of self-importance,
penetrate sufficiently; oral medication may cause irregular menstruation and constant need for attention or praise, N
may take months to be effective. abnormal hair growth, in women. inability to cope with criticism or defeat,
and poor relationships with other peo-
nail-biting nappy rash ple. People with a narcissistic personality
A common habit in children during An inflammatory skin condition com- believe themselves to be unique, special,
their early years at school. Most children mon in babies, causing soreness and a and superior to others; in addition, they
grow out of it, although nail-biting red rash in the skin covered by a nappy. may lack concern for the wellbeing or
sometimes continues as a nervous habit CAUSES AND SYMPTOMS problems of others.
in adolescents and adults. Persistent nail- Nappy rash is most commonly caused
biting may make the nails unsightly and by urine or faeces irritating the skin. It narcolepsy
cause pain and, sometimes, bleeding. usually occurs only where the skin and A sleep disorder characterized by chronic
Various preparations with an unpleas- the soiled nappy have been in direct daytime drowsiness with recurrent epi-
ant taste can be painted on the nails as a contact; it does not spread to creases in sodes of sleep occurring throughout the
preventive measure. the baby’s skin. Nappy rash becomes day. The exact cause of narcolepsy is
worse if the baby’s nappy is not unknown, although it can run in fami-
nalidixic acid changed frequently or if the nappy area lies. The condition usually develops
An antibiotic drug used in the prevention is not cleaned thoroughly. Perfumed before the age of 20.
and/or treatment of urinary tract infec- skin products and some washing pow- SYMPTOMS
tions. Possible side effects of nalidixic ders used to clean fabric nappies can People who suffer from narcolepsy tend
acid include nausea, vomiting, increased also result in a rash. to fall asleep at any time of the day,
sensitivity to sunlight, blurred vision, Nappy rash may also be caused by a often when they are carrying out a
drowsiness, and dizziness. fungal infection of the skin, such as can- monotonous task. Sleep may occur at
didiasis (thrush), or, less commonly, by inappropriate times, such as while eat-
naloxone a bacterial infection, such as impetigo. A ing. Narcoleptic attacks may last from a
An opioid antagonist (a drug that coun- rash caused by infection affects the few seconds to more than an hour.
teracts the effects of opioid analgesic whole nappy area, including the creases In narcolepsy, the REM (rapid eye
drugs). Naloxone reverses the breathing in the baby’s skin. movement) state of sleep is entered
difficulty caused by high doses of opioid Discomfort from the rash may make a abnormally rapidly. Affected people can
drugs given during surgery. It may also baby irritable. A severe rash may pro- be awakened easily but may fall asleep
be given to people who have taken an gress to blistering. again a short time afterwards.

531
 NARCOSIS

Some people with narcolepsy have vivid Decongestant drugs that are taken as endoscopy (inspection and examination
hallucinations just before falling asleep. drops and sprays should be used spar- of the nasal cavity using a viewing
Others find that they are unable to move ingly, but tablets and syrups may be instrument). Most nasal polyps are non-
while they are falling asleep or waking up recommended for long-term use. Per- cancerous; however, a biopsy (removal of
(see sleep paralysis). About three in four sistent nasal congestion should be a small sample of tissue for microscopic
people with narcolepsy also have cata- investigated by a doctor. analysis) may be performed to exclude
plexy, in which there is a temporary loss the possibility of cancer.
of strength in the limbs that causes the nasal discharge TREATMENT
person to fall to the ground. Cataplexy is The emission of fluid from the nose. Nasal polyps do not need treatment
sometimes triggered by an emotional Nasal discharge is commonly caused by unless they are interfering with breath-
response, such as fear or laughter. inflammation of the mucous membrane ing, are cancerous, or are causing other
TREATMENT AND OUTLOOK lining the nose and is often accompanied symptoms. Small nasal polyps may be
Treatment of narcolepsy usually involves by nasal congestion. treated by using a corticosteroid nasal
regular naps, along with stimulant drugs A discharge of mucus may indicate spray (see corticosteroid drugs), which
to control drowsiness and antidepressant hay fever (see rhinitis, allergic), a cold shrinks the polyps over a few weeks.
drugs to suppress cataplexy. (see cold, common), or an infection that Larger or cancerous polyps may be
Although narcolepsy is usually a life- has spread from the nearby sinuses (see removed during an endoscopic proce-
long condition, in some cases there is sinusitis). A persistent runny discharge dure or by surgery. In certain people,
spontaneous improvement over time. may be an early indication of a tumour polyps may recur after treatment.
(see nasopharynx, cancer of).
narcosis Bleeding from the nose (see nosebleed) nasal septum
A state of stupor, usually caused by an is usually caused by injury or by a foreign The dividing partition in the nose. The
opioid analgesic drug or other chemical. body in the nose. In rare cases, bleeding nasal septum consists of cartilage (con-
Narcosis resembles sleep, being marked from the nose may be a sign of an under- nective tissue formed of collagen) at the
by reduced awareness and diminished lying bleeding disorder or a tumour. A front and bone at the rear, both of
ability to respond to external stimula- discharge of cerebrospinal fluid from the which are covered by mucous membrane.
tion. However, unlike someone who is nose may follow a fracture at the base of DISORDERS
sleeping, a person in narcosis cannot the skull (see skull, fracture of). A deviated septum (twisting of the sep-
be roused completely. tum to one side) may be present from
nasal obstruction birth or caused by injury. The condition
narcotic drugs Blockage of the nasal passage on one is rarely troublesome, but surgery may be
The former name for opioid drugs. (See or both sides of the nose, which inter- needed if breathing is obstructed.
N also analgesic drugs.) feres with breathing. The most common Injury may also lead to formation
cause is inflammation of the mucous of a haematoma (a collection of clotted
nasal congestion membrane lining the passage (see nasal blood) between the cartilage of the
Partial blockage of the nasal passage by congestion). Other causes include devi- septum and the wall of one of the nasal
the swelling of the mucous membrane ation of the nasal septum; nasal polyps; cavities. A haematoma may obstruct
that lines the nose. Nasal congestion is a haematoma (a collection of clotted breathing and may become infected,
sometimes accompanied by the accu- blood), which is usually caused by causing an abscess (collection of pus)
mulation of thick nasal mucus, which injury; and, rarely, a cancerous tumour. that may require surgical drainage.
further impedes breathing. Nasal con- In children, enlargement of the adenoids Occasionally, an abscess develops on a
gestion produces the feeling of a stuffy, is a common cause of nasal obstruction. child’s septum without prior injury.
“full” nose. There is a frequent desire to Rarely, a hole may be eroded in the
blow the nose, but blowing usually has nasal polyp nasal septum by tuberculosis, syphilis,
little effect on the congestion. A growth in the lining of the nose, usu- Wegener’s granulomatosis, or as a result
CAUSES ally attached by a small stalk. Large or of snorting cocaine.
Nasal congestion is a symptom of the numerous nasal polyps may cause nasal
common cold (see cold, common) and obstruction, a runny nose, and an im- Naseptin
hay fever (see rhinitis, allergic). In these paired sense of smell. A brand name for a combination of
conditions, the swelling is due to inflam- CAUSES chlorhexidine (an antiseptic for the
mation of the membrane lining the inside The exact cause of nasal polyps is not skin) with neomycin (an antibiotic drug).
of the nose. The swelling may become known. However, they are more com- Naseptin cream is used to eliminate
persistent in disorders such as chronic mon in people with asthma or rhinitis (a organisms, such as staphylococci, from
sinusitis or nasal polyps. The congestion condition in which the membrane that the inside of the nostrils.
may also be caused by certain drugs, such lines the nose and throat becomes
as methyldopa (an antihypertensive drug). inflamed). Although nasal polyps rarely nasogastric tube
TREATMENT occur in children, they do sometimes A narrow plastic tube that is passed
Placing the head over a basin of hot develop in those children who have the through the nose, down the oesophagus
water, possibly containing aromatic oils inherited condition cystic fibrosis. (gullet), and into the stomach.
such as menthol or eucalyptus, and DIAGNOSIS WHY IT IS USED
inhaling the steam for several minutes Nasal polyps are diagnosed by physical Nasogastric tubes are commonly used
can help loosen the mucus. examination and sometimes also by to suck or drain digestive juices from

532
 NAVICULAR BONE

the stomach when there is a blockage East; the reasons for this are not clear. It natriuretic peptide
in the intestine (such as in pyloric steno- occurs most often in people between See atrial natriuretic peptide.
sis) or it is not working properly (as the ages of 30 and 60.
may occur after an abdominal opera- Factors that increase the risk of this natural childbirth
tion). A nasogastric tube is also used to cancer include diet (a high intake of See childbirth, natural.
give liquid nourishment to patients salt-cured fish); smoking; and viral
who cannot eat (see feeding, artificial), to infections, especially infection with the natural immunity
obtain specimens of stomach secretions Epstein–Barr virus. People who inhale A type of immunity (protection against
for examination, and to wash out the hardwood dust or nickel dust at work disease) that is manifested by a species
stomach after a drug overdose or after over a long period are also at increased not previously sensitized to the disease
swallowing poison (see lavage, gastric). risk and should take precautions. in question either through infection or
HOW IT IS USED SYMPTOMS through vaccination.
Inserting the tube is a quick, simple Initially, cancer of the nasopharynx may The mechanisms that are involved in
procedure that causes little discomfort not cause any symptoms. It may remain natural immunity are still poorly under-
and does not require an anaesthetic. unnoticed until the tumour spreads to a stood. This condition, however, is not
After it has been lubricated, the tube is lymph node, causing a painless swelling believed to be stimulated by specific
passed into one nostril and then, while in the neck. antigens (substances that trigger an
the patient is swallowing, slid down the If symptoms do develop, they may immune response), as is the case with
throat and into the stomach. To ensure include facial swelling, recurrent nose- acquired immunity. Natural immunity
that the tube is in the stomach, a sample bleeds, a runny nose, and discomfort on (also known as innate immunity) is
of fluid is withdrawn through a syringe swallowing. Loss of the sense of smell, inherited and present at birth.
and may be tested for acidity. The stom- double vision, deafness, paralysis of one
ach contents are then either allowed to side of the face, voice change, and severe natural killer cells
drain or sucked out through a syringe facial pain may also develop if nearby A specific type of lymphocyte (a type of
or a suction device. Fluids for lavage or nerves are affected. white blood cell) that is able to destroy
feeding may be introduced through a DIAGNOSIS AND TREATMENT cells infected with viruses as well as
funnel. If the tube is to be left in place Diagnosis is through endoscopy (internal some types of cancer cell. Natural killer
for some time, the protruding end is examination and inspection using a cells, also known as NK cells, constitute
taped to the patient’s face. viewing tube), during which a biopsy the immune system’s first line of defence
(removal of a small sample of tissue for against cancerous or infected cells. NK
nasolacrimal duct microscopic analysis) can also be taken. cells are neither T nor B lymphocytes
A channel that drains tears into the nose. An MRI scan (a technique that produces (unlike killer T-cells, for example).
The nasolacrimal duct forms part of the cross-sectional or three-dimensional
naturopathy
N
lacrimal apparatus. images of internal body structures) and
X-rays are required to assess the extent A form of complementary medicine based
nasopharynx of the tumour and the involvement of on the principle that disease occurs as
The passage that connects the nasal cav- nearby structures. a result of the accumulation of waste
ity behind the nose to the top of the Treatment is usually with radiotherapy, products and toxins in the body; symp-
throat behind the soft palate. The naso- but, in some cases, the tumour may be toms are thought to reflect the attempts
pharynx is part of the respiratory tract surgically removed. If the tumour is of the body to rid itself of these
and forms the upper section of the treated early, the outlook can be good. substances. Practitioners of naturopathy
pharynx. During swallowing, the naso- believe that health is maintained by
pharynx is sealed off by the soft palate avoiding anything artificial or unnatural
pressing against the back of the throat, LOCATION OF THE in the diet or in the environment.
NASOPHARYNX
thereby preventing food from entering.
The nasopharynx contains the lower nausea
The nasopharynx forms the upper
openings of the eustachian tubes (pas- The sensation of needing to vomit.
part of the pharynx and connects the
sages connecting the back of the nose to nasal cavity to the top of the throat. Although nausea may occur without
the middle ear). In children, it also con- vomiting, the causes are the same.
Nasal cavity Soft palate Nasopharynx
tains the adenoids, which can enlarge to
block the nasopharynx, forcing the child navel
to breathe through the mouth. Hard
A popular term for the umbilicus, the
palate depression in the abdomen that marks
nasopharynx, cancer of the point at which the umbilical cord
A cancerous tumour that originates in was attached to the fetus.
the nasopharynx (the uppermost part of
the throat, behind the nose) and usually Epiglottis navicular bone
spreads to the nasal cavity, nasal sinuses, Vocal cord A foot bone that articulates with the
base of the skull, and neck lymph nodes. Trachea
head of the talus (one of the bones in
CAUSES AND INCIDENCE the ankle joint) and with three of the
Oesophagus
Cancer of the nasopharynx is rare in the bones in the tarsus (which makes up
West but relatively common in the Far the back of the foot and the ankle).

533
 NEBULIZER

nebulizer
An aerosol device used to administer ANATOMY OF THE NECK
drugs, such as bronchodilators, especially
The neck contains many important neck; a complex system of muscles
in the emergency treatment of asthma. structures, including the larynx, thyroid is connected to these vertebrae, the
Usually an electric pump sends a stream and parathyroid glands (embedded in clavicles, the upper ribs, and the lower
of air or oxygen across a chamber that the back of the thyroid), many lymph jaw. Contraction of these muscles
contains the drug. This stream of air dis- nodes, and carotid arteries. The upper allows the head to turn and the jaw
perses the drug into a fine mist, which seven vertebrae of the spine are in the to open and close.
is then conveyed to the face mask and
inhaled by the user.
neck Salivary Trapezius
gland
The part of the body that supports the Sternomastoid
head and serves as a passageway bet- Carotid
ween the head (and brain) and the rest artery
Clavicle
of the body. The neck contains many Thyroid
important structures: the spinal cord cartilage
Lymph
(which carries nerve impulses to and Jugular nodes
from the brain); the trachea (windpipe); vein
Muscles of the
the larynx (voice-box); the oesophagus side of the neck
(gullet); the thyroid and parathyroid Muscles on the side (here,
the left side) and back of
glands; lymph nodes; and several major
the neck support and
blood vessels. Seven spinal vertebrae are move the head.
Trachea Thyroid gland Clavicle
located in the neck; they are surrounded
by a complex system of muscles.
DISORDERS
Torticollis (wry neck), in which the head neck dissection, radical necrolysis, toxic epidermal
is twisted to one side, may result from A surgical procedure for the removal of A severe, blistering rash in which the
injury to a neck muscle or from skin cancerous lymph nodes in the neck. The surface layers of the skin peel off, expos-
contracture (shrinkage) after burns or operation is often part of the treatment ing large areas of red, raw skin. The
other injuries. Fractures and dislocations for cancer of the tongue, the tonsils, or condition carries a risk of widespread in-
of vertebrae in the neck, as well as other structures in the mouth and throat. fection and loss of body fluids and salts.
N whiplash injury, can cause injury to the Under general anaesthetic (see anaes- The most common cause of toxic epi-
spinal cord, causing paralysis or even thesia, general), a flap of skin on the dermal necrolysis is an adverse reaction
death (see spinal injury). affected side of the neck is raised to to a drug, particularly a barbiturate,
Degeneration of the joints between expose the underlying sternomastoid sulphonamide, or penicillin.The condition
the neck vertebrae may occur as a result muscle. The muscle is cut just above the usually clears up when the causative
of cervical osteoarthritis, resulting in neck clavicle (collarbone) and lifted up. All drug is discontinued. Intravenous fluid
pain, stiffness, and sometimes tingling the components of the lymphatic system replacement is sometimes necessary.
and weakness in the arm and hand. in the neck (the lymph vessels as well as In newborn babies, the condition
Similar symptoms may also be caused the lymph nodes) are then removed, may be due to a staphylococcal infection
by a disc prolapse. In ankylosing spondy- together with the internal jugular vein, and is called scalded skin syndrome.
litis, fusion of the vertebrae may result the lower salivary gland, and other Treatment is with antibiotic drugs and
in permanent neck rigidity. surrounding tissue. fluid replacement.
Cervical rib is a rare congenital defect
in which there is a small extra rib in the neck rigidity necrophilia
neck. This condition often causes no Marked stiffness of the neck caused by A rare sexual perversion in which
symptoms until middle age, when it spasm of the muscles in the neck and orgasm is achieved by means of sexual
may result in pain, numbness, and a spine. Neck rigidity is an important acts with dead bodies.
pins-and-needles sensation in the fore- clinical sign of meningitis (inflamma-
arm and hand. tion of the membranes that envelop the necropsy
Neck pain of unknown origin is very brain and spinal cord). Severe neck A little-used medical term for an autopsy
common. However, as long as there are rigidity may cause the head to arch (postmortem examination of a body).
no neurological symptoms (such as loss backwards, especially in babies.
of sensation or a decrease in muscle necrosis
power), the condition is unlikely to be necrobiosis lipoidica The death of tissue cells. Necrosis can
serious and usually disappears over the A skin condition, usually associated with occur as a result of ischaemia (inade-
course of a few weeks. However, any diabetes mellitus, in which reddened quate blood supply), which may lead to
condition causing a large swelling in patches with yellowish centres develop, gangrene (tissue death); infection; or
the neck (such as enlargement of the most commonly on the shins. The skin damage by extreme heat or cold, nox-
thyroid gland) may interfere with in the centre of the patches becomes ious chemicals, or excessive exposure to
breathing or swallowing. thin and may ulcerate. X-rays or other forms of radiation.

534
 NEONATAL JAUNDICE

The appearance of the dead tissue The possible side effects of nefopam neonatal death
depends on the cause of the necrosis and include nausea, dry mouth, nervous- The death of a live-born infant in the first
on the type of tissue affected. In necrosis ness, and difficulty sleeping. four weeks of life. Neonatal death is clas-
due to tuberculosis, the dead tissue is soft, sified as early or late: early neonatal
dry, and cheeselike. Fatty tissue beneath negativism deaths are deaths in the first week of life;
the skin that has died as a result of dam- The tendency to resist or oppose advice, late neonatal deaths are those occurring
age or infection develops into tough scar suggestions, or commands. There are between the end of the first week of life
tissue that may form a firm nodule. two principal types of negativism: active and 27 days after birth. About half of all
negativism and passive negativism. In neonatal deaths in the UK are attributed
necrotizing fasciitis active negativism, the individual does to prematurity; about a quarter to congen-
A rare but serious infection of tissues the opposite of what he or she is re- ital malformations; and the remainder to
beneath the skin by a type of strep- quested to do; such behaviour is seen in various causes, including infection and
tococcal bacterium (see streptococcal toddlers and is uncommon in adult life, difficulties with delivery. (See also infant
infections) and other bacteria. Necro- although it may be a feature of catatonia. mortality; stillbirth.)
tizing fasciitis is most likely to occur as In passive negativism, the person does
a complication of surgery. Initial symp- not cooperate simply by failing to do neonatal hypoglycaemia
toms of the infection are inflammation something that has been suggested. This An abnormally low blood glucose level
and blistering of the skin. The infection often occurs in depression and may also (see hypoglycaemia) in an infant that is
spreads very rapidly and the bacteria be a feature of schizophrenia. under four weeks of age. Neonatal hypo-
release enzymes and toxins (poisons) glycaemia commonly causes problems in
that can cause extensive destruction of neisserial infections the first 24 hours of life. Persistent low
deeper tissues and damage to internal Infections caused by bacteria belonging glucose levels may result in permanent
organs. Urgent treatment with antibiotic to the NEISSERIA genus. NEISSERIA GONORR- damage to the brain (see cerebral palsy).
drugs and surgical removal of all infec- HOEAE (gonococcus) causes gonorrhoea (a CAUSES AND INCIDENCE
ted tissue are essential. The infection is common sexually transmitted infection) in Neonatal hypoglycaemia is uncommon
life-threatening. humans. NEISSERIA MENINGITIDIS (meningo- in healthy babies carried to full term.The
coccus), is the causative agent of the condition is likely to occur in premature
nedocromil condition meningococcal meningitis (in- infants and those of low birth weight,
A drug similar to sodium cromoglicate flammation of the membranes covering due to their reduced reserves of glycogen
that is used to prevent asthma attacks. the brain and spinal cord). (main form of the body’s stored carbo-
hydrate). It is also more common in
needle aspiration Nelson’s syndrome babies whose mothers had diabetes melli-
See biopsy. A rare disorder of the endocrine system tus during pregnancy. These babies N
that causes increased skin pigmentation. produce the extra insulin they require
needle exchange Nelson’s syndrome results from enlarge- before delivery, but their glucose levels
A health scheme that enables intravenous ment of the pituitary gland, which can fall after birth. Also at risk of neonatal
drug abusers to exchange used hypo- follow removal of the adrenal glands (to hypoglycaemia are infants with inborn
dermic needles for new, sterile ones. treat Cushing’s disease). errors of metabolism (see metabolism,
The scheme is aimed at reducing the Nelson’s syndrome is treated by inborn errors of) and those who are
risks of infections, such as HIV and hepa- hypophysectomy (removal or destruction unwell at birth. Difficulties with breast-
titis, that are transmitted by the sharing of the pituitary gland). feeding during the first days of life may
of contaminated needles. also cause the condition to develop.
nematodes SYMPTOMS AND SIGNS
needlestick injury The scientific name for a group of Neonatal hypoglycaemia is usually char-
Accidental puncture of the skin by a con- cylindrically shaped worms (see round- acterized by jitteriness, seizures, irri-
taminated hypodermic needle. Hospital worms); some are human parasites. tability, floppiness, apnoea (interruption
staff are most likely to be at risk. Needle- in breathing), and poor feeding.
stick injuries carry the risk of serious neologism DIAGNOSIS AND TREATMENT
infections, such as HIV and hepatitis, and The act of making up new words that A diagnosis of neonatal hypoglycaemia
need immediate medical attention. The have a special meaning for the inventor. is confirmed using blood tests to check
wound should be cleaned thoroughly; The term neologism also refers to the blood glucose levels.
blood tests may be needed to determine invented word itself. Persistent neolo- In babies at increased risk of the con-
whether infection has been transmitted. gism can be a feature of speech in dition, preventive treatment involves the
people with schizophrenia. immediate establishment of regular
nefopam feeding, ideally breast-feeding. Hypo-
An analgesic drug used to relieve moder- neomycin glycaemia that is severe enough to cause
ate pain caused, for example, by injury, An antibiotic drug used to treat ear, eye, symptoms requires an intravenous infu-
surgery, or cancer. Nefopam reduces the and skin infections, often in combina- sion of glucose along with, if possible,
perception of pain by the brain. Unlike tion with other drugs. Neomycin is also treatment of the underlying cause.
most analgesics that act on the brain, it given to prevent infection of the intes-
neither interferes with breathing nor tine prior to surgery. Possible adverse neonatal jaundice
causes dependence. effects include a rash and itching. See jaundice, neonatal.

535
 NEONATAL URTICARIA

neonatal urticaria of the ribs, from the spine to the front It is now often possible to avoid surgery
See urticaria, neonatal. of the abdomen, in order to expose the by using lithotripsy (a procedure that
kidney. The ureter (the tube that carries uses ultrasonic waves to break up calculi
neonate urine from the kidney to the bladder) for excretion in the urine).
A newly born infant, specifically up to and the renal blood vessels are tied off,
the age of 27 days. (See also newborn.) then the kidney is removed. The inci- nephrology
sion is stitched up after insertion of a The medical speciality concerned with
neonatology drainage tube, which is left in place for the normal functioning of the kidneys
The branch of paediatrics concerned with between 24 and 48 hours. and with the causes, diagnosis, and
the care of newborn infants and the treat- OUTLOOK treatment of kidney disease.
ment of disorders that occur during the On removal of a single kidney, the re- Methods of investigating the kidneys
first few weeks of life. Such problems maining kidney takes over the workload. include kidney biopsy (removal of a
may be short-term (such as those associ- If both kidneys are removed, the patient small sample of tissue for microscopic
ated with prematurity or low birth requires regular dialysis (artificial purifi- analysis), kidney function tests, and kidney
weight) or lifelong (such as spina bifida). cation of blood) or a kidney transplant. imaging techniques, such as ultrasound
scanning and intravenous urography.
neoplasia nephritis Treatment of kidney disorders may
A medical term for the process of tumour Inflammation of one or both of the kid- involve drugs (for example, to control
formation, characterized by progressive, neys. Nephritis may be caused by an high blood pressure, inflammation, or
abnormal cell multiplication. The term infection (see pyelonephritis), by abnor- infection) and surgery (for the treatment
neoplasia does not necessarily imply that mal responses of the immune system (see of stones or tumours). In advanced
the new growth is cancerous; neoplasia glomerulonephritis), or by drugs – for cases, regular dialysis (artificial purifica-
also results in noncancerous tumours. example, penicillin. (See also Disorders tion of the blood) or a kidney transplant
of the kidney box.) may be required. (See also Disorders of
neoplasm the kidney box.)
A medical term for a tumour (any new nephroblastoma
abnormal growth). Neoplasms may be A type of kidney cancer that mainly nephron
cancerous or noncancerous. affects children. The functional microscopic unit of the
kidney that consists of a glomerulus (a
neostigmine nephrocalcinosis filtering unit made up of a cluster of
A drug that is used in the treatment of Deposits of calcium within the tissue of capillaries) and a tubule. Each kidney
myasthenia gravis (a rare autoimmune one or both of the kidneys. Nephrocalci- contains about one million nephrons.
N disorder that causes muscle weakness). nosis is not the same as kidney stones The nephrons filter waste products
Neostigmine increases the activity of (see calculus, urinary tract), in which from the blood and modify the amount
acetylcholine, a neurotransmitter (a chemi- particles of calcium develop inside the of salt and water excreted in the urine,
cal released from nerve endings) that drainage channels of the kidney. according to the body’s needs. This
stimulates the contraction of muscles. Nephrocalcinosis may occur in any process involves blood filtration in the
Possible side effects of neostigmine condition in which the level of calcium glomerulus followed by further pro-
include nausea and vomiting, increased in the blood is raised – for example, in cessing of the filtrate as it flows through
salivation, diarrhoea, abdominal cramps, hyperparathyroidism (overactivity of the the various parts of the tubule: the
blurred vision, muscle cramps, sweat- parathyroid gland) and renal tubular proximal convoluted tubule, the loop of
ing, and twitching. acidosis (in which the kidney produces Henlé, and the distal convoluted tubule.
urine of lower-than-normal acidity).
nephrectomy Nephrocalcinosis may also occur as a nephropathy
The surgical removal of one or both of result of taking excessive amounts of A term for any disease of, or damage
the kidneys. certain antacid drugs or vitamin D. to, the kidneys. The term is usually
WHY IT IS DONE Treatment is of the underlying cause combined with a word that indicates the
One of the most common reasons for in order to prevent further calcification. cause of the damage, for example dia-
nephrectomy is to remove a cancerous betic nephropathy, obstructive nephro-
tumour (see kidney cancer). A kidney nephrolithotomy pathy, hypertensive nephropathy, and
may also be removed if it is not func- The surgical removal of a kidney stone toxic nephropathy. The treatment and
tioning properly because of injury, (see calculus, urinary tract) by cutting outlook are dependent on the cause. (See
infection, or the presence of stones (see into the main part of the kidney. also Disorders of the kidney box.)
calculus, urinary tract) or if it is causing Nephrolithotomy may be performed
severe hypertension (high blood pres- through an abdominal incision, an inci- nephrosclerosis
sure). Nephrectomy may also be neces- sion in the back, or using pyelolithotomy Hardening of the arterioles and arteries
sary if a kidney is so badly injured that (a surgical procedure in which a kidney within the kidney, usually as a result of
bleeding cannot be stopped. stone is removed through an incision at atherosclerosis (the deposition of fatty
HOW IT IS DONE the renal pelvis). Instruments are used material within blood vessels).
Nephrectomy takes place under general to grasp and remove the calculus; the
anaesthetic (see anaesthesia, general). An breaking up of large calculi may be nec- nephrosis
incision is made along the lower edge essary before removal. See nephrotic syndrome.

536
 NERVE INJURY

nephrostomy effects are short lived. Corticosteroid DISORDERS

The introduction of a small tube into drugs may also be prescribed and are Nerve function is sensitive to cold, pres-
the kidney to drain urine to the abdomi- often effective in cases of nephrotic sure, and injury (see nerve injury). The
nal surface, thereby bypassing the ureter syndrome in childhood. peripheral nerves can be damaged by a
and bladder. Nephrostomy is sometimes OUTLOOK variety of disorders, including infection,
performed after an operation (typically The outlook for someone with nephrotic inflammation, poisoning, nutritional
removal of a kidney stone) on the syndrome depends on the extent of the deficiencies, and metabolic disorders
ureter or the kidney–ureter junction. kidney damage. Recurrent episodes may (see neuropathy). (See also radiculopathy.)
occur even after treatment. Problems
nephrotic syndrome with excessive blood clotting are com- nerve block
A collection of symptoms and signs mon and may require treatment with The injection of a local anaesthetic (see
resulting from damage to the glomeruli anticoagulant drugs. Infections may occur anaesthesia, local) around a nerve in
(the filtering units of the kidney), which as a result of immunoglobulin loss into the order to produce loss of sensation in a
causes severe proteinuria (leakage of pro- urine. Nephrotic syndrome is usually part of the body supplied by that nerve.
tein from the blood into the urine), low associated with raised cholesterol, which For example, the palm of the hand may
blood levels of protein, and swelling. increases the risk of myocardial infarction be anaesthetized by giving injections at
CAUSES (heart attack) due to atherosclerosis (fatty sites up the arm, thereby blocking the
Nephrotic syndrome may occur as a deposits on the artery walls). In the most ulnar and median nerves.
result of diabetes mellitus, amyloidosis severe cases, chronic kidney failure, and WHY IT IS DONE
(accumulation of amyloid, an abnormal eventually an irreversible loss of kidney A nerve block is performed when it is
protein, in the tissues), or any type of function, may develop. not possible to inject anaesthetic directly
glomerulonephritis (inflammation of the into the tissues being treated because the
glomeruli). The conditions may also be nephrotoxic area is painfully inflamed or because
due to severe hypertension (high blood A term meaning toxic (poisonous) to there is a risk of spreading infection.
pressure), reactions to poisons (such as kidney cells, resulting in damage to or The technique may also be used to
mercury or cadmium), or adverse reactions destruction of the cells. anaesthetize a large area or an area not
to drugs, such as gold or penicillamine. suitable for injection because it is deep
Nephrotic syndrome may also be a nerve within the body or is covered with bone.
complication of an infection elsewhere A bundle of nerve fibres travelling to a TYPES
in the body, such as hepatitis B or mal- common location. Nerve fibres, which Spinal nerve block A nerve may be
aria. In children, the syndrome is most are also known as axons, are the fila- blocked as it leaves the cord. This hap-
commonly due to a condition known as mentous projections of many individual pens both in epidural anaesthesia, which
minimal change glomerulonephritis. neurons (nerve cells). is used mainly in childbirth, and in N
SYMPTOMS STRUCTURE spinal anaesthesia, which is used for sur-
The symptoms of nephrotic syndrome The most obvious nerves in the body gery on the lower abdomen and limbs.
appear gradually over days or weeks and are the peripheral nerves, which extend Caudal block In a caudal block, an anaes-
worsen as more and more protein is lost from the central nervous system (consist- thetic is injected around the nerves
in the urine. Early signs include frothy ing of the brain and the spinal cord) to leaving the lowest part of the spinal
urine and decreased urine production. other parts of the body. Of these, 12 cord. It produces a loss of sensation in
The main symptom is swelling of the pairs of cranial nerves link directly to the the buttock and genital areas and is
legs and face as a result of oedema (accu- brain and 31 pairs of spinal nerves join occasionally used in childbirth.
mulation of fluid in the tissues). Fluid the spinal cord. In the shoulder and hip Pudendal block A pudendal nerve block
may also collect in the chest cavity, regions, the spinal nerves join to form involves the injection of an anaesthetic
resulting in pleural effusion and shortness plexuses, from which branch the main into nerves passing under the pelvis
of breath, or in the abdomen, causing nerves to the limbs, such as the median into the floor of the vagina. This type of
ascites. Lethargy and loss of appetite nerve in the arm and the sciatic nerve in nerve block is sometimes used during
(leading to weight loss) may also occur. the leg. Most nerves divide at numerous childbirth in a forceps delivery.
DIAGNOSIS AND TREATMENT points to send branches to all parts of
Diagnosis involves blood tests; the urine the body, particularly to the sense nerve conduction studies
must also be examined under a micro- organs, the skin, the skeletal muscles, Electrical tests carried out to assess the
scope and the amount and type of the internal organs, and the glands. extent of nerve damage caused by dis-
protein lost assessed over a 24-hour FUNCTION orders of the peripheral nervous system
period (see urinalysis). In most cases, a Nerve fibres may have a sensory func- (see neuropathy). In the test, an electrical
kidney biopsy (removal of a small sample tion, carrying information from a stimulus is applied to a nerve; the speed
of tissue for microscopic analysis) is also receptor or sense organ towards the at which the nerve responds to the
required to establish the exact cause and central nervous system (CNS), or they stimulus and transmits its signal is
help with treatment decisions. may have a motor function, carrying recorded by specialized equipment.
Treatment is aimed at the underlying instructions from the CNS to a muscle
condition. A low-sodium diet may be re- or a gland. The messages are carried by nerve injury
commended and diuretic drugs may be electrical impulses propagated along the Damage or severance of conducting
given to reduce oedema. Protein may fibres. Some nerves carry only sensory fibres within a nerve as a result of
need to be given intravenously, but the or motor fibres, but most carry both. trauma, resulting in the loss of skin

537
 NERVE, TRAPPED

sensation and muscle power. (See neuro- nerve, trapped skeletal muscles, the muscles controlling
pathy for nerve damage from causes Compression or stretching of a nerve, speech, internal organs and glands, and
other than injury.) causing numbness, tingling, weakness, the sweat glands in the skin. This infor-
Nerves may be damaged in many dif- and, sometimes, pain in the area sup- mation is carried along nerves that fan
ferent injuries, including knife wounds, plied by the nerve. Common examples out from the CNS to the entire body,
bullet wounds, penetrating injuries (such of a trapped nerve include carpal tunnel together making up what is known as
as from flying glass), or from accidental syndrome, in which pressure on the the peripheral nervous system (PNS).
contact with powered devices (such as median nerve as it passes through the Each nerve is a bundle consisting of
rotary saws and propellers). wrist causes symptoms in the thumb, the axons (filamentous projections) of
PERIPHERAL NERVE INJURY index, and middle fingers; a disc pro- many individual neurons.
If injury to a peripheral nerve (a nerve lapse, in which pressure on the nerve FUNCTION
outside the brain or spinal cord) results root leading from the spinal cord pro- There are also functional divisions. Two
in severance of some, but not all, of the duces symptoms in the back and legs; of the most important are the autonomic
individual fibres within the nerve, the and crutch palsy, in which the radial nervous system, which is concerned with
cut fibres degenerate on both sides of nerve presses against the humerus the automatic regulation of internal
the injury. This leads to loss of power in (upper arm bone), producing symp- body functions, and the somatic ner-
the muscles and loss of sensation in the toms in the wrist and hand. vous system, controlling the muscles
skin area supplied by the fibres. A damaged nerve may take some time responsible for voluntary movement.
In cases of partial severance in which to heal. In severe cases, surgical decom- The overall function of the nervous
the ends of the severed fibres are still pression to relieve pressure on the nerve system is to gather and analyse infor-
aligned, new fibres can regenerate along may be necessary. mation about the external environment
channels left by the degenerated ones. and the body’s internal state and to
These new fibres begin to grow within a nervous breakdown initiate appropriate responses aimed at
few days of injury, but they grow slowly A nontechnical term used to describe satisfying certain drives.
(at a rate of about 1 mm per day). unusual behaviour (such as episodes of The most powerful drive is for sur-
If there is total severance of a nerve, tearfulness or shouting and screaming) vival. Many survival responses, which
the individual fibres try to regenerate that may be part of a crisis of severe range from avoiding physical pain and
but, with no directing channels, simply anxiety, depression, or other psychiatric danger to shivering in response to the
bunch up to form a lump of tissue. In illness. The condition affects the suffer- cold, are initiated unconsciously and
such cases, function does not recover. er’s ability to cope with everyday life. automatically by the nervous system.
Regenerating nerve fibres sometimes Other drives are more complex, revolv-
pass down the wrong channels. So, when nervous energy ing around a need to experience positive
N function is restored, actions may differ A nontechnical term for the increased emotions (such as pleasure and excite-
from what was intended (for example, drive and activity of individuals who are ment) and to avoid negative emotions
an attempt to move the index finger may always restless, anxious, and on the go. (such as pain, anxiety, and frustration).
move the middle finger as well). Move- The nervous system functions largely
ment skills and the interpretation of nervous habit through automatic responses to stimuli
sensations may need to be relearned. A nontechnical term for a minor repeti- (see reflex), but it can also improve its
BRAIN AND SPINAL CORD INJURY tive movement or activity. A nervous performance through learning, which
Nerve tracts within the brain and spinal habit can consist of involuntary twitches relies on memory. Voluntary actions can
cord are structurally different from the and facial tics, such as in Gilles de la be initiated via activity in conscious areas
peripheral nerves, and severed fibres in Tourette’s syndrome and some forms of of the brain. Certain functions (such as
these tracts do not regenerate. Vision dyskinesia. Voluntary nervous habits, visual perception, memory, thought, and
cannot be restored if, for example, the such as nail-biting and thumb-sucking, are speech production) are extremely com-
optic nerves are cut. common in young children, but usually plex and still not fully understood.
TREATMENT disappear naturally with time. All ner- DISORDERS
Surgery can sometimes repair a severed vous habits increase during periods of Disorders of the nervous system may be
nerve, but such treatment is possible tension or anxiety and may be severe in caused by damage to or dysfunction of
only for peripheral nerves. In micro- some forms of depression, anxiety dis- any of its parts (see disorders of the brain
surgery, the neurosurgeon ensures that order, or drug withdrawal. box; spinal cord; neuropathy; nerve injury).
the severed fibres are meticulously They may also be due to impaired senso-
brought together and stitched into place nervous system ry, analytical, or memory functions (see
using delicate needles and sutures. Care- The body system that gathers and stores vision, disorders of; deafness; numbness;
ful realignment of the nerve ends gives information. It is in control of the body. anosmia; agnosia; amnesia), or motor
the fibres the best chance of regen- (See Nervous system box, overleaf.) functions (see aphasia; dysarthria; ataxia).
erating along the correct channels. STRUCTURE
However, even with the best surgical The brain and spinal cord form the central netilmicin
repair, recovery is rarely complete. nervous system (CNS), which consists of An antibiotic drug usually prescribed only
A programme of physiotherapy is need- billions of interconnected neurons (nerve to treat serious infection in hospital,
ed to keep paralysed muscles healthy and cells). The input of information to the when other antibiotic drugs have proved
free from contracture (abnormal shorten- CNS comes from the sense organs. ineffective. In rare cases, netilmicin can
ing) during the recovery period. Motor instructions are sent out to damage the inner ear or the kidneys.

538
 NETILMICIN

NERVOUS SYSTEM

The nervous system detects and Spinal nerve

Brain
interprets changes in conditions inside
and outside the body and responds Brainstem
to them. The central nervous system Spinal cord
analyses information and initiates
responses; the peripheral nervous
system gathers information and carries
Ventral root
the response signals. Some responses
are involuntary; others are dictated by Dorsal root
conscious thought. All nervous system
activity consists of signals passed Grey matter
through pathways of interconnected
neurons (nerve cells).
White matter

Median nerve
Vertebra

Ulnar nerve

Structure of the spinal cord

Femoral nerve
The grey matter contains nerve cell bodies;
white matter contains their conducting fibres.
Posterior tibial nerve On joining the cord, spinal nerves split into
two. The dorsal root carries sensory fibres;
the ventral root carries motor fibres.

Peripheral nervous system

This system comprises all the nerves connecting Central nervous system
the brain and spinal cord to the rest of the body. This system consists of the brain and spinal cord,
Of these, 31 pairs (the spinal nerves) connect to protected by the skull and spine. The CNS
the spinal cord and 12 pairs (cranial nerves) receives input from sense organs and receptors
connect to the brain. The main nerves of the and sends signals to muscles and glands, via the
limbs are labelled. peripheral nervous system. N
HOW IT WORKS
Some possible events in response
Brain
to a finger touching a hot object When impulses reach the cerebral cortex,
are shown. A receptor sends a pain is felt. Other activity (concerned, for
message, via a sensory fibre, to the example, with memorizing the painful
stimulus) may also be initiated.
spinal cord. This triggers a signal
that travels, via a motor fibre, back
Cerebral cortex
to a muscle, which contracts to
move the finger away from the
Brainstem
heat. This action is called a reflex
arc. Other signals pass to the brain. Motor fibre Eye movement
Signals arriving at the brainstem
may cause more action, such
as the eyes moving towards
Sensory receptors Muscle action the stimulus.

Nerve fibres to brain

Grey matter
Sensory fibre Motor fibres

Spinal cord
Sensory and motor fibres
The signal entering
Although the sensory and motor fibres
the spinal cord passes
carry signals in opposite directions,
to other nerve cells by
along part of their lengths they may Sensory fibres separate connections.
occupy exactly the same nerve.

539
 NETTLE RASH

nettle rash over the area or a dimple in the skin.This Blood tests and ultrasound scanning in
A common name for urticaria. may cause no problems, although there pregnancy can help to detect neural
may be tethering of the spinal column, tube defects before birth. Over the last
neuralgia which may need releasing surgically. 25 years, there has been a substantial
Pain caused by irritation of, or damage If the bone defect is more extensive, decline in the numbers of babies born
to, a nerve. The pain usually occurs in there may be a meningocele (a protru- with these defects.
brief bouts, may be severe, and can often sion of the meningeal membranes) or a
be felt shooting along the affected nerve. myelomeningocele (a malformation in neurapraxia
TYPES AND CAUSES which part of the spinal cord and the A type of nerve injury in which the
Some types of neuralgia are features of a meninges overlying it are completely outward structure of a nerve appears
disorder. Migraine sufferers commonly exposed). Myelomeningocele is likely intact, but some conducting fibres have
experience a form of neuralgia compri- to cause severe handicap, with paralysis been damaged and thus do not transmit
sing attacks of intense, radiating pain of the legs, loss of sensation in the lower signals normally.
around the eye. Postherpetic neuralgia is body, and paralysis of the anus and blad-
a burning pain that may recur at the site der, causing incontinence (see incon- neurasthenia
of an attack of herpes zoster (shingles) for tinence, faecal; incontinence, urinary). The An outdated term that literally means
months or even years after the illness. higher up the spine the malformation is, “nervous exhaustion”. The term neuras-
Other types of neuralgia result from the more severe the handicap. thenia was once used to describe a
disturbance of a particular nerve. In Associated problems include hydro- number of physical and mental symp-
glossopharyngeal neuralgia, intense pain cephalus, in which extra fluid forms in toms, such as insomnia, loss of energy,
is felt at the back of the tongue and in the brain; insertion of a shunt to relieve aches and pains, depression, irritability,
the throat and ear, all of which are areas the pressure is often needed in the first and reduced concentration.
supplied by the glossopharyngeal nerve. few weeks of life. However, some chil-
The cause is unknown. The same is true dren will also have cerebral palsy, neuritis
of trigeminal neuralgia, a severe paroxysm epilepsy, or learning difficulties. Children A term that literally means inflamma-
of pain affecting one side of the face with neural tube defects are at particular tion of a nerve. True nerve inflammation
supplied by the trigeminal nerve. risk of developing meningitis, a serious may be caused by infection (for exam-
TREATMENT infection of the membranes covering the ple, by a virus in herpes zoster or by a
Neuralgia may be relieved by analgesic brain and spinal cord. bacterium in Hansen’s disease). The
drugs (painkillers), such as paracetamol. CAUSES term neuritis is also often applied to
Glossopharyngeal, trigeminal, and post- The cause of neural tube defects is not nerve damage or disease from causes
herpetic neuralgia may respond to fully understood, but they tend to run other than inflammation. It has become
N treatment with carbamazepine or other in families, which suggests that genetic virtually synonymous with neuropathy.
anticonvulsant drugs, or to tricyclic anti- factors are involved. Certain types of
depressant drugs. anticonvulsant drug are associated with neuroblastoma
neural tube defects if they are taken by A cancerous tumour that develops from
neural tube defect women during pregnancy. nervous tissue in the adrenal glands or in
A once common developmental failure TREATMENT AND OUTLOOK part of the sympathetic nervous system
affecting the spinal cord or brain of the Surgery is usually performed a few days (see autonomic nervous system). Neuro-
embryo. The neural plate, which de- after birth. In mild cases, the defect can blastomas from the sympathetic nervous
velops along the back of the embryo by usually be corrected completely; but in system usually develop in the sympa-
about the third week of pregnancy, then myelomeningocele, some handicap will thetic nerves along the back wall of
folds to form the neural tube that later remain and affected children usually the abdomen. Less commonly, tumours
becomes the brain, the spinal cord, and need lifelong care. Physiotherapy and originate in the sympathetic nerves of
their coverings (the meninges). If the mobility aids may be useful to maintain the chest or neck. The tumours often
neural tube does not form properly, activity and allow as great a degree of spread to other sites in the body.
defects in any of these parts can result. independence as possible. INCIDENCE AND CAUSE
TYPES AND SYMPTOMS Children with extensive damage to Neuroblastomas are the most common
The most serious neural tube defect is the brain and/or spinal cord usually extracranial (outside the skull), solid
anencephaly (failure of the skull and brain have a reduced life expectancy. tumour of childhood. Most cases develop
to develop), which is fatal before birth PREVENTION during the first ten years of life, especially
or soon afterwards. More common is The risk of a neural tube defect can be in the first five. The disorder is slightly
spina bifida, in which the vertebrae do substantially reduced if the mother takes more common in boys than in girls.
not form a complete ring around the folic acid supplements before conception The cause of these tumours is not
spinal cord. Spina bifida can occur any- and during the early part of the preg- known, although a genetic factor is
where on the spine, but it is most nancy. A mother who has previously had thought to be involved.
common in the lower back. a child affected by a neural tube defect SYMPTOMS
There are different forms of spina should seek specialist advice before The symptoms of neuroblastoma may
bifida. In spina bifida occulta, the only planning another pregnancy. In such be present from birth or may develop
defect is a failure of the bony arches cases, a higher dose of folic acid may be gradually during childhood. Typical
behind the spinal cord to fuse, which is recommended in order to reduce the symptoms of the condition include a
sometimes associated with a tuft of hair risk of having another affected child. lump in the abdomen, tiredness, weight

540
 NEURON

loss, aches and pains, pallor, and irri- neurofibromatosis neurology

tability. In some cases, there is also A genetic disorder that causes numerous The medical discipline concerned with
diarrhoea, hypertension (high blood soft, noncancerous growths, known as the study of the nervous system and its
pressure), and flushing of the skin. neurofibromas, to appear throughout the disorders. Neurologists are trained to
If a tumour spreads through the body. These tumours grow from nerve examine the nerves, reflexes, motor and
body, other symptoms, such as bone tissue and develop along nerve path- sensory functions, and muscles to deter-
pain or, if the lymph nodes are affected, ways. If the condition is severe, it can be mine a disorder’s cause and extent. They
swellings in the neck or armpits, may very disfiguring. are specialists in the treatment of condi-
occur. Anaemia (a reduced level of the TYPES AND CAUSES tions, such as migraine and Parkinson’s
oxygen-carrying pigment haemoglobin There are two types of neurofibro- disease, that have a neurological basis,
in the blood) may result if the cancer matosis. The more common of the two, and in the care and support of patients
spreads to the bone marrow. known as neurofibromatosis 1, is usually with progressive disorders such as multi-
DIAGNOSIS apparent in early childhood. The other ple sclerosis and muscular dystrophy. (See
The diagnosis of a neuroblastoma is type, neurofibromatosis 2, is extremely also neuropathology; neurosurgery.)
made from MRI and CT scanning (tech- rare and the symptoms do not usually
niques that produce cross-sectional or appear until adulthood. neuroma
three-dimensional images of internal Both types are caused by an abnormal A noncancerous tumour of nerve tissue.
body structures), blood tests, urine tests, gene that shows an autosomal dominant In most cases, the cause is unknown;
and biopsy (removal of a small sample of pattern of inheritance. rarely, a neuroma develops as a result of
tissue for analysis) of the bone marrow SYMPTOMS damage to a nerve.
and any accessible tumours. In neurofibromatosis 1, numerous pale- A neuroma may affect any nerve in
TREATMENT AND OUTLOOK brown, flat patches with irregular the body. Symptoms vary according to
If possible, the tumour is surgically edges, which are known as café au lait the nerve involved. In most cases, there
removed; this is not possible if it has spots, develop on the skin. The growths is intermittent pain in the areas of the
grown around the large blood vessels in under the skin feel soft to the touch and body supplied by the affected nerve.The
the abdomen, however. Treatment is range in size from hardly noticeable to same areas may also become numb and
primarily with anticancer drugs (chemo- large bumps. In addition there may be weak if the neuroma develops in a con-
therapy). Radiotherapy and a bone marrow numerous freckles in the armpit and the fined space and presses on the nerve.
transplant are other treatments that may groin areas. If symptoms are troublesome, the
also be considered. Adults with neurofibromatosis 2 tend tumour may be surgically removed.
The outlook varies because neuro- to develop tumours in the inner ear, (See also acoustic neuroma.)
blastomas range from being relatively which can affect hearing, but they
harmless to aggressively cancerous. Even rarely have tumours under the skin. neuron N
if the tumour is widespread at the time COMPLICATIONS The medical term for a nerve cell.
of diagnosis, however, cure rates may Complications may occur when the STRUCTURE
still reach 30 per cent. growing tumours press on surrounding A typical neuron consists of a cell body,
organs or nerves. For example, vision several branching projections called
neurocutaneous disorders may be affected if a tumour develops on dendrites, and a filamentous projection
A group of conditions characterized by the optic nerve, which connects the eye called an axon (also known as a nerve
abnormalities of the skin and of the to the brain. Tumours can also cause cur- fibre). An axon branches at its end to
nerves and/or the central nervous system. vature of the spine. Some children with form terminals through which nerve
The best known of the neurocuta- neurofibromatosis may develop epilepsy signals are transmitted to target cells.
neous disorders is neurofibromatosis, in or have learning problems. In rare cases, Most axons are coated with a layered
which there are brown patches on the tumours become cancerous. insulating myelin sheath, which speeds
skin and numerous fibrous nodules on TREATMENT the transmission of nerve signals. The
the skin and nerves. Another example is There is no cure for neurofibromatosis, myelin sheath is punctuated along its
tuberous sclerosis, which is characterized and its progression cannot be slowed. length by gaps called nodes of Ranvier,
by small skin-coloured swellings over However, surgical removal of neuro- which help this process. Because the
the cheeks and the nose, mental defic- fibromas may be carried out if there are myelin sheath is nonconductive, ion ex-
iency, and epilepsy. complications or if large, disfiguring change (depolarization) only occurs at
tumours are causing distress. Anyone a node; signals leap from node to node
neurodermatitis with this disorder, and parents of an along the length of the axon.
An itchy, eczema-like skin condition affected child, may wish to seek genetic FUNCTION
caused by repeated scratching. (See also counselling when planning a pregnancy. The nervous system contains billions of
lichen simplex.) OUTLOOK neurons, of which there are three main
In mild cases, life expectancy is normal, types: sensory neurons, which carry
neuroendocrinology but if the tumours are extensive and signals from sense receptors into the
The study of the interactions between become cancerous, lifespan is reduced. central nervous system (CNS); motor neu-
the nervous system and the endocrine rons, which carry signals from the CNS
system that control internal body func- neuroleptic drugs to muscles or glands; and interneurons,
tions and the body’s response to the An alternative name for antipsychotic which form all the complex electrical
external environment. drugs. circuitry within the CNS itself.

541
 NEURON

STRUCTURE OF A NEURON

A neuron (nerve cell) consists of a cell body and several to form terminals, via which signals are transmitted to target
branching projections, which are called dendrites. Every cells, such as the dendrites of other neurons, muscle cells,
neuron has a filamentous projection called an axon (nerve or glands. Bundles of the axons of many neurons are known
fibre). Axons vary greatly in length – from a fraction of a as nerves or, when they are located within the brain or spinal
centimetre to about a metre. An axon branches at its end cord, as nerve tracts or pathways.

Nerve Myelin sheath

Most axons are coated with
a layered insulating myelin Cell body
sheath made by the specialized
(Schwann’s) cells. Myelin speeds
the transmission of electrical
signals along the axon.

Bundles Schwann’s cell

of fibres
Axon
An axon is the conducting
fibre of a neuron. Axons
vary from a fraction of a
centimetre to about a
metre in length.

Dendrite Synapse
This is a gap between an
axon terminal and the
Axon terminals receiving cell. Signals
Connecting to the cell body and to pass across the gap by
dendrites of the neuron depicted means of chemicals
here are the terminals of an axon called neurotransmitters.
Node of Ranvier coming from a second neuron.

BASIC TYPES OF NEURON

N Sensory neurons carry signals from

sense receptors along their axons
Nucleus Axon Muscle fibre

into the central nervous system Dendrite Motor neuron

(CNS). Motor neurons carry signals
from the CNS to muscles or glands; Motor endplate
the axon terminals form a motor
Axon Sense
endplate. Interneurons form all the Nucleus receptor
complex interconnecting electrical
circuitry within the CNS itself. For
Sensory neuron
each sensory neuron in the body, Axon terminals
there are about 10 motor neurons Axon
and 99 interneurons. Neuron in a cell culture
A sensory neuron from an
Nucleus Interneuron adult dorsal root ganglion.

When a neuron transmits (“fires”) a released from adjacent neurons. Certain never replaced. A baby is born with
nerve impulse, a chemical called a neu- neurotransmitters generate a sudden the maximum number of neurons, and
rotransmitter is released from the axon change in the balance of electrical poten- this number decreases continuously
terminals at synapses (junctions with tial inside and outside the cell (an “action throughout life. However, because peo-
other neurons). This neurotransmitter potential”), which occurs at one point on ple are born with a very large number
may make a muscle cell contract, cause the cell’s membrane and flows at high of neurons, problems normally only
an endocrine gland to release a hor- speed along it. Others stabilize neuronal arise when disease, injury, or persistent
mone, or affect an adjacent neuron. membranes, preventing an action poten- alcohol abuse affects the CNS, and dra-
Different stimuli excite different types tial. Thus, a neuron’s firing pattern matically increases the rate at which
of neurons to fire. For example, physical depends on the balance of excitatory and neurons are lost.
stimuli such as cold, pressure, or light of inhibitory influences acting on it. If a peripheral nerve is damaged, its
a certain wavelength may excite sensory LIFESPAN individual nerve fibres have the ability
neurons. Most neurons’ activity is con- If the cell body of a neuron is damaged to regenerate themselves (see nerve
trolled by the effects of neurotransmitters or degenerates, the cell dies and is injury; neuropathy).

542
 NEUROSURGERY

neuropathic joint Polyneuropathy (also known as poly- or muscle biopsy (removal of a small
A joint that has been damaged by neuritis) refers to damage to several sample of tissue for microscopic analy-
inflammation and a series of injuries, nerves; mononeuropathy (or mono- sis) may also be required.
which pass unnoticed due to a loss of neuritis) indicates damage to a single TREATMENT AND OUTLOOK
sensation in the joint resulting from nerve. The term neuralgia describes pain Treatment is aimed at the underlying
neuropathy (nerve damage caused by caused by irritation or inflammation of cause. For example, vitamin injections
disease). Neuropathic joints develop in a particular nerve. may be given to correct a nutritional
a number of conditions, including CAUSES deficiency; blood sugar levels are care-
diabetes mellitus and untreated syphilis. There are some cases of neuropathy that fully controlled to reduce the risk of
SYMPTOMS have no obvious cause. Among the many further nerve damage and promote re-
When sensation to pain is lost, ab- specific causes are diabetes mellitus, covery in people with diabetes mellitus.
normal stress and strain on a joint dietary deficiencies (particularly of the If the cell bodies of the damaged
do not stimulate the protective reflex B vitamins), excessive alcohol consump- nerve cells have not been destroyed, full
spasm of the surrounding muscles; this tion, and metabolic upsets such as recovery from the neuropathy is pos-
failure of the protective reflex allows uraemia. Other causes include Hansen’s sible. (See also radiculopathy.)
exaggerated movement that can lead to disease (leprosy), lead poisoning, or poi-
damage within and around the joint. soning by drug overdose. neuropsychiatry
Osteoarthritis, swelling, and deformity Nerves may become acutely inflamed The branch of medicine that deals with
are features of a neuropathic joint. after a viral infection, such as in Guillain- the relationship between psychiatric
TREATMENT AND OUTLOOK Barré syndrome. Neuropathies may also symptoms and neurological disorder
An orthopaedic brace or caliper splint result from autoimmune disorders (dis- (see neurology). This may include the
may be necessary to restrict any abnor- orders in which the immune system effects of head injury and alcohol on the
mal movement of the joint. Occasionally, attacks the body’s own healthy tissues) brain or specific disorders such as brain
arthrodesis (a surgical operation to fuse such as rheumatoid arthritis, systemic lupus tumours, infections, inherited illnesses,
a joint) is performed. The nerve damage erythematosus, or polyarteritis nodosa. In and disorders causing brain damage in
is irreversible. these disorders, there is often damage childhood. Brain imaging techniques are
to the blood vessels supplying the nerves. often used to demonstrate abnormalities
neuropathology Neuropathies may occur secondarily to of structure and function in disorders
The branch of pathology that is concerned cancerous tumours, such as lung cancer, with psychiatric symptoms.
with the causes and effects of disorders of or with lymphomas and leukaemias.
the nervous system. (See also neurology.) There is also a group of inherited neu- neurosis
ropathies, the most common being An old term for a range of psychiatric
neuropathy peroneal muscular atrophy. disorders in which there was no loss of N
Disease or inflammation of, or damage SYMPTOMS contact with reality (unlike psychosis).
to, the peripheral nerves, which connect The symptoms of neuropathy depend Disorders classed as neurotic included
the central nervous system (the brain and on whether it affects mainly sensory mild forms of depression, anxiety, hypo-
the spinal cord), to the muscles, glands, nerve fibres or mainly motor nerve chondriasis, and dissociative disorders.
sense organs, and internal organs. The fibres. Damage to sensory nerve fibres
term neuritis is now used more or less may cause numbness, tingling, sensa- neurosurgery
interchangeably with neuropathy. tions of cold, and pain, which often The specialty concerned with the surgi-
TYPES starts in the hands and feet and spreads cal treatment of disorders of the brain,
Most nerve cell axons (the conducting towards the centre of the body. Damage spinal cord, or other parts of the nervous
fibres that make up nerves) are insulat- to motor fibres may cause muscle weak- system. Many generalized nervous sys-
ed by a sheath of the fatty substance ness and muscle wasting. Damage to tem disorders do not respond to
myelin. Most neuropathies arise from nerves of the autonomic nervous system surgical treatment, but neurosurgery
damage to, or irritation of, either the may lead to blurred vision, impaired or can deal with most conditions in which
axons or their myelin sheaths. This may absent sweating, faintness, and distur- a localized structural change interferes
cause the passage of nerve signals to be bance of gastric, intestinal, bladder, and with nerve function. Improvements in
slowed or blocked completely. sexual functioning, including inconti- monitoring techniques and control of
Various types of neuropathy are des- nence and impotence. post-operative complications, such as
cribed according to the site and the Some neuropathies are linked with swelling of the brain, have reduced the
distribution of the damage. For exam- particular symptoms; for example, dia- risk of serious problems developing.
ple, a distal neuropathy starts with betic neuropathy can cause severe pain. Conditions treated by neurosurgery
damage at the far end of a nerve (the DIAGNOSIS include tumours of the brain, spinal
end farthest from the brain or spinal In order to determine the extent of the cord, or meninges (the membranes sur-
cord). A symmetrical neuropathy affects damage, nerve conduction studies are car- rounding the brain and spinal cord);
nerves at the same places on each side ried out together with EMG tests, which brain abscesses; trauma to part of the
of the body. Some neuropathies are record the electrical activity in muscles. nervous system, such as that caused by
described according to the underlying Diagnostic tests such as blood tests, a penetrating wound; abnormalities of
cause of the condition, for example MRI scans (a technique that produces the blood vessels supplying the brain,
diabetic neuropathy, entrapment neuropa- cross-sectional or three-dimensional such as an aneurysm (a balloonlike swel-
thy, or alcoholic neuropathy. images of body structures), and nerve ling at a weak point in an artery);

543
 NEUROSYPHILIS

bleeding inside the skull (see extradural also function as hormones, being re- and is well prepared for survival. The
haemorrhage; intracerebral haemorrhage; leased into the bloodstream to act on newborn baby may have an oddly
subdural haemorrhage); a number of distant target cells. shaped skull or a swollen skull as a
birth defects (such as neural tube defects TYPES AND FUNCTIONS result of the transition from the uterus
and hydrocephalus); certain types of One of the most important neurotrans- to the outside world. Such differences
epilepsy; and nerve damage caused by mitters is acetylcholine, which causes are normal, and they usually disappear
illness or accidents. Neurosurgery may skeletal muscles to contract when it is relatively quickly.
also be performed to relieve pain that released by neurons connected to the In a newborn baby, other structures,
would otherwise be untreatable. muscles. Acetylcholine is also released such as the long bones in the legs, are
by neurons that control the sweat not yet fully formed. The eyelids are
neurosyphilis glands and the heartbeat and transmits puffy and vision is poor even when the
Infection of the brain or spinal cord that messages between neurons in the brain eyes are wide open. The umbilical cord,
occurs in untreated syphilis many years and neurons in the spinal cord. Inter- which is cut at delivery, shrivels and
after initial infection. ference with the action of acetylcholine falls off within about ten days to form
Damage to the spinal cord due to on skeletal muscles is the cause of myas- the navel. The skin is often covered with
neurosyphilis may cause tabes dorsalis, thenia gravis. It is thought that depletion vernix, a greasy substance that protects
a condition characterized by poor co- of the nerve cells that release acetyl- the skin in the uterus. Premature babies
ordination of leg movements when choline in the brain may be a factor in may have downy hair, called lanugo hair,
walking, urinary incontinence, and inter- Alzheimer’s disease. all over the body; this hair disappears
mittent pains in the abdomen and Another chemical, noradrenaline (nor- after about a month. Blisters, or small
limbs. Damage to the brain may cause epinephrine), aids the nervous control of white bumps, can sometimes be seen
dementia, muscle weakness, and, in rare heartbeat, blood flow, and the body’s on the lips of a newborn baby; these are
cases, total paralysis of the limbs. response to stress. This substance is due to vigorous sucking. The genitals
made by the adrenal glands as well as may appear large in relation to the rest
neurotic being produced by neurons. of the body.
Suffering from neurosis (any of a range The neurotransmitter dopamine plays At birth, there are changes in the
of psychiatric disorders in which there an important role in parts of the brain structure of the heart that result in all
is no loss of contact with reality). that control movement. A malfunction of the blood circulating through the lungs
the neurons that respond to dopamine is (see fetal circulation).
neurotoxin thought to underlie Parkinson’s disease. The baby has primitive reflexes, such
A chemical that damages nervous Serotonin is one of the main neurotrans- as a grasp reflex, which were important
tissue. The principal effects of neuro- mitters found in the parts of the brain to survival; although, these disappear
N toxic nerve damage are numbness, concerned with conscious processes. with increasing age.
weakness, or paralysis of the part of the Another group of neurotransmitters MEDICAL EXAMINATION
body supplied by the affected nerve. are called neuropeptides. This group Immediately after birth, the newborn
Neurotoxins occur in the venom of includes the endorphins, which are used baby is usually given straight to the
certain snakes (see snake bites) and are by the brain to control sensitivity to pain. mother unless there is concern about its
released by some bacteria (such as those condition. Later, it is checked by the
that cause tetanus and diphtheria). Some neutropenia nurse, midwife, or doctor in attendance.
chemical poisons, such as arsenic and An abnormally low number of neutro- This usually includes checking the heart
lead, are neurotoxic; certain drugs, such phils (a type of white blood cell) in the rate with a stethoscope and establishing
as nitrofurantoin, may cause neurodamage blood, which results in an increased sus- that breathing is normal.
in high doses or in susceptible people. ceptibility to infection. Symptoms may The Apgar score and other tests are
include a sore throat and fever. Neutro- performed to confirm that the baby is
neurotransmitter penia can be due to aplastic anaemia in good health. The baby’s sex, weight,
A chemical released from a nerve end- (see anaemia, aplastic), agranulocytosis, length, and head circumference are
ing that transmits impulses from one acute leukaemia (see leukaemia, acute), noted and a check is made for any obvi-
neuron (nerve cell) to another neuron or drugs such as anticancer drugs. ous birth defect. The vernix is wiped off
or to a muscle cell. and the baby is then usually given back
ACTION neutrophil to the mother to hold. If very small or
When a nerve impulse reaches a nerve A type of phagocyte (a cell in the sick, the baby may need to be moni-
ending, neurotransmitters are released immune system). Neutrophils are a very tored in a neonatal unit.
from synaptic vesicles and cross a tiny important part in the immune system, Within 24 hours of birth, the baby is
gap (a synapse) to reach the target cell. and their role is to engulf and destroy given a complete medical examination.
Here, they cause channels in the target invading bacteria. The skull, eyes, face, abdomen, heart,
cell to open, letting through charged spine, hips, genitals, and limbs are
particles that stimulate an impulse in newborn checked, and the baby’s posture, move-
the cell. Alternatively, neurotransmitters A general term for an infant at birth and ments, behaviour, cry, reflexes, and
may inhibit nerve impulses. during the first few weeks of life. responsiveness are noted. The doctor or
Scores of different chemicals fulfil APPEARANCE OF A NEWBORN BABY midwife will confirm that the baby has
this function in different parts of the A full-term newborn baby weighs, on passed urine and meconium (faeces).
nervous system. Many neurotransmitters average, 3.5 kg, measures 51 cm long, During the second week of life, blood

544
 NICOTINE

new variant CJD

HOW NEUROTRANSMITTERS WORK One form of Creutzfeldt–Jakob disease.
When an electrical impulse travels NGU
down a nerve cell axon, it causes the
release of a chemical neurotransmitter An abbreviation for the condition
at the axon terminals. The chemical nongonococcal urethritis.
released is not the same in every
case; acetylcholine, noradrenaline niacin
(norepinephrine), dopamine, and See vitamin B complex.
serotonin are all important examples. Example of neurotransmitter activity
Neurotransmitters enable the pupil to change nickel
size in different light conditions.
A metallic element that is present in the
Nerve cell axon
body in minute amounts. Nickel is
Cell body thought to activate certain enzymes
(substances that promote biochemical
reactions) and it may also play a part in
stabilizing chromosomal material in the
nuclei of cells.
Electrical impulse Axon terminal Dendrites
Disease due to a deficiency of nickel
The impulse travels down the is unknown. Exposure to nickel may
1 neuronal axon (above), from the
cell body towards the axon terminals;
Axon cause dermatitis (inflammation of the
the neurotransmitter is released from
terminal skin). Lung cancer has been reported in
tiny swellings, called synaptic knobs, Synapse workers in nickel refineries.
at the axon terminals.
niclosamide
The neurotransmitter crosses the gap,
2 or synapse, to the surface membrane
of the target cell (right), where it binds to
Receptors An anthelmintic drug used to treat tape-
worm infestation. Niclosamide causes the
a protein called a receptor. tapeworm to loosen its grip on the inner
wall of the intestine. The worm is then
If sufficient target cell receptors are Presynaptic Postsynaptic Neurotransmitter
3an impulse
activated by neurotransmitter binding,
is initiated and passes in turn
membrane
(axon terminal)
membrane
(dendrite of
chemical passed out of the body in the faeces. Side
effects of niclosamide include abdomi-
target cell)
down the target cell’s axon (below right). nal pain, lightheadedness, and itching.
nicorandil
N
A potassium channel activator drug used in
the prevention and long-term treatment
Electrical impulse of angina pectoris (chest pain due to inad-
to target
equate blood supply to the heart). Side
effects, which include flushing, nausea,
vomiting, and dizziness, are mainly due
tests are performed to check for phenyl- if it occurs during the first 24 hours, if to nicorandil’s vasodilation (widening of
ketonuria (an inherited enzyme defect) it is severe (see kernicterus), or if it the blood vessels) effects and usually wear
and hypothyroidism (underactivity of the affects a premature infant. off with continued treatment. Rarely,
thyroid gland). Other tests may also be Some newborn baby girls have slight mouth ulcers and muscle pain can occur.
performed, depending on family history vaginal bleeding or discharge, and
and the baby’s health. babies of either sex may have enlarged nicotinamide
CONDITIONS IN THE NEWBORN breasts. These conditions are harmless See vitamin B complex.
Some babies suffer injury during birth and are the result of the mother’s circu-
(see birth injury), such as cephalhaema- lating sex hormones that reach the nicotinamide adenine
toma (a swelling of part of the head fetus through the placenta. Any extra dinucleotide
caused by bleeding between the scalp hormones leave the baby’s bloodstream See NAD.
and the skull). and their effects soon disappear.
Jaundice (a yellowing of the skin and Infections of the umbilical cord nicotine
the whites of the eyes; see jaundice, stump sometimes occur, and antiseptic A stimulant drug found in tobacco that
neonatal) is an extremely common con- solution is usually applied to prevent is responsible for tobacco dependence.
dition that occurs in newborn babies, this. A blotchy, red rash (see urticaria, After inhalation, nicotine in tobacco
especially if the baby is breast-fed. Usu- neonatal) affecting the face, chest, arms, smoke passes rapidly into the blood-
ally appearing on the second or third and thighs of the baby may occur stream. Nicotine in chewing tobacco is
day of life, the jaundice usually disap- around the second day after birth; this absorbed more slowly via the lining of
pears over the next few days. In most condition is harmless, of no known the mouth. The drug stimulates the ner-
cases, neonatal jaundice is harmless; cause, and disappears without treat- vous system until it is broken down by
however, the condition may be serious ment. (See also prematurity; postmaturity.) the liver and excreted in the urine.

545
 NICOTINE REPLACEMENT THERAPY

EFFECTS NIDDM Episodes of night terror occur during

Nicotine acts primarily on the autonomic The abbreviation for noninsulin-depen- NREM (nonrapid eye movement) sleep,
nervous system, which controls involun- dent diabetes mellitus (type 2 diabetes). usually half an hour to three and a half
tary body activities such as heart rate.The hours after falling asleep. Sufferers wake
effects of the drug vary from one person nifedipine up screaming, in a semiconscious state,
to another and also depend on dosage A calcium channel blocker drug used and remain frightened for some min-
and past usage. In someone who is not mainly to prevent and treat angina pectoris utes.They do not recognize familiar faces
used to smoking, even a small amount of (chest pain due to inadequate blood or surroundings and usually cannot be
nicotine may slow the heart rate and supply to the heart). Nifedipine is also comforted. Physical signs of agitation,
cause nausea and vomiting. However, in frequently used to treat hypertension (high such as sweating or an increased heart
habitual smokers, the drug increases the blood pressure) and disorders affecting rate, are common. The sufferer gradually
heart rate and narrows the blood vessels, the circulation, such as Raynaud’s disease. falls back to sleep and has no memory of
the combined effect of which is to raise Possible side effects of nifedipine the event the following day.
blood pressure. Nicotine also stimulates include swelling of the hands and feet Though distressing to parents, night
the central nervous system, thereby reduc- as a result of oedema (accumulation of terror in children has no serious signif-
ing fatigue, increasing alertness, and fluid in tissues), flushing of the skin, icance. However, in adults, it is likely to
improving concentration. headache, and dizziness. be associated with an anxiety disorder.
Regular use of tobacco results in tol-
erance to nicotine, so that a higher night blindness nipple
intake is needed for the same effects. The inability to see well in dim light. The small prominence at the tip of each
WITHDRAWAL Many people with night blindness have breast. Women’s nipples contain tiny
Because most regular smokers are no discernible eye disease. The condi- openings through which milk can pass.
physically dependent on nicotine, the tion may be an inherited functional The nipple and the areola, the surround-
act of stopping smoking often causes defect of the retina (the light-sensitive ing dark area, both increase in size
withdrawal symptoms such as headaches, inner layer at the back of the eye), an during pregnancy. Involuntary muscle in
fatigue, drowsiness, and difficulty in con- early sign of retinitis pigmentosa (degen- the nipple allows it to become erect.
centrating. Nicotine replacement therapy, eration of the light-sensitive cells of the DISORDERS
such as the use of nicotine skin patches retina), or a result of vitamin A deficiency. Structural defects of the nipple are rare.
and chewing gum, can be effective in One or both nipples may be absent or
aiding withdrawal from nicotine. (See nightmare there may be additional nipples along a
also smoking.) An unpleasant, vivid dream, sometimes line extending from the armpit to the
accompanied by a sense of suffocation. groin. An inverted nipple is usually a
N nicotine replacement therapy Nightmares occur during REM (rapid harmless abnormality of development,
Preparations containing nicotine that are eye movement) sleep in the middle and which can be corrected by drawing out
used in place of cigarettes as an aid to later parts of the night and they may the nipple between finger and thumb
stopping smoking. Nicotine products are be clearly remembered if the dreamer daily for several weeks. Nipple inversion
available in the form of sublingual tablets awakens completely during the course that develops in older women is mostly
(placed under the tongue), chewing of the nightmare. due to aging, but mammography may be
gum, skin patches, nasal spray, or inhalers. Nightmares are especially common in advisable to rule out the possibility of
Side effects of such preparations may children aged between eight and ten and breast cancer.
include nausea, headache, palpitations, are particularly likely to occur when the Cracked nipples, common during
cold- or flulike symptoms, hiccups, and child is unwell or anxious. In adults, breast-feeding, may lead to infective mas-
vivid dreaming. Nicotine replacement nightmares may be a side effect of certain titis (inflammation of the breast tissue).
therapy should be used as part of a drugs, including beta-blocker drugs and Washing, drying, and moisturizing the
complete package of measures, includ- benzodiazepine drugs. Repeated night- nipple daily can help to prevent cracking.
ing the determination to succeed. mares may be associated with traumatic Papilloma of the nipple is a non-
experiences. However, there is no specific cancerous swelling attached to the skin
nicotinic acid relationship with psychiatric illness. by a stalk. Paget’s disease of the nipple
A form of niacin (see vitamin B complex). Nightmares should not be confused appears initially as persistent eczema of
Apart from its use as a vitamin supple- with hypnagogic hallucinations, which the nipple and is due to a slow-growing
ment, nicotinic acid is also prescribed as a occur while falling asleep, nor with cancer arising in a milk duct. Surgical
lipid-lowering drug and as a vasodilator drug. night terror, which occurs in NREM treatment is required.
High doses are used to treat certain types (nonrapid eye movement) sleep and is Discharge from the nipple occurs for
of hyperlipidaemia (a metabolic disorder not remembered on waking. various reasons. A clear, straw-coloured
in which there are high levels of fats in discharge may develop in early preg-
the blood). Nicotinic acid derivatives are night terror nancy; a milky discharge may occur after
used to improve circulation in disorders A disorder, occurring mainly in children, breast-feeding is over. Galactorrhoea (milk
such as peripheral vascular disease. that consists of abrupt arousals from discharge in someone who is not preg-
Adverse effects of nicotinic acid are sleep in a terrified state. Night terror (or nant or breast-feeding) may be due to a
more common with high doses and sleep terror) usually starts between the hormone imbalance or, rarely, a galacto-
include flushing, dizziness, nausea, pal- ages of four and seven, gradually dis- cele (cyst under the areola). A discharge
pitations, and itching. appearing in early adolescence. containing pus indicates a breast abscess.

546
 NOCARDIOSIS

A bloodstained discharge may be due to nitrofurantoin

a noncancerous breast disorder such as An antibiotic drug that is used in the LOCATION OF THE NIPPLE
fibroadenosis (general lumpiness of the treatment of urinary tract infection. Nitro-
The protrusion at the tip of the
breast) or a cancerous tumour. furantoin should be taken with food to breast, surrounded by the areola.
reduce the risk of stomach irritation, Milk ducts emerge at the nipple.
nitrate drugs which can cause abdominal pain and
COMMON DRUGS nausea. More serious side effects, such Fat
• Glyceryl trinitrate • Isosorbide dinitrate as breathing difficulty, numbness, and
• Isosorbide mononitrate jaundice (yellowing of the skin and the Skin
whites of the eyes), occur rarely.
A group of vasodilator drugs used to treat Nipple
or prevent attacks of angina pectoris nitrogen
(chest pain due to impaired blood sup- A colourless, odourless gas that makes
ply to the heart) and to treat severe heart up 78 per cent of the Earth’s atmos-
failure (reduced pumping efficiency). phere. Atmospheric nitrogen has no
Possible side effects of nitrate drugs biological action.
include headaches, flushing of the skin, Nitrogen gas cannot be utilized by the
and dizziness. Tolerance (the need for body, but compounds of nitrogen are
greater amounts of a drug for it to have essential to life. The most important of
the same effect) may develop when some such compounds are amino acids, the
nitrate drugs are taken regularly.To avoid building blocks of proteins, which repre-
this, a change in dosage, frequency, or sent the fundamental structural substances
Areola
timing of the drug, or prescription of a of all cells and tissues. Humans cannot
different nitrate drug, may be required. make certain amino acids (called essential Milk ducts

amino acids), which must be obtained

nitrazepam from the diet in the form of animal and
A benzodiazepine drug used in the short- plant proteins. The proteins are then surgery, which requires deeper anaesthe-
term treatment of insomnia. Nitrazepam broken down by digestion into their sia, a nitrous oxide and oxygen mixture
is long-acting and may cause a hangover constituent amino acids to be absorbed needs to be combined with other drugs.
effect, with drowsiness and lighthead- and reconstituted into the specific pro- The advantages of the combination of
edness, the following day. Regular use teins needed by the body.These processes nitrous oxide and oxygen over other
over several weeks can lead to reduced of protein breakdown and reconstitution agents are its rapid action and nonflam-
effectiveness as tolerance develops. produce a variety of nitrogen-containing mability. Adverse effects of nitrous N
Nitrazepam can lead to drug depen- waste products, primarily urea, which oxide may include nausea and vomiting
dence and to withdrawal symptoms, are excreted by the body in the urine. during the recovery period.
such as nervousness and restlessness. (See also nitrate drugs; nitrites.)
nits
nitric oxide (NO) nitroglycerine The eggs of lice. Both head lice and pubic
A gas that is produced both outside the A former name for glyceryl trinitrate, a lice produce eggs, which they stick to the
body as a pollutant (for example, in car nitrate drug. base of hairs growing from their host’s
exhaust fumes) and inside the body, head or pubic area. Nits are tiny, mea-
where it takes the form of a molecule Nitrolingual Pumpspray suring only about 0.5 mm in diameter.
that acts as a messenger between cells. The brand name for an aerosol prepara- They are light brown when newly laid
Nitric oxide causes blood vessels to tion of glyceryl trinitrate. This is sprayed and white when hatched. Hatching takes
dilate, affecting the flow of oxygenated under the tongue to treat angina pectoris place within about eight days of being
blood and regulating blood pressure. (chest pain due to impaired blood sup- laid. Louse infestations are frequently
Overproduction of nitric oxide is asso- ply to the heart muscle). identified by the presence of nits.
ciated with various disorders, including
toxic shock syndrome, and rheumatoid nitroprusside nocardiosis
arthritis; underproduction may cause An antihypertensive drug given as an An infection caused by a funguslike
impotence and angina. The control of infusion in the emergency treatment of bacterium present in soil. The infection,
nitric oxide is an important element of hypertension (high blood pressure). which is acquired through inhalation,
many drug treatments. usually starts in the lung and spreads to
nitrous oxide the brain and tissues under the skin.
nitrites A colourless gas, also called laughing Nocardiosis is rare, except in people
Salts of nitrous acid (a nitrogen-contain- gas, that has a sweet smell and the with immunodeficiency disorders or those
ing acid). To preserve meat, sodium chemical formula N2O. Nitrous oxide is already suffering from a serious disease.
nitrite is added in small amounts, to- used with oxygen to provide analgesia The resulting illness, similar to pneu-
gether with potassium nitrate and salt, to (pain relief) and light anaesthesia (see monia with fever and cough, fails to
inhibit the growth of potentially harmful anaesthesia, general) at the site of a seri- respond to short-term antibiotic drug
bacteria. In large amounts, nitrites can ous accident or during childbirth, dental treatment, and progressive lung damage
cause dizziness, nausea, and vomiting. procedures, and minor surgery. For major occurs. Brain abscesses may follow.

547
 NOCTURIA

Nocardiosis is diagnosed by microscopic node within the conducting system of nourished children in developing coun-
examination of sputum.Treatment, which the heart. (See also Bouchard’s node; tries. Noma can also occur in the last
may have to be continued over several Heberden’s node; nodule; singer’s nodes.) stages of leukaemia (cancer of the blood).
months, is with sulphonamide drugs, often The first symptom is inflammation of
in conjunction with other antibiotic nodule the gums and the inner surface of the
drugs, such as trimethoprim. A small lump of tissue. A nodule may cheeks. Without treatment, this leads to
protrude from the skin’s surface or severe ulceration (with a foul-smelling
nocturia form deep under the skin. Nodules may discharge), eventual destruction of the
The disturbance of sleep at night by the be hard or soft. (See also rheumatoid bones around the mouth, and loss of
need to pass urine. In most people, a nodules; surfer’s nodules.) teeth. Healing occurs naturally after a
moderately full bladder does not usually time, but scarring may be severe.
disturb sleep, although light sleepers are noise Antibiotic drugs and improved nutri-
more likely to wake with an urge to Any sound, particularly one that is dis- tion halt the progress of the disease.
empty their bladders. Drinking alcohol ordered and irregular, that is unwanted Plastic surgery may be used to recon-
in the evening stimulates urine produc- or interferes with the ability to hear. struct damaged bones or to improve
tion and may result in nocturia. (See also noise-induced hearing loss.) facial appearance.
A common cause of nocturia in men
is enlargement of the prostate gland (see noise-induced hearing loss nonaccidental injury
prostate, enlarged), which obstructs the Loss of hearing caused by prolonged See child abuse.
normal outflow of urine and causes exposure to excessive noise or by brief
the bladder to empty incompletely. In exposure to intensely loud noise. nongonococcal urethritis
women, a common cause is cystitis (in- Exposure to a sudden, extremely loud Inflammation of the urethra (the tube
flammation of the bladder), in which noise (above 130 decibels) can cause that carries urine from the bladder to
irritation of the bladder wall increases its immediate and permanent hearing loss. be excreted) due to a cause other than
sensitivity so that smaller volumes of Normally, muscles in the middle ear gonorrhoea. Nongonococcal urethritis
urine trigger a desire to urinate. A com- respond to loud noise by repositioning (NGU) was previously known as non-
mon cause of nocturia in both sexes is the ossicles (bones that pass vibrations to specific urethritis (NSU). Worldwide,
heart failure (reduced pumping efficiency the inner ear) to damp down the noise. the condition is a very common type of
of the heart), leading to the retention of If these reflexes have no time to respond, sexually transmitted infection.
excess fluid in the legs during the day, the full force of the vibrations is carried CAUSES
which is absorbed into the bloodstream to the inner ear, severely damaging deli- Almost half of all cases of nongono-
while lying down at night and is carried cate hair cells in the cochlea. Loud noises coccal urethritis are known to be caused
N to the kidneys to make more urine. can even rupture the eardrum. by CHLAMYDIA TRACHOMATIS (see chlamydial
Less common causes of nocturia More commonly, noise damage occurs infections); others may be caused by the
include diabetes mellitus, in which greater by prolonged exposure to lower levels of virus that causes herpes simplex, the pro-
volumes of urine are produced both dur- noise. Any noise above 85 to 90 decibels tozoan trichomonas (see trichomoniasis),
ing the day and night; chronic kidney may cause gradual destruction of the or other microorganisms. In some cases,
failure, in which the normal ability of the cochlea’s hair cells, leading to permanent the cause remains unknown.
kidney to produce a reduced quantity of hearing loss. Prolonged exposure to loud SYMPTOMS
more concentrated urine at night is lost; noise leads initially to a loss of the ability Symptoms generally appear one to five
and diabetes insipidus, in which the kid- to hear certain high tones. Later, deafness weeks after infection, usually in week
neys fail to concentrate the urine due to extends to all high frequencies, and two or three. In men, the infection may
the lack of a pituitary hormone. speech perception is impaired. Eventu- cause a urethral discharge, which may
ally, lower tones are also affected. be accompanied by stinging on passing
nocturnal emission Sounds at 85 to 90 decibels or above urine. There may be redness, crusting,
Ejaculation that occurs during sleep, com- may initially cause pain and temporary and soreness at the urethral opening.
monly called a “wet dream”. Nocturnal deafness. Prolonged tinnitus (ringing or However, often no symptoms are present.
emission is normal in male adolescents buzzing in the ears) occurring after a The equivalent condition in women,
and may also occur in adult men. noise has ceased is an indication that sometimes called nonspecific genital
some damage has probably occurred. infection, may not cause symptoms
nocturnal enuresis PREVENTION unless there are complications. How-
See enuresis, nocturnal. People who cannot avoid exposure to ever, a woman who has the infection
loud noise (for example, workers using can pass it on to her sexual partners.
nodal pneumatic drills) should wear ear pro- DIAGNOSIS AND TREATMENT
Pertaining to a node (a small, rounded tection and have their hearing monitored Diagnosis is made from a swab taken
knot of tissue). regularly (see hearing tests). from the urethra and a urine sample;
both enable identification of the causa-
node noma tive organism. Antibiotic drugs, such as
A small, rounded mass of tissue.The term Also called cancrum oris, noma is the doxycycline, are the usual treatment.
commonly refers to a lymph node (a nor- death of tissue in the lips and cheeks due With treatment, the infection usually
mal structure in the lymphatic system) or to bacterial infection. The condition is clears up in about a week. Follow-up
to the sinoatrial node or atrioventricular largely confined to young, severely mal- visits may be advised after treatment as

548
 NORMOCYTIC ANAEMIA

the infection can recur. Sexual partners • Flurbiprofen • Ibuprofen • Indometacin There is a family history of the condition
must be tested and treated if necessary • Ketoprofen • Mefenamic acid • Nabumetone in approximately half of all cases; the
in order to prevent reinfection. • Naproxen • Phenylbutazone • Piroxicam remainder are due to new mutations.
COMPLICATIONS • Sulindac • Tenoxicam • Tiaprofenic acid There is no treatment for the condition
In men, epididymitis (inflammation of as a whole, but many of its features
the epididymis in the testes), prostatitis A group of drugs, also known as NSAIDs, (such as undescended testes and heart
(inflammation of the prostate gland), that produce analgesia (pain relief) and problems) may be treated successfully.
and urethral stricture (narrowing of the reduce inflammation in joints and soft
urethra) can occur as complications of tissues such as muscles and ligaments. noradrenaline
nongonococcal urethritis. Reiter’s syn- WHY THEY ARE USED Also known as norepinephrine, a hor-
drome (in which there is arthritis and Nonsteroidal anti-inflammatory drugs mone secreted by certain nerve endings
conjunctivitis as well as the urethritis) (NSAIDs) are widely used to relieve (principally those of the sympathetic
occurs as a complication in some men symptoms caused by types of arthritis, nervous system) and by the medulla (the
who develop nongonococcal urethritis. such as rheumatoid arthritis, osteoarthritis, central region) of the adrenal glands.
In women, pelvic inflammatory disease and gout. They do not cure or halt the Noradrenaline’s primary function is to
and infection in the Bartholin’s glands progress of disease but help to improve help maintain a constant blood pressure
may occur. Ophthalmia neonatorum, a type mobility of the affected joints and relieve by stimulating certain blood vessels to
of conjunctivitis, sometimes develops in pain and stiffness. NSAIDs are also used constrict (narrow) when blood pressure
babies born to women who have in the treatment of back pain, menstrual falls. For this reason, it may sometimes
chlamydial cervicitis at delivery. pain, headaches, pain following minor be administered by injection in the
surgery, and injuries to soft tissue. emergency treatment of shock or severe
non-Hodgkin’s lymphoma HOW THEY WORK bleeding. (See also adrenaline.)
See lymphoma, non-Hodgkin’s. NSAIDs reduce pain and inflammation by
blocking the action of the enzyme cyclo- norepinephrine
noninvasive oxygenase (COX), which is involved in An alternative term for noradrenaline.
A term used to describe any medical pro- the body’s production of prostaglandins
cedure that does not involve penetration (chemicals that cause inflammation and norethisterone
of the skin or entry into the body trigger transmission of pain signals to the A progestogen drug used primarily as an
through any natural opening. Examples of brain, but that also protect the stomach ingredient of some oral contraceptives
noninvasive procedures include CT scan- lining). Most NSAIDs block both COX-2 and HRT preparations. Norethisterone
ning and echocardiography. (providing the anti-inflammatory effect) is sometimes prescribed to postpone
The term is sometimes also applied to and COX-1 (leading to stomach irrita- menstruation. It is also used to treat pre-
noncancerous tumours that do not tion). COX-2 inhibitors were developed menstrual syndrome, menstrual disorders N
spread throughout body tissues. to block COX-2 alone, thereby reducing such as menorrhagia (heavy periods),
the risk of stomach irritation. endometriosis, and certain types of breast
non-nucleoside reverse POSSIBLE ADVERSE EFFECTS cancer. Norethisterone is given by injec-
transcriptase inhibitors NSAIDs may cause a range of side effects, tion as a long-acting contraceptive.
A type of antiretroviral drug that is used including nausea, indigestion, bleeding Possible side effects include swollen
to delay the progression of HIV infec- from the stomach, fluid retention, and, ankles, weight gain, depression and,
tion. (See also AIDS.) occasionally, peptic ulcer. They may also rarely, jaundice (yellowing of the skin
worsen heart failure or kidney failure. and the whites of the eyes).
nonoxinol 9 COX-2 inhibitors cause less gastro-
A spermicide used in contraceptive prepa- intestinal irritation than other NSAIDs. norfloxacin
rations such as gels, foams, and creams. An antibiotic drug used in the treatment
Noonan’s syndrome of urinary tract infections.
nonspecific urethritis An inherited condition that shares many
The former term for the condition non- features with Turner’s syndrome, but in norgestrel
gonococcal urethritis. which there is a full complement of See levonorgestrel.
chromosomes. Noonan’s syndrome can
nonstarch polysaccharide (NSP) affect both males and females. Features Noriday
Another name for dietary fibre (see include congenital heart disease (see A brand name for norethisterone tablets,
fibre, dietary). heart disease, congenital), webbing of the which are progesterone-only oral contra-
neck, ptosis (drooping eyelids), myopia ceptives.
nonsteroidal anti-inflammatory (shortsightedness), feeding problems in
drugs infants, short stature, hypotonia (poor mus- normocytic anaemia
COMMON DRUGS cle tone), hearing difficulties, delayed Any form of anaemia in which the
COX-2 INHIBITORS • Celecoxib • Etodolac speech development, delayed puberty, amount of haemoglobin (oxygen-carrying
• Meloxicam • Rofecoxib and undescended testes (see testis, unde- pigment) in the blood is reduced, due to
OTHER NSAIDS • Aceclofenac • Acemetacin scended) in males. a reduction in the total number of red
• Aspirin • Azapropazone • Benorilate In terms of inheritance, Noonan’s blood cells, but the size and haemoglobin
• Benzydamine • Diclofenac • Diflunisal syndrome demonstrates an autosomal content of the individual cells is normal.
• Felbinac • Fenbufen • Fenoprofen dominant pattern (see genetic disorders). Normocytic anaemia can develop as a

549
 NOSE

result of chronic diseases (such as renal

failure or chronic inflammatory joint dis- ANATOMY OF THE NOSE
eases such as rheumatoid arthritis), or as a
The nose is involved in breathing and moistens air and traps particles to
result of a problem in the bone marrow the sense of smell. It is a hollow prevent them from being inhaled. The
itself. (See also microcytic anaemia.) passage that connects the nostrils and upper part contains the receptors that
the top of the throat. It warms and transmit sensations of smell.
nose
The uppermost part of the respiratory Frontal sinus
Olfactory bulb
tract and the organ of smell. Olfactory nerve
Nasal bone
STRUCTURE
The nose is an air passage connecting the Nasal conchae
nostrils at its front to the nasopharynx
(the upper part of the throat) at its rear. Cartilage
The nasal septum, which is made of carti-
Nasal cavity
lage at the front and bone at the rear,
divides the passage into two chambers.
The bridge of the nose is formed
from two small nasal bones and from
cartilage. The roof of the nasal passage
is formed by bones at the base of the Hard palate
skull; the walls by the maxilla (upper
jaw); and the floor by the hard palate.
Three conchae (thin, downward-curv-
ing plates of bone) covered with mucous
membrane project from each wall.
Air-filled, mucous membrane-lined Nasopharynx
cavities (called paranasal sinuses) open
into the nasal passage. There is an open-
ing in each wall to the nasolacrimal may come from the back of the nose the nose (pressing both sides together)
duct, which drains away tears. Projecting and be hard to stop. If the blood is swal- for about 15 minutes. If membranes in
into the roof of the nasal passage are the lowed, bleeding may not be seen. the nose are dry or cracked, rubbing
hairlike endings of the olfactory nerves, CAUSES water-based ointment on the area may
N responsible for the sense of smell. Nosebleeds often occur spontaneously. help to prevent nosebleeds.
FUNCTION In dry environments or during the win- A nosebleed that persists for more
One important function of the nose is ter months, the membranes lining the than about an hour requires medical
to filter, warm, and moisten inhaled air nose may become dry and cracked, attention. Treatment for a serious nose-
before it passes into the rest of the res- causing bleeding to occur. Nosebleeds bleed may involve nasal sponges placed
piratory tract. Just inside the nostrils, may also occur if the lining of the nose into the nostrils to absorb the blood or
small hairs trap large dust particles and is injured by a blow to the nose or by the insertion and inflation of a balloon
foreign bodies. Smaller dust particles nose-picking or forceful nose-blowing. catheter to stop the bleeding. If the cause
are filtered from the inhaled air by the In children, nosebleeds often occur as a is not obvious, the nasal passages may be
microscopic hairlike projections of the result of rough play. examined with a viewing instrument to
conchae. The mucus on the conchae A foreign body in the nose or an look for ruptured blood vessels or a
flows inwards, carrying microorganisms infection in the upper respiratory tract tumour (see endoscopy). Alternatively,
and other foreign bodies back towards may also result in a nosebleed. In peo- imaging techniques such as X-rays or
the nasopharynx to be swallowed and ple over the age of 50, the small blood MRI (a technique that produces cross-
destroyed in the stomach. vessels in the nose may be more fragile sectional or three-dimensional images
The nose also detects smells by means and therefore more likely to rupture of body structures) may be used. Treat-
of the olfactory nerve endings, which, and cause bleeding. ment will then be of the underlying
when stimulated by inhaled vapours, Rarely, recurrent nosebleeds are a sign cause. Occasionally, surgery is required
transmit this information to the olfacto- of an underlying disorder, such as hyper- to tie off leaking blood vessels.
ry bulb in the brain. (See also nose tension (high blood pressure), a bleed-
disorders box.) ing disorder such as thrombocytopenia, nose, broken
or a tumour of the nose or paranasal Fracture of the nasal bones or dis-
nosebleed sinuses. Nosebleeds may also be caused location of the cartilage that forms the
Loss of blood from the mucous mem- by drugs that prevent blood clotting bridge of the nose. A blow from the side
brane that lines the nose. Nosebleeds are (see anticoagulant drugs). may knock the bones or cartilage out of
common in children, but the bleeding TREATMENT position or cause displacement of the
is usually minor and stops by itself. The vast majority of nosebleeds are nasal septum (the dividing partition
Nosebleeds are also common, but in short-lived and do not require specific inside the nose). A frontal blow tends to
some cases serious, in people over the treatment. A nosebleed can usually be splay the bones of the nose outwards,
age of 50. In this age group, bleeding stopped by pressing on the soft part of depressing the bridge. The fracture is

550
 NUCLEAR ENERGY

DISORDERS OF THE NOSE

The nose is susceptible to a wide range disappear spontaneously before puberty. Allergies
of disorders. Infections and allergic Basal cell carcinoma and squamous cell Hay fever (see rhinitis, allergic) is one
conditions, leading to stuffiness or carcinoma (types of skin cancer) may of the most common allergies and may
sneezing, are common. Due to its occur in or around the nostril. The nose be brought on by a reaction to various
prominent position, the nose is also may also be invaded by cancers allergens, such as pollens, animal
prone to injury. originating in the sinuses. dander, house mites, or fungal spores.

Infection Injury Obstruction

The common cold (see cold, common), a Because of its prominent position, the nose A nasal polyp (a projection of swollen
viral infection, causes inflammation of is also particularly prone to injury. Fracture mucous membrane) may block a nostril,
the lining of the nasal passages and of the nasal bones (see nose, broken) is a causing a feeling of congestion.Young
excessive production of mucus, leading common sports injury that can lead to children frequently insert foreign bodies,
to nasal congestion. Small boils deformity and may require corrective such as beads, peas, or pebbles, into their
(infected hair follicles) sometimes surgery. Nosebleeds are also common, nostrils. Objects can become stuck,
occur just within the nostril, where particularly in children; they may be caused leading to obstruction and discharge.
they may cause pain. Backward spread by fragile blood vessels, infection of the
of infection from the nose may cause lining of the nose, or a blow to the nose.
cavernous sinus thrombosis, a serious INVESTIGATION
condition that, without antibiotic Drugs
Repeated sniffing of cocaine interferes To inspect the inside of the nose, the
drugs, can be fatal.
doctor uses a speculum in order to
with the blood supply to the mucous
open up the nostrils. If a fracture is
Tumours membrane lining the nose and can cause suspected, X-rays are taken. If cancer
Noncancerous tumours of blood perforation of the nasal septum. Persistent is suspected, a nasal endoscopy and
vessels, known as haemangiomas, may taking of snuff can irritate or damage the a biopsy are performed.
affect the nasal cavity in babies. Many nasal lining.

usually accompanied by severe swelling nose reshaping REM sleep throughout the night. An
of overlying soft tissue. A fractured nose See rhinoplasty. average cycle of sleep is made up of
is painful and remains tender for about
nosocomial
three-quarters NREM sleep and one- N
three weeks after the injury. quarter REM sleep.
TREATMENT A term that means associated with
Resetting is usually carried out either hospitals. A nosocomial infection, for NSAID
before the swelling has started or when example, is an infection acquired by a The abbreviation for nonsteroidal anti-
it has subsided, usually about ten days patient during a stay in hospital. inflammatory drugs.
after the injury. Occasionally, a displaced
bridge can be carefully manipulated into notifiable diseases NSU
position under a local anaesthetic (see Medical conditions that must be report- The abbreviation for nonspecific ure-
anaesthesia, local). However, a general ed to the local health authority. The thritis, the former term for non-
anaesthetic (see anaesthesia, general) is notification of certain potentially harm- gonococcal urethritis.
usually needed. A plaster splint is some- ful infectious diseases enables public
times required during healing. health physicians to monitor and con- nuchal thickness scan
trol the spread of infection and records Ultrasound scanning performed in early
to be kept of disease patterns. pregnancy in order to identify fetuses at
Examples of notifiable infectious dis- high risk of chromosomal abnormalities,
eases are food poisoning, viral hepatitis, such as Down’s syndrome. The scan inves-
measles, malaria, pertussis (whooping tigates the thickness of the nuchal fold,
cough), tetanus, tuberculosis, meningitis, an area of skin at the back of the neck.
mumps, and rubella (German measles). Excessive thickness of the nuchal fold
Similar information is also collected on is an indication that there may be chro-
cancers, occupational diseases, birth mosomal abnormalities.
defects, and other noninfectious health
problems. (See also prescribed diseases.) nuclear energy
The energy that is released as a result
NREM sleep of changes in the nuclei (see nucleus) of
CT scan showing broken nose The abbreviation for nonrapid eye atoms. Nuclear energy is also known as
In this three-dimensional image of the skull, a
fracture of the nasal bone is clearly visible. The
movement sleep, the period of sleep atomic energy and it is principally
damaged bone is asymmetrical and has a during which the brain is less active. released in the form of heat, light, and
V-shaped notch on the right-hand side. NREM sleep occurs alternately with ionizing radiation, such as gamma rays.

551
 NUCLEAR MAGNETIC RESONANCE

Nuclear energy is released in certain

natural processes, examples of which NUCLEIC ACIDS
include the spontaneous decay of radio-
Two types of nucleic acid are found in There are four different bases in DNA:
active substances, such as uranium ores, body cells: DNA and RNA, both of which adenine (A), cytosine (C), guanine (G),
and the nuclear reactions that power the are long, chainlike molecules (strands). and thymine (T). These bases pair up,
sun. Nuclear energy is also released in DNA consists of two intertwined adenine with thymine and cytosine
specifically designed devices, for ex- strands (a double helix), and RNA is with guanine, to form the characteristic
ample in nuclear reactors. usually just a single strand. double helix structure of DNA. RNA is
Nucleic acids are made up of units like a single strand of DNA but has a
nuclear magnetic resonance called nucleotides, each consisting of a base called uracil (U), instead of
See MRI. sugar, a phosphate group, and a base. thymine, which pairs with adenine.
One nucleotide
nuclear medicine
Techniques that use radioactive sub- Sugar Base Phosphate
DNA molecule
stances (see radioactivity) in the detection
and treatment of disease.
Radioactive materials, which may be
injected, inhaled, or swallowed, are
taken up by body tissues or organs in
different concentrations, and an instru-
ment called a gamma camera is used to
detect and map the distribution of radi-
ation within the body (see radionuclide
scanning). The technique uses only Guanine (G) Adenine (A) Cytosine (C) Thymine (T)
minuscule quantities of radiation.
In techniques for treatment, higher
doses of radiation are used. Diseased tis- Each DNA chain has a “backbone” con- nucleus into the cell cytoplasm (a thick
sues are destroyed by exposure to an sisting of a string of sugar and phosphate fluid that forms the bulk of the cell),
external radioactive source or by inser- chemical groups. Attached to each sugar where it is decoded to form proteins
tion of a radioactive substance into a is a chemical called a base, which can be (see protein synthesis).
body cavity (see radiotherapy; interstitial any of four types (adenine, thymine, When a cell undergoes mitotic (see
radiotherapy; intracavitary therapy). guanine, and cytosine) and forms half a mitosis) division, identical copies of its
N nucleic acid
rung of the DNA ladder. The four bases DNA must go to each of the two daugh-
can occur in any sequence along the ter cells.The structure of DNA makes this
A substance found in all living matter chain. The sequence, often many mil- process possible. Starting at one end of
that has a fundamental role in the prop- lions of individual bases long, provides the molecule, the two chains “unzip”. As
agation of life. Nucleic acids provide the the code for the activities of the cell (see they do so, two more chains are formed
inherited coded instructions (or “blue- genetic code). Because the two bases that (side by side with the original chains) by
print”) for an organism’s development; form each rung of the ladder conform to the linking of free, unlinked nucleotides
they also provide apparatus by which certain pairings, known as base pairs that are present in cells. Because only
these instructions are carried out. (adenine pairs with thymine; and gua- certain base pairings are possible, the
TYPES nine with cytosine) the sequence of new double chains are identical to the
There are two types of nucleic acid: bases on one chain determines the original DNA molecule. Thus a dividing
deoxyribonucleic acid (DNA) and ribo- sequence on the other. This is of funda- cell provides an exact copy of its DNA to
nucleic acid (RNA). In all animal and mental importance for the copying of its daughter cells. Each of a person’s cells
plant cells, including human cells, DNA DNA molecules when a cell divides. carries the same DNA replica that was
permanently holds the coded instruc- RNA is like a single strand of DNA; present in the fertilized ovum, thus the
tions, which are first translated and then the main difference is that the base DNA message passes from one genera-
implemented by RNA. DNA is the main thymine is replaced by another base, tion of cells to the next.
constituent of chromosomes, which are uracil, and the sugar and phosphate
carried in the nucleus of the cell. chain is chemically slightly different. nucleoside reverse
STRUCTURE FUNCTION transcriptase inhibitors
DNA and RNA are similar in structure, DNA controls a cell’s activities by speci- An antiretroviral drug used to delay the
both comprising long, chainlike mol- fying and regulating the synthesis of progress of HIV infection. (See also AIDS.)
ecules. However, DNA usually consists enzymes (substances that promote bio-
of two intertwined chains, whereas chemical reactions) and other proteins in nucleotide
RNA is generally single-stranded. the cell. Different genes (sections of A compound that consists of a base,
The basic structure of DNA is like a DNA) regulate the production of differ- linked to a sugar and a phosphate group.
rope ladder; the chains form the two ent proteins. For a particular protein to The nucleic acids DNA and RNA are
sides, and interlinking structures in bet- be made, an appropriate section of DNA chains of linked nucleotides. There are
ween form the rungs. The ladder twists acts as a template for an RNA chain. This four different bases in DNA, adenine,
into a spiral shape called a double helix. “messenger” RNA then passes out of the cytosine, guanine, and thymine, which

552
 NUTRITION

always pair up, adenine with thymine the CNS) are damaged. In a stroke, pres- gained by nutritionists from studying
and cytosine with guanine, to form the sure on, or reduced blood supply to, the effects of diet on health in different
characteristic double helix of DNA. RNA nerve pathways in the brain often causes countries has led to the development of
is like a single strand of DNA but has loss of feeling on one side of the body. guidelines to ensure a healthy, balanced
uracil as a base instead of thymine. The Severe cold, as in frostbite, causes diet that can reduce the risk of ill health.
sugar molecule in DNA is deoxyribose; in numbness by direct action on the nerves. A BALANCED DIET
RNA it is ribose. Numbness is a symptom of Raynaud’s A good diet supplies adequate quantities
disease, a disorder of the blood vessels in of the main nutrients: proteins, carbo-
nucleus which exposure to cold causes the small hydrates, fats and oils, vitamins, minerals,
The central core, structure, or focus of arteries supplying nerves in the fingers dietary fibre (see fibre, dietary), and
any of a variety of objects or structures. and toes to contract suddenly. water. Each one of these elements makes
CELL NUCLEUS Numbness may indicate psychological an important contribution to health, but
The nucleus of a living cell is a roughly disorders, such as anxiety, panic attack, or it is important that they are consumed in
spherical unit at the centre of the cell. It a hysterical conversion disorder. the correct proportions, with carbohy-
contains the chromosomes (composed DIAGNOSIS AND TREATMENT drates forming the bulk of the diet and
mainly of nucleic acid), which are resp- Examination usually reveals an area of fats only a relatively small proportion.
onsible for directing the cell’s activities, sensory loss or impairment correspond- The daily diet should include foods
and is surrounded by a membrane. The ing to the skin distribution of a single from each of the five main food groups.
membrane has small pores through peripheral nerve, several nerves, or a Bread, potatoes, pasta, and other com-
which various substances can pass bet- sensory area in the CNS. The distribu- plex carbohydrates provide energy,
ween the nucleus and the cytoplasm, a tion of the affected area may suggest the plenty of dietary fibre, some minerals,
thick fluid that forms the bulk of the cell. site and mechanism of the nerve dam- and vitamins in the B group (see vitamin
Usually, the nucleus has one nucleolus, a age. Treatment depends on the cause. B complex). Milk and dairy foods provide
smaller dense region with no membrane protein and are a good source of calcium
concerned with protein manufacture. nummular and certain vitamins, such as B12, A, and
NERVE NUCLEUS Round, flat, and disc-shaped. The term D; low-fat versions are useful for reduc-
A nerve nucleus is a group of neurons may also be used to describe a structure ing the overall fat intake in the diet.
(nerve cells) within the brain and the or condition that features round, flat, Meat, fish, and pulses provide protein,
spinal cord that work together to per- disc-shaped abnormalities. For example, iron, B vitamins, and some minerals. A
form a particular function. nummular eczema is a skin disorder variety of fruit and vegetables should be
ATOMIC NUCLEUS defined by the appearance of character- eaten, ideally five portions each day. Fruit
The nucleus of an atom is composed istic coin-shaped patches of itchy skin. and vegetables provide fibre and carbo-
of protons and neutrons and accounts for
nurse
hydrate and are rich in vitamins and N
almost the total mass of the atom, but minerals. Fatty and sugary foods (such as
only a tiny proportion of its volume. A person trained and experienced in the sweets, cakes, and chips), although pro-
Nuclear energy is produced through scientific basis of nursing. He or she is viding energy, have little other nutritional
changes in atomic nuclei. entrusted with the care of the sick and value and should be limited in the diet.
the carrying out of medical and surgical Consumption of saturated fats should be
nulliparous duties. Worldwide, nurses must meet kept to an absolute minimum.
A term that refers to a woman who has certain prescribed standards of education In addition to foods from the main
never given birth to a live infant, includ- and clinical competence. They must gen- groups, the diet should contain plenty of
ing a woman who has never conceived. erally undergo a period of training in a water, as much as eight glasses a day.
(See also grand multipara; multiparous.) hospital and pass a final examination in The need for water is increased by diar-
order to qualify in the profession. rhoea, vomiting, and taking diuretic
numbness The term nursing may also be used drugs. Drinks that contain sugar, caffeine,
Loss of sensation in part of the body interchangeably with breast-feeding. (See or alcohol should be consumed in mod-
caused by interference with the passage also doctor; midwifery.) eration. Sugar contributes to tooth decay;
of impulses along sensory nerves. carbonated drinks, even those low in
CAUSES nutrient sugar, can damage the teeth because they
Numbness can occur naturally (such as An essential dietary factor, such as carbo- are acidic. Excessive intake of caffeine
when blood supply to a nerve in the leg hydrates, proteins, certain fats, vitamins, can cause palpitations and insomnia.
is cut off temporarily by sitting cross- and minerals. (See Essential nutrients ENERGY REQUIREMENTS
legged); it can be induced artificially boxes, overleaf.) The body needs a constant reserve of
(for example by a dentist anaesthetizing energy to function properly. Energy from
a nerve before filling a tooth); or it may nutrition food is measured in units called kilo-
be the result of a disorder of the nervous The scientific study of food and the joules (kJ) or kilocalories (kcal), which
system or its blood supply. processes of digestion and assimilation. are usually referred to simply as calories.
Multiple sclerosis can cause loss of sen- Nutritionists look at the ways in which The number of calories needed by an
sation in any part of the body through various types of food are used by the individual depends on how much ener-
damage to nerve pathways in the central body, the chemical components of dif- gy their body uses. This depends partly
nervous system (CNS). In a neuropathy, ferent foods, and the effects of eating on how efficiently the body’s cells use
the peripheral nerves (nerves outside certain foods on health. The knowledge energy, which is genetically determined,

553
 NUTRITIONAL DISORDERS

and on the level of physical activity. The

ESSENTIAL NUTRIENTS rate at which the body uses energy sim-
Proteins The main structural component and the remaining eight can only
ply to maintain basic processes such as
of tissues and organs. We need be obtained by eating a balanced breathing and digestion is called the
proteins for growth and repair diet. A vegetarian diet that contains basal metabolic rate (BMR). Extra calo-
of cells. Each protein contains eggs, milk, and cheese provides ries are needed for all other activities;
hundreds and sometimes sufficient amounts of all the energetic sports increase calorie require-
thousands of units called amino essential amino acids. A vegan diet,
acids in specific combinations. which also excludes dairy products, ment. Energy requirements also depend
In the body there are 20 different needs careful planning in order to on gender (for example, an average
amino acids; 12 of these can be prevent a deficient intake of protein woman requires about 2,000 kcal daily,
manufactured by the body itself (see Vegetarianism). compared with about 2,500 kcal for an
average man) and age (a growing
Carbohydrates The two carbohydrate food groups, Complex carbohydrates should teenager requires more calories than an
sugars (simple carbohydrates) and make up at least half of the diet. adult and the BMR declines with increas-
starches (complex carbohydrates), Complex carbohydrates found in ing age). A pregnant woman needs more
are the main energy sources that cereals and fruit are rich in fibre and calories than a nonpregnant woman.
are required for metabolism nutrients. Refined carbohydrates
(chemical processes that take such as sugar and white flour If more calories are consumed than are
place in cells). should be kept to a minimum. needed, the excess energy is stored as fat
and weight is gained.Weight loss occurs if
demands for energy exceed calorie intake.
Fats Fats provide energy for metabolism tend to increase the amounts of
and are a structural component of unwanted types of cholesterol in (See also energy requirements; metabolism.)
cells. Most people in developed the blood whereas polyunsaturated
countries eat too much fat; fats fats and monounsaturated fats have nutritional disorders
should constitute no more than the opposite effect. Studies have Nutritional disorders may be caused by
30 per cent of total calorie intake. indicated that a high level of low- a deficiency or excess of one or more
There are three types of dietary fats: density lipoprotein cholesterol
saturated fats (found mostly in the blood is associated with nutrients, or by the presence of a toxin
in meat and dairy products), coronary artery disease. Our (poisonous element) in the diet.
monounsaturated fats (found in bodies naturally produce enough NUTRITIONAL DEFICIENCY
olive oil and avocados), and cholesterol for our needs; excess A diet deficient in carbohydrates is usually
polyunsaturated fats (found in fish is mostly due to eating too much
and vegetable oils). Saturated fats saturated fat.
also deficient in protein, leading to pro-
tein–calorie malnutrition, which most
often occurs as a result of severe poverty
N Fibre This is the indigestible structural
material that is found in plants.
High-fibre diets (including plenty of
fruit, raw vegetables, grains and
and famine (see kwashiorkor; marasmus).
Although fibre passes through the cereals) provide bulk without excess
Inadequate intake of protein and cal-
intestine unchanged, it is an calories. Low-fibre diets tend to be ories may also occur in people who
essential part of a healthy diet. high in refined carbohydrates and restrict their diet excessively to lose
A diet low in fibre may lead to fats, and thus increase the risk of weight (see anorexia nervosa), hold mis-
constipation, diverticular disease, developing obesity, heart disease, taken beliefs about diet and health (see
and other disorders. and some cancers.
food fad), or lose interest in food due to
alcohol dependence or drug dependence.
Water Our bodies are composed of about metabolism (chemical processes Deficiency of specific nutrients is
60 per cent water. Water constitutes in cells) and normal kidney and commonly associated with a disorder of
a high proportion of many foods, bowel function. Water is also the
particularly fruit and vegetables, major component of the volume the digestive system, such as coeliac dis-
and is essential to maintain of blood in the circulation. ease, Crohn’s disease, or pernicious
anaemia (see anaemia, megaloblastic).
NUTRITIONAL EXCESS
Vitamins Regulators of metabolism. Vitamins usually necessary. Indeed, some
ensure the healthy functioning of vitamins that are stored in fats Obesity results from taking in more
the brain, nerves, muscles, skin, (A, D. E. and K) are dangerous if energy from the diet than is used up by
and bones. Although vitamins do taken in excess. The body can store the body. It is a major threat to health
not supply energy, some enable only relatively small amounts of and is associated with disorders such as
energy to be released from the food. water-soluble vitamins (B and C), coronary artery disease, hypertension (high
A healthy, balanced diet contains but even on a very restricted diet,
enough vitamins for most people’s vitamin deficiency is rare until blood pressure), and stroke (damage to
needs, and supplements are not several months have elapsed. part of the brain due to interruption to
its blood supply). An excessive intake of
saturated fat is thought to be a factor in
Minerals A balanced diet provides enough The only mineral commonly
minerals for most people. Calcium required as a supplement is iron, cardiovascular disease and in certain can-
is necessary for the maintenance of which is used to prevent anaemia cers. Nutritional disorders may also result
healthy teeth and bones. Other in women who have heavy periods. from excessive minerals and vitamins.
minerals, such as zinc and Sodium chloride (salt) is needed to TOXINS
magnesium, are needed in minute maintain fluid balance; excess may
amounts to control cell metabolism. cause high blood pressure.
Naturally occurring toxins can interfere
with the digestion, absorption, and/or
utilization of nutrients or cause specific

554
 NYSTATIN

nystagmus
FOOD SOURCES OF ESSENTIAL NUTRIENTS A condition in which there is involun-
tary movement of the eyes. This
The tables list a selection of foods that here are averages, because the exact
movement is usually horizontal, but can
are good sources of carbohydrate, nutrient content of many foods
protein, fat or fibre, together with the depends on variable factors such as be vertical or rotatory. In almost all
amount of the nutrient concerned in the method of preparation. (See also cases, both eyes move together.
100 g of each food. The figures given vitamins; minerals.) TYPES
In the most common type, jerky nystag-
PROTEIN FAT mus, the eyes repeatedly move slowly in
one direction and then rapidly in the
Food Protein content Food Fat content
(g of protein per (g of fat per
other. This may also occur as a normal
100g of food) 100g of food) effect of attempting to follow a sequence
Yeast extract 40 Coconut oil (saturated fat) 92
of objects rapidly passing the eyes, such
as when looking out of the window of
Beef, lean, roast 31 Butter and margarine 81
a moving vehicle. This phenomenon is
Tuna, canned 28 Brazil nuts, shelled 67 known as “optokinetic nystagmus”. Less
Wheatgerm 27 Peanuts, shelled, roasted 49 commonly, nystagmus is “pendular”,
Cheese, cheddar 26 Sausage, pork, cooked 42 with the eyes moving evenly up and
Chicken, lean, roast 26 Beef, lean with fat, roast 40 down or from side to side.
CAUSES
Peanuts, shelled, roasted 24 Low-fat spread 39
Nystagmus may be congenital (present
Cod, grilled 17 Cream, whipping 38 at birth), in which case the cause is
Soya beans 14 Cheese, cheddar 32 unknown. Because a steady gaze is impos-
Cottage cheese, low-fat 13 Chocolate, milk 30 sible, there is almost always a moderate to
Eggs, boiled 12 Egg yolk 30 severe defect of visual acuity. The condi-
Brazil nuts 12 Olive oil (saturated fat) 14
tion also occurs in albinism and as a result
of any very severe defect of vision present
Tofu (soft) 9 Corn oil (saturated fat) 13
at birth, such as congenital cataract.
Chick peas 9 Sunflower oil (saturated fat) 9 Persistent nystagmus appearing later
in life usually indicates a nervous sys-
tem disorder (such as multiple sclerosis,
CARBOHYDRATE FIBRE
a brain tumour, or an alcohol-related dis-
Food Carbohydrate content
(g of carbohydrate
Food Fibre content
(g of fibre per
order), or a disorder of the balancing N
mechanism in the inner ear. Adult-onset
per 100g of food) 100g of food)
nystagmus is occasionally seen as an
Sugar, white 100 Bran 44 occupational disorder in people who
Sugar, brown 100 Apricots, dried, stoned 24 work in poor light, such as coal miners.
Rice, white, uncooked 87 Prunes 14 INVESTIGATION AND TREATMENT
Cornflakes 87 Peas, boiled 12 Electronystagmography, which is a method
of recording eye movements, may be
Pasta, uncooked 84 Blackcurrants 9
used to differentiate between the differ-
Brown rice 81 Brazil nuts 9 ent types of nystagmus. Treatment is of
Honey 81 Bread, wholemeal 9 the underlying cause, if possible.
Flour, white 80 Peanuts, shelled, roasted 8
Apricots, dried, stoned 67 Sweetcorn 6 nystatin
Chocolate, milk 57 Celery 5
An antifungal drug used in the treatment
of candidiasis (thrush). Nystatin may be
Beans, haricot, uncooked 45 Tofu 4
taken as a tablet, liquid, pessary, cream,
Bread, white 45 Broccoli 4 or ointment and can be safely used dur-
Bread, wholemeal 37 Lentils 2 ing pregnancy. High doses taken orally
Prunes 34 Bread, white 2 may cause diarrhoea, nausea, vomiting,
and abdominal pain.

disorders due to their toxic effects. For nymphomania

example, the ergot fungus on rye can An outdated term for a condition in
cause ergotism, symptoms of which which a woman has an insatiable
include gangrene (tissue death) of the toes appetite for sexual activity with many
and fingers, seizures, and mental disorders. partners. The equivalent behaviour in
Industrial pollutants, pesticides, ferti- men is called satyriasis or Don Juanism.
lizers, and various other chemicals may It was said to be caused by intense nar-
also contaminate food. cissism and feelings of inferiority.

555
 OAT CELL CARCINOMA

Appetite suppressant drugs are rarely Compulsive acts may have to be perfor-

O
used because of their side effects. Orlis- med so many times that they seriously
tat, a drug that prevents absorption of disrupt work and social life.
fat from the intestine, is effective only The disorder is often accompanied by
while being taken. Side effects include depression and anxiety. If severe, a per-
diarrhoea and vitamin deficiencies. son may become housebound.
Radical procedures are sometimes TREATMENT
considered for severely obese people Many sufferers respond well to behaviour
who have failed to lose weight using therapy, sometimes combined with anti-
routine methods. Wiring of the jaws may depressant drugs (see selective serotonin
be carried out to restrict food intake. An reuptake inhibitors). Most recover within
oat cell carcinoma operation in which part of the stomach a year, but symptoms may recur under
A form of lung cancer, also known as is stapled together to reduce its capacity stress. For the most severely affected,
small cell carcinoma. may be performed. Intestinal bypass OCD can be a lifelong problem.
operations are occasionally performed
obesity to reduce the length of the digestive obstetrics
An increasingly common condition in tract and allow less food to be absorbed. The branch of medicine concerned
which a large amount of excess fat has However, due to the risk of adverse with pregnancy and antenatal care, child-
accumulated in the body. An obese per- effects, such procedures are only consid- birth, and postnatal care. Obstetrics also
son is defined as having a body mass ered if obesity is seriously endangering involves the study of the structure and
index (BMI) (calculated from height and a person’s health. function of the female reproductive sys-
weight) of over 30. A BMI of between 25 tem. (See also gynaecology.)
and 30 is overweight, but not obese. obsessive–compulsive disorder
CAUSES A psychiatric condition, often known as obstructive airways disease
Obesity is usually caused by the regu- OCD, in which an individual is dogged See pulmonary disease, chronic obstructive.
lar consumption of more food than is by persistent ideas (obsessions) that lead
needed for energy. Energy requirements to repetitive, ritualized acts (compuls- obstructive jaundice
are determined partly by metabolic rate ions). The disorder, which usually starts A type of jaundice (yellowing of the skin
(see metabolism) and partly by level of in adolescence, is rare. However, minor and the whites of the eyes) resulting
physical activity. Genetic factors may obsessional symptoms probably occur from an obstruction to the flow of bile
play a significant part in obesity. How- in about one sixth of the population, (an alkaline liquid that carries waste
ever, environmental influences (such as particularly at times of stress. products away from the liver) between
eating and exercising patterns) are also CAUSES the liver and the small intestine. Causes
important. In a small minority of cases, OCD may have a genetic element, but include gallstones and cancer of the
O obesity is due to an underlying disorder,
such as hypothyroidism (underactivity of
environmental factors also play a part.
Personality traits of orderliness and
pancreas (see pancreas, cancer of).

the thyroid gland), Cushing’s syndrome, cleanliness are thought to be related, as obstructive sleep apnoea
damage to the hypothalamus (the area of is a tendency to neurotic symptoms. A type of sleep apnoea due to obstruc-
the brain responsible for controlling the Certain brain damage, especially that of tion of breathing by repeated blockage
appetite), or the effects of drug treat- encephalitis, can cause obsessional symp- of the upper airway during sleep.
ment (such as with corticosteroid drugs). toms. Tests on people with OCD show
COMPLICATIONS overactivity in frontal areas of the brain. occipital lobe
Obesity substantially increases the risk SYMPTOMS One of the two areas of brain tissue that
of serious illness. Hypertension (high Obsessions are recurrent thoughts or lie beneath the occipital bone at the
blood pressure), stroke, and type 2 dia- feelings that come into the mind seem- back of the brain. The occipital lobe is
betes mellitus are much more likely to ingly involuntarily. Although people primarily concerned with vision.
occur in obese people. Coronary artery who are affected regard such thoughts
disease is also more common in the as senseless, they are unable to ignore occiput
obese, particularly in men under 40. or resist them. Thoughts of violence, The lower back part of the head, where
Obesity is also associated with an in- fears of being infected by germs or dirt, it merges with the neck.
creased risk of some cancers, including and constant doubts (for example,
cancer of the colon, rectum, breast, and whether the front door is shut or the occlusion
uterus. Extra weight may aggravate ost- oven turned off) are the most common Blockage of a passage, canal, opening,
eoarthritis due to strain on the joints. obsessions. In obsessional rumination, or vessel in the body. Occlusion may be
TREATMENT there is constant brooding over a word, caused by disease (for example, a pulm-
The first line of treatment is a weight- phrase, or unanswerable problem. onary embolism) or may be medically
reducing diet (see weight reduction) plus Compulsions are repetitive, apparently induced. The term also describes eye-
regular exercise. Fad diets may cause a purposeful acts that are carried out in a patching for the treatment of amblyopia
dramatic weight loss within a short ritualized fashion. They are performed (a defect of visual acuity) in children.
period of time but, in almost all cases, for the purpose of warding off fears or In dentistry, occlusion is the relation-
the weight is quickly regained when relieving anxiety. Handwashing, count- ship between the upper and lower teeth
normal eating habits are resumed. ing, and checking are the most common. when the jaw is shut. In an ideal occlu-

556
 OCULOGYRIC CRISIS

sion: the upper incisors and canines condition associated with asbestos in workforce. Assessment of psychological
(front teeth) slightly overlap the lower industry. Allergic alveolitis (inflamma- stress and hazards of new technology
ones; the front two upper incisors are tion of the tiny air sacs in the lungs) is are part of the remit.
aligned centrally with the front two caused by inhalation of organic dusts Occupational health risks are reduced
lower incisors; the remaining upper (often containing fungal spores) (see by dust control, appropriate waste dis-
teeth are positioned in an alternating farmer’s lung). posal, use of safe work stations and
pattern relative to the equivalent lower CHEMICAL POISONING practices, limiting exposure to harmful
teeth; and the outer ridges of the lower Industrial chemicals can damage the substances, and screening for early evi-
premolars and molars (back teeth) fit lungs if they are inhaled, or other major dence of occupational disorders.
into the hollows in the corresponding organs if they enter the bloodstream
upper teeth. Very few people have an through the lungs or skin. Examples occupational mortality
ideal occlusion, but in the majority the of harmful chemicals include fumes of Death due to work-related disease or
arrangement of the teeth allows effi- cadmium, beryllium, lead, and ben- injuries. Annual death rates (deaths per
cient biting and chewing of food. (See zene. Carbon tetrachloride and vinyl million at risk) vary widely between
also malocclusion; retinal artery occlusion; chloride are causes of liver disease. occupations, ranging from very low lev-
retinal vein occlusion.) Many of these compounds can cause els in clothing and footwear manu-
kidney damage. facture to very high levels in industries
occult OCCUPATIONAL SKIN DISEASE such as the offshore oil and gas indus-
Hidden or obscure. For example, the Work-related skin disorders include tries. The pattern of deaths varies over
term occult blood is often used to contact dermatitis (skin inflammation), time as industrial standards change.
describe blood in a sample of faeces which results either from allergy or Certain diseases that take many years to
that is not visible to the naked eye but from direct irritation by chemicals in develop may reflect occupational prac-
can be detected by chemical tests. contact with the skin, and squamous tices that have since been improved.
cell carcinoma, which may be caused by
occult blood, faecal exposure to tar. occupational therapy
The presence in the faeces of blood that INFECTIOUS DISEASES Treatment comprising individually tail-
cannot be seen by the naked eye, but Rare infectious diseases that are more ored programmes of activities to help
can be detected by chemical tests (see common in certain jobs include brucel- people who have been disabled by illness
faecal occult blood test). losis and Q fever (acquired from live- or accident to improve their function
Faecal occult blood tests are widely stock), psittacosis (acquired from birds), and ability to carry out everyday tasks.
used in screening for cancer of the colon and leptospirosis (caused by a bacterium Occupational therapy also involves rec-
(see colon, cancer of). Finding faecal excreted in rat’s urine). People who ommending aids and changes to the
occult blood may also be a sign of vari- work with blood or blood products are home that help to increase an indi-
ous gastrointestinal disorders including at increased risk of viral hepatitis (see vidual’s independence.
oesophagitis (inflammation of the gul-
let); gastritis (inflammation of the
hepatitis, viral) and AIDS, as are health-
care professionals. octreotide O
stomach lining); stomach cancer; cancer RADIATION HAZARDS A somatostatin analogue, a hormone that
of the intestine (see intestine, cancer of); The nuclear industry and some health- acts on the pituitary gland. Given by
rectal cancer (see rectum, cancer of); care professions use measures to reduce injection, octreotide is used mainly in
diverticular disease (in which pouches the danger from radiation hazards. Expo- the treatment of acromegaly (a rare dis-
form in the wall of the intestine); polyps sure to certain types of radiation order that causes abnormal enlargement
in the colon; ulcerative colitis (inflamma- increases the risk of cancer. of certain body parts) and hormone-
tion and ulceration of the lining of the OTHER DISORDERS secreting intestinal tumours. Octreotide
colon and rectum); or irritation of the Other occupational disorders include is also used to prevent complications
stomach or intestine by drugs such as writer’s cramp, carpal tunnel syndrome, and following pancreatic surgery.
aspirin. (See also rectal bleeding.) singer’s nodes. Raynaud’s phenomenon is Side effects of octreotide may include
associated with the handling of vibrat- various gastrointestinal disturbances such
occupational disease and injury ing tools. Deafness may be caused by as nausea, vomiting, abdominal pain
Illnesses, disorders, or injuries that are exposure to excessive noise. and bloating, flatulence, and diarrhoea.
the result of exposure to chemicals or
dust, or are caused by physical, psycho- occupational medicine ocular
logical, or biological factors that occur A branch of medicine that deals with Relating to or affecting the eye and its
in the workplace. Serious occupational the effects of various occupations on structures; also the eyepiece of an opti-
diseases are far less common than for- health and with an individual’s capacity cal device, such as a microscope.
merly, but still make up an important for particular types of work. It includes
group of conditions. They include the prevention of occupational disease and oculogyric crisis
following main categories. injury and the promotion of health in A state in which the eyes are fixed, usu-
DUST DISEASES the working population. ally upwards, for minutes or hours. The
The term pneumoconiosis is used to refer Epidemiology is used to analyse pat- crisis may occur with muscle spasm of
to fibrosis (formation of scar tissue) in terns of sickness absence, injury, illness, the tongue, mouth, and neck, and is
the lung due to inhalation of industrial and death. Clinical techniques are used often triggered by stress. It may occur
dusts, such as coal. Asbestosis is a lung to monitor the health of a particular following encephalitis (inflammation of

557
 OCULOMOTOR NERVE

the brain) and in parkinsonism (a move- oedema of the liver, lowers blood protein (and
ment disorder), or may be induced by Abnormal fluid accumulation in body therefore osmotic pressure), and causes
drugs such as phenothiazine derivatives. tissues that may be localized (as in salt retention. A deficiency of protein in
swelling from an injury) or generalized the diet, as may occur in alcoholics, can
oculomotor nerve (as in heart failure). also reduce osmotic pressure.
The third cranial nerve, controlling most WATER BALANCE IN THE BODY Injury or inflammation may lead to
of the muscles that move the eye. The Water accounts for roughly three fifths oedema by causing capillaries to leak.
oculomotor nerve also supplies the of body weight and is constantly ex- The blockage of lymphatic vessels may
muscle that constricts the pupil, that changed between blood and tissues. The result in lymphoedema.
which raises the upper eyelid, and the pressure of blood being pumped Oedema may also be caused by cer-
ciliary muscle, which focuses the eye. around the body forces water out of the tain drugs, such as corticosteroid drugs,
The oculomotor nerve may be dam- capillaries (tiny blood vessels) and into that have an action on the kidneys,
aged due to a fracture to the base of the the tissues. By a reverse process, which resulting in salt retention.
skull or a tumour. Symptoms of damage depends on the water-drawing power of SYMPTOMS
to the oculomotor nerve include ptosis the proteins in the blood (see osmosis), Symptoms of generalized oedema, such
(drooping of the upper eyelid), squint, water is reabsorbed into the capillaries as swelling around the base of the spine
dilation of the pupil, inability to focus and lymphatic vessels from the tissues. (in bedridden people) or in the ankles,
the eye, double vision, and a slight pro- Normally, these two mechanisms are occur when excess body fluid increases
trusion of the eyeball. (See also trochlear in balance, keeping the distribution of by more than 15 per cent. In severe
nerve; abducent nerve.) water between the blood and tissues cases, fluid accumulates in large body
more or less constant. cavities, such as the peritoneal cavity of
The action of the kidneys and hor- the abdomen in ascites or the pleural
LOCATION OF THE mones, including ADH, regulate the total cavity of the lungs in pleural effusion. In
OCULOMOTOR NERVE amount of fluid in the body. Any excess pulmonary oedema, the air sacs of the
is excreted from the body as urine. lungs become waterlogged, causing
The oculomotor nerve originates breathlessness.
CAUSES OF OEDEMA
high in the brainstem and passes
forward through a slit in the bony
Various disorders can disrupt these pro- TREATMENT
eye socket to reach the muscles cesses. Heart failure leads to congestion The underlying cause of the oedema
that move the eye and eyelids. in the veins, which creates backward should be remedied. If this is not pos-
pressure in the capillaries.This overcomes sible, symptoms can be relieved by ex-
Cerebrum osmotic pressure in the capillaries and cretion of the excess fluid. Output of
causes more fluid than normal to be urine by the kidneys is increased by
Bony forced into the tissues. Backward pres- restricting dietary salt and by the use of
eye sure can also be created by a tumour diuretic drugs.
O socket
pressing on veins, causing oedema in
the area drained by the obstructed vein. Oedipus complex
In nephrotic syndrome, an abnormal A psychoanalytic term defined as the
loss of protein from the blood reduces unconscious sexual attachment of a
osmotic pressure and prevents enough child for the parent of the opposite sex,
fluid being drawn from the tissues into which is manifested by the consequent
Eye
muscle
the blood. Kidney failure prevents salt jealousy of, and desire to eliminate, the
being excreted from the body, allowing parent of the same sex.
it to accumulate in the tissues and
attract water to it. oesophageal atresia
Oculomotor Other disorders that can cause oede- A rare birth defect in which the oesopha-
nerve ma include cirrhosis of the liver, which gus forms into two separate sections
leads to blood congestion in the veins during embryonic development. A short
Brainstem
section of the oesophagus is absent, the
part of the oesophagus above the gap
terminates in a pouch, and the lower
OD part of the oesophagus, projecting up-
The abbreviation for an overdose (see wards from the stomach, may also be
drug overdose). blind-ended. In most cases, however,
the upper or lower section of oesopha-
odontoid gus connects with the trachea (wind-
The peglike process on the second pipe) to form an abnormal channel,
cervical vertebra (one of the vertebral called a tracheoesophageal fistula.
bones in the neck) on which the first The condition may be suspected
cervical vertebra rests. The odontoid is before birth if the mother has polyhy-
Appearance of oedema
dislocated during judicial hanging, and This photograph shows the characteristic swelling dramnios (excess amniotic fluid); this
the resultant pressure on the spinal cord that occurs with oedema and the dimpling of the indicates that the fetus is unable to
is the cause of death. skin when it is pressed. swallow the amniotic fluid as normal.

558
 OESOPHAGEAL VARICES

SYMPTOMS sistent reflux oesophagitis, in which

The infant cannot swallow saliva or constant irritation from gastric acid
milk, and drools and regurgitates milk causes inflammation and swelling fol-
continually. If there is an upper tracheo- lowed by the formation of fibrous scar
esophageal fistula, milk may be sucked tissue and narrowing. In Plummer–Vinson
into the lungs, provoking coughing fits syndrome, a web of tissue forms in the
and cyanosis (a bluish skin coloration). Epiglottis upper oesophagus in association with
TREATMENT AND OUTLOOK
Larynx
iron deficiency anaemia (see anaemia,
Immediate surgery is needed in order iron deficiency). A Schatzki ring (a non-
to join the blind ends of the oesophagus cancerous fibrous ring found in the
Pharyngeal pouch
and close the fistula. In some cases, lower oesophagus) can also cause diffi-
more than one operation may be neces- Mid-oesophageal culty swallowing. Prolonged use of a
sary. If surgery is successful, the baby diverticulum nasogastric tube may inflame the oeso-
should develop normally. Trachea phagus, leading to a stricture, as may
swallowing a corrosive liquid.
oesophageal dilatation DIAGNOSIS AND TREATMENT
A procedure to stretch the oesophagus A barium swallow (see barium X-ray
when it has been narrowed by disease Diverticulum examinations) may help to confirm the
(see oesophageal stricture) and swallow- Throat muscles diagnosis. Endoscopy (passage of a view-
ing is difficult. ing instrument down the oesophagus)
Endoscopy is used to locate the is used to look at the narrowed area,
obstruction. The narrowed area is then Sphincter and a biopsy (removal of a sample of tis-
stretched by passing bougies (cylindri- sue for microscopic analysis) is carried
cal rods with olive-shaped tips) down out to exclude the possibility of cancer.
the oesophagus, or by using a balloon In some cases, the narrowed area can
catheter (a fine tube with an inflatable Location of oesophageal diverticula be stretched by oesophageal dilatation. In
balloon at the end). A pharyngeal pouch forms at the top of the cases where the narrowing is caused by
oesophagus as a reaction to the sphincter’s
failure to relax during swallowing. A mid-
cancer, or in very rare cases where there
oesophageal diverticulum oesophageal diverticulum is a pouch further is severe narrowing over a long segment
A saclike protrusion of part of the wall down the oesophagus. It is usually symptomless. of oesophagus (usually due to the swal-
of the oesophagus. There are two types: lowing of corrosives), the affected area
a pharyngeal pouch (also known as a oesophageal spasm may have to be removed surgically.
Zenker’s or pulsion diverticulum), and Uncoordinated muscle contractions in The stomach can then be drawn up into
a mid-oesophageal diverticulum (also the oesophagus, which cause intermit- the chest or the missing oesophagus
known as a traction diverticulum).
PHARYNGEAL POUCH
tent swallowing difficulties and chest or
upper abdominal pain. The spasm may
replaced with a section of colon. O
This type is located at the top of the be due to reflux oesophagitis but often oesophageal varices
oesophagus, at its entrance from the occurs for no apparent reason. Women Widened veins in the walls of the lower
pharynx (throat). The pouch usually are more commonly affected than men. oesophagus and, sometimes, the upper
projects backwards. The cause is a fail- A barium swallow (see barium X-ray part of the stomach.
ure of the sphincter (circular muscle) at examinations) and endoscopy may be CAUSE
the entrance to the oesophagus to relax used to rule out a more serious condi- Oesophageal varices develop as a con-
during the act of swallowing, due to tion, such as cancer. Treatment is of any sequence of portal hypertension (an in-
muscular incoordination. Instead, the underlying cause. crease in blood pressure in the portal
sphincter resists the passage of food. As vein that is usually caused by liver dis-
the powerful throat muscles used for oesophageal speech ease). Blood in the portal vein, passing
swallowing work against this resistance, A technique for producing speech after from the intestines to the liver, meets
part of the lining of the oesophagus is surgical removal of the larynx (voice- resistance due to liver disease, and is
forced through the oesophageal wall, box) (see laryngectomy). Air is trapped diverted into small veins in the walls of
forming the diverticulum. in the oesophagus and is gradually the oesophagus and stomach. The in-
Once the diverticulum is formed, it expelled while the tongue, palate, and creased blood pressure causes the veins
gradually enlarges. Food and fluids be- lips form distinguishable sounds. to balloon outwards.
come trapped in it and may spill into SYMPTOMS
the trachea (windpipe), causing cough- oesophageal stricture There are generally no symptoms until
ing and recurrent chest infections. The Narrowing of the oesophagus that may an episode of bleeding, which results
condition is usually treated surgically. cause pain, swallowing difficulties, regur- in repeated episodes of haematemesis
MID-OESOPHAGEAL DIVERTICULUM gitation of food, and weight loss. (vomiting of blood) and the passage of
This disorder consists of a pouch that is CAUSES black faeces. There are usually other
formed further down the oesophagus. It Oesophageal stricture may be due to symptoms of chronic liver disease.
rarely causes symptoms and may only cancer of the oesophagus (see oesopha- TREATMENT
be discovered accidentally. It does not gus, cancer of) or to any of numerous To control acute bleeding, urgent endo-
usually require treatment. noncancerous causes.These include per- scopic injection of a sclerosant to seal

559
 OESOPHAGITIS

off the affected veins is required. Alter- oesophagogastroscopy circular, and others longitudinal. The
natively, banding (in which tight rubber Examination of the oesophagus and also inner lining of the oesophagus consists
bands are placed over the base of each the stomach with the use of an endo- of smooth, squamous epithelium that is
enlarged vein) may be used. Replace- scope (see gastroscopy). made up of flattened cells.
ment of lost blood and intravenous FUNCTION
injection of drugs to constrict the blood oesophagoscopy Powerful waves of contractions (peristal-
vessels, such as octreotide and terli- Examination of the oesophagus using an sis) pass through the muscles in the
pressin, are also carried out. Creation of endoscope (see gastroscopy). oesophageal wall, propelling food and
a shunt (a surgically created passage) to liquids down towards the stomach and
direct blood away from the varices may oesophagus intestines for digestion. Gravity plays
also be considered. Despite treatment, an The muscular tube that carries food little part in getting food into the stom-
episode of bleeding may still prove fatal. from the throat to the stomach. The ach, making it possible to drink while
oesophagus is part of the digestive tract upside down. (See also swallowing).
oesophagitis (see digestive system).
Inflammation of the oesophagus. There STRUCTURE oesophagus, cancer of
are two main types: corrosive oesopha- The top end of the oesophagus is the A malignant tumour, most common in
gitis, caused by accidental or intentional narrowest section of the entire digestive people over the age of 50, that mainly
swallowing of caustic chemicals, and tract. It is encircled by a sphincter (cir- affects the middle or lower oesophagus
reflux oesophagitis, caused by regurgi- cular muscle) that is normally closed and leads to swallowing difficulties.
tation of the stomach’s contents. but can open to allow the passage of Smoking and heavy alcohol intake are
CORROSIVE OESOPHAGITIS food. A similar sphincter operates where risk factors; people with certain disor-
Chemicals that are likely to cause severe the oesophagus joins the stomach. The ders of the oesophagus (such as Barrett’s
corrosive oesophagitis include many oesophageal walls consist of strong mus- oesophagus) are also at increased risk.
cleaning and disinfecting products. The cle fibres arranged in bundles: some SYMPTOMS
oesophagus may rupture, with fatal The tumour is often present for some
consequences; alternatively it may heal time before it begins to cause symp-
but may result in an oesophageal stricture ANATOMY OF THE toms. Early symptoms may include pain
OESOPHAGUS
(narrowing of the oesophagus). on, and difficulty in, swallowing foods
REFLUX OESOPHAGITIS A muscular tube that propels food and/or liquids. The patient’s condition
Reflux oesophagitis is due to poor func- to the stomach from the throat. The progressively worsens to a point where
tion of the muscles in the lower upper and lower ends are bounded food is immediately regurgitated and
oesophagus, which permits the stom- by sphincters – muscular valves that there is rapid weight loss. Regurgitated
ach’s acidic contents to rise back into open to allow food to pass through. fluid spilling into the trachea (windpipe)
the oesophagus (see acid reflux). The often causes respiratory infections.
O main symptom, heartburn, may be
worsened by alcohol, smoking, and
DIAGNOSIS, TREATMENT, AND OUTLOOK
Diagnosis usually involves a barium
obesity. Poor function of the lower swallow (see barium X-ray examinations)
oesophagus may be linked with a hiatus to detect an obstruction in the oesopha-
hernia, in which the top part of the gus and a biopsy (removal of a small
stomach slides back and forth through sample of tissue for microscopic analy-
the muscular diaphragm between the Pharynx sis) taken during endoscopy.
chest and the abdomen. Treatment depends on whether or not
COMPLICATIONS the cancer has spread to surrounding
Barrett’s oesophagusis a complication of structures. Removal of the oesophagus
reflux oesophagitis in which cells that may be possible in some localized, and
Epiglottis
normally line the stomach extend up Larynx
early diagnosed, cancer. Radiotherapy may
into the oesophagus. It may lead to can- cause regression of the cancer, relieve
cer. Severe, chronic oesophagitis can Oesophagus
symptoms, and occasionally cure older
cause an oesophageal stricture. patients who might not be suitable for
TREATMENT Diaphragm major surgery. Permanent insertion of a
The treatment for most cases of persis- rigid tube (a stent) through the tumour,
tent reflux oesophagitis is a change of Stomach or laser treatment to burn through it,
diet and lifestyle: weight loss, avoiding can help temporarily to relieve symp-
heavy meals, limiting alcohol intake, toms and improve nutrition.
and stopping smoking. Antacid drugs The outlook depends on whether the
help to reduce acidity. Surgical treat- cancer has spread at the time of diagno-
ment (such as minimally invasive surgery) sis. In cases in which there is no spread
may be necessary for a hiatus hernia. and surgery is carried out successfully,
50 per cent of patients survive for more
oesophagogastroduodenoscopy than five years. If the cancer is more
Examination of the upper digestive tract widespread, less than a quarter of
using an endoscope (see gastroscopy). patients survive longer than one year.

560
 OLECRANON BURSITIS

blood clotting and susceptibility to

DISORDERS OF THE OESOPHAGUS hypertension (high blood pressure).
Oestrogen drugs should not be taken
Several disorders affect the oesophagus, is usually difficulty in swallowing. The
during pregnancy because they may
many of which cause swallowing majority of oesophageal tumours are
adversely affect the fetus.
difficulties and/or chest pain. cancerous (see oesophagus, cancer of).
oestrogen hormones
Infection and inflammation Injury
A group of hormones that are essential for
Infections of the oesophagus are rare Severe vomiting and retching can tear
normal female sexual development and
but may occur in immunosuppressed the oesophageal lining and, in extreme
healthy functioning of the reproductive
patients whose defences are weakened. cases, lead to rupture. A swallowed
system. In women, they are produced
The most common are herpes simplex foreign body can also cause injury, even
mainly in the ovaries and also in the pla-
and candidiasis (thrush) spreading perforation, if it penetrates the
centa in pregnancy. Small amounts are
downwards from the mouth. Both oesophageal wall.
produced in the adrenal glands in both
cause pain on swallowing. Oesophagitis
men and women, but oestrogens have
(inflammation of the oesophagus) is Other disorders
no specific function in men. When lev-
usually due to reflux of stomach Oesophageal varices (dilated blood
els are low, oestrogen hormones can be
contents, causing heartburn. A more vessels) at the junction of the stomach
replaced with oestrogen drugs.
severe form, corrosive oesophagitis, can and oesophagus may be associated
occur as a result of swallowing caustic with cirrhosis. An oesophageal oestrogen–progestogen pill
chemicals. Both types may cause an diverticulum is a protruding sac in
An alternative name for the combined
oesophageal stricture (narrowing of which food may collect, causing
pill (see oral contraceptives).
the oesophagus) with difficulty in difficulty in swallowing. In oesophageal
swallowing. Barrett’s oesophagus is a spasm, the oesophageal muscles oestrone
complication of long-term reflux contract uncontrollably. In achalasia,
See estrone.
oesophagitis; it may lead to cancer. the sphincter at the junction between
the oesophagus and stomach fails to ofloxacin
Congenital defects relax to allow the passage of food,
A quinolone antibiotic used to treat skin,
Oesophageal atresia (the congenital causing pain on swallowing and
soft tissue, and lower respiratory tract
absence of a section of the oesophagus, sometimes regurgitation of food.
and urinary tract infections. It is usually
with the remaining sections ending in
taken in tablet form to treat infections
dead ends) requires urgent surgical
that have not responded to other drugs
treatment. Babies are occasionally also INVESTIGATION but is also given by intravenous infu-
born with weblike constrictions of the
sion for severe systemic infections. Side
oesophagus. These are rarely serious
enough to require treatment, but they
Disorders of the oesophagus are
investigated by barium swallow (see
effects may include nausea, vomiting,
diarrhoea, and abdominal pain.
O
can be broken down with a dilator. barium X-ray examinations) and by
endoscopy during which a biopsy oils
Tumours (tissue sample) can be taken for
microscopic examination. See fats and oils.
Tumours of the oesophagus are
relatively common.The initial symptom ointment
A greasy preparation that is used as a
vehicle to apply drugs in dry skin con-
oestradiol WHY THEY ARE USED ditions such as eczema or to protect or
See estradiol. Oestrogens suppress the production of lubricate the skin.
gonadotrophin hormones, which stimu-
oestriol late cell activity in the ovaries. They are olanzapine
See estriol. used in HRT to treat, or sometimes to An antipsychotic drug used for the treat-
prevent, menopausal symptoms and ment of schizophrenia.
oestrogen drugs disorders. Oestrogens may also be used
COMMON DRUGS to treat female hypogonadism (under- olecranon
•Conjugated oestrogens •Diethylstilbestrol activity of the ovaries), abnormal The bony projection at the upper end of
•Estradiol •Estriol •Estrone •Estropipate menstrual bleeding, and prostatic can- the ulna (the inner bone of the fore-
•Ethinylestradiol •Mestranol cer (see prostate, cancer of). arm) that forms the point of the elbow.
POSSIBLE ADVERSE EFFECTS
A group of synthetically produced Oestrogens may cause breast tenderness olecranon bursitis
drugs that are used in oral contraceptives and enlargement, bloating, weight gain, Inflammation of the small, fluid-filled
and additionally to supplement or re- nausea, reduced sex drive, depression, pad that cushions the olecranon at the
place the body’s own oestrogen hor- migraine, and bleeding between per- tip of the elbow. The condition causes
mones in hormone replacement therapy iods. Most of the side effects subside pain and swelling but usually clears up
(HRT). Oestrogen drugs are often used after two or three months. Oestrogens after a few days of rest and avoiding
with progestogen drugs. can also increase the risk of abnormal pressure on the joint. (See also bursitis.)

561
 OLFACTORY BULB

oligohydramnios zoospermia. It may be a cause of infertil-

LOCATION OF THE A condition in which an insufficient ity,especially when other disorders of
OLECRANON
amount of amniotic fluid surrounds a the sperm are also present.
This is the curved projection at the
fetus in the uterus. CAUSES
upper end of the ulna. It acts to CAUSES Normally, there are more than 20 mil-
prevent elbow overextension. Amniotic fluid is produced partly by lion sperm per millilitre of semen. A low
the placenta, but mainly from the urine sperm count can be due to various dis-
View from behind produced by the fetus. Oligohydram- orders, including hormonal disorders,
nios may occur if the placenta is not orchitis (inflammation of a testis), unde-
Humerus
functioning properly, which can occur scended testis (see testis, undescended),
in severe pre-eclampsia, or if there is an and, infrequently, a varicocele (varicose
Olecranon
abnormality of the kidneys or bladder vein in the scrotum). Smoking, alcohol
of the fetus. Reduced quantities of abuse, and some drugs may also reduce
Ulna amniotic fluid may also result from the sperm count.
leakage due to a premature rupture of TREATMENT
Radius the amniotic membranes. Treatment of oligospermia is for the
TREATMENT AND OUTLOOK underlying cause. If the cause is a hor-
Side view Oligohydramnios may be suspected if mone deficiency, gonadotrophin hormones
the woman’s uterus is smaller than may be prescribed. If infertility is a
Radius expected; diagnosis is confirmed using problem, artificial insemination within
Ulna ultrasound scanning. the uterus or in vitro fertilization (IVF)
In some cases, the underlying dis- with intracytoplasmic sperm injection may
Olecranon
order can be treated, but this may not be successful. (See also azoospermia.)
be possible (particularly if the fetus is
not developing normally). If oligohy- oliguria
olfactory bulb dramnios occurs early in pregnancy, it The production of low quantities of
The swelling at the end of each olfactory usually results in miscarriage. In later urine in proportion to the volume of
nerve that deals with the sense of smell. pregnancy, the pressure of the uterus on fluid taken in. The condition may be
These bulbs lie on the brain’s lower sur- the fetus may cause a deformity such as caused by excessive sweating; in some
face, just above the roof of the nose. talipes (club-foot). cases, it is a sign of kidney failure.
olfactory nerve oligospermia olive oil
The first cranial nerve, which conveys A temporary or permanent deficiency An oil, obtained from the fruit of the
sensations of smell as nerve impulses in the number of sperm in the semen. olive tree OLEA EUROPAEA, that may be
O from the nose to the brain. Each of the
two olfactory nerves has receptors in
This condition is also known as oligo- used to soften earwax or to treat cradle
cap in babies. Olive oil is high in mono-
the mucous membrane lining the nasal unsaturated fat (see fats and oils); it is an
cavity. These receptors detect smells LOCATION OF THE important part of a Mediterranean diet.
and send signals along nerve fibres, OLFACTORY NERVE
which pass through tiny holes in the Ollier’s disease
Each olfactory bulb lies on top of a
roof of the nasal cavity and combine to thin bony plate in the roof of the See dyschondroplasia.
form the olfactory bulbs. From here, nose and connects to the brain via
nerve fibres come together to form an olfactory nerve. Nerve twigs pass -oma
the olfactory nerve, which leads to the through the bony plate to enter the A suffix denoting a tumour, which may
olfactory centre in the brain. Sense of nasal lining. be cancerous or noncancerous, as in
smell may be lost or impaired due to lipoma and carcinoma.
damage to the olfactory nerves, usually
as a result of head injury.
Olfactory
nerve omega-3 fatty acids
A group of polyunsaturated fatty acids
oligo- Olfactory that are found mainly in oily fish (such
A prefix meaning few, scanty, or little, bulb as mackerel, herring, and sardines).
as in oligospermia (the presence of too Omega-3 fatty acids are also found in
few sperm in the semen). certain vegetable oils (such as rapeseed
oil and soya oil) and nuts such as
oligodendroglioma walnuts and peanuts.
A rare and slow-growing type of pri- Omega-3 fatty acids have been found
mary brain tumour that originates in the to lower raised levels of triglycerides (a
oligodendroglial cells that support brain type of fat) in the blood. Fish-oil prepa-
cells. Oligodendroglioma mainly affect rations containing omega-3 fatty acids
Nerve
young or middle-aged adults. Surgical twigs are used to treat severe hypertriglycer-
removal of the tumour can, in some idaemia, in which levels of triglycerides
cases, lead to a total cure. in the blood are greatly elevated (see

562
 OOGENESIS

hyperlipidaemias).The principal side The dead larvae can cause an allergic Because there are many different types
effects are nausea and belching, but reaction resulting in inflammation and of tumours, developing in virtually any
these are uncommon. the formation of fibrous tissue. When tissue in the body, oncology encom-
this occurs in the eye, the damage is passes a wide range of experimental
omentum permanent and leads to blindness. techniques and investigative approach-
A double fold of fatty membrane in the Symptoms of the condition include es.These include surveying the frequency
abdomen (peritoneum) hanging in front itchy, swollen patches; they usually arise and distribution of tumours, testing new
of the intestines that acts as a fat store. about a year after infestation. treatments, investigating the biochemical
TREATMENT AND PREVENTION processes involved in tumour formation,
omeprazole Treatment involves taking anthelmintic and studying abnormal genes that are
A proton pump inhibitor drug used to treat drugs, which quickly kill the microfilar- associated with tumours. Doctors spe-
peptic ulcer, reflux oesophagitis (inflam- iae. Such treatment needs to be repeated cializing in the study and treatment of
mation of the gullet), and Zollinger– annually because the adult worms are cancer are known as oncologists.
Ellison syndrome. Possible adverse effects not affected. Travellers to areas where
include rashes, headache, nausea, diar- the disease is prevalent should take ondansetron
rhoea, and constipation. measures to discourage insect bites. A serotonin antagonist drug used to con-
trol the nausea and vomiting that occur
omphalocele oncogenes following an operation or that are indu-
An alternative name for exomphalos. Genes found in every cell of the body ced by radiotherapy or anticancer drugs.
that control growth, repair, and replace- Ondansetron is taken in the form of
onchocerciasis ment. Activation of an oncogene is a tablets or suppositories or is given by
A tropical disease, also called river factor in the development of cancerous injection. Side effects may include con-
blindness, caused by infestation with cells. Mutations (structural changes) in stipation, headache, and hiccups.
the worm ONCHOCERCA VOLVULUS. The dis- oncogenes, resulting from damage by
ease, a type of filariasis, affects millions carcinogens, can cause a cell to grow onychogryphosis
of people in some regions of Africa and uncontrollably and infiltrate and destroy Abnormal thickening, hardening, and
Central and South America. normal tissues (see cancer). Factors curving of the nails that occurs mainly
CAUSES AND SYMPTOMS known to encourage oncogene mutation in elderly people. It may be associated
Onchocerciasis is transmitted from per- include ultraviolet light, radioactivity, with fungal infection or poor circulation,
son to person by small, fiercely biting, tobacco smoke, alcohol, asbestos, and or it may occur for no apparent reason.
black simulium flies. These flies, which some chemicals. In addition, some
breed in, and always remain near, fast- viruses can activate oncogenes.
running streams, ingest microfilariae
(tiny worms) and inject their larvae oncology
into human skin, where they multiply
and spread around the body under the
The study of the causes, development,
characteristics, and treatment of tumours,
O
skin (see the illustrated box). particularly cancers (malignant tumours).

LIFE-CYCLE OF ONCHOCERCIASIS

The infestation is
spread by a fly that the T he
l Onychogryphosis
d in prod arvae This thickening, hardening, and overgrowth of the
ingests microfilariae ite uce gr
p os ly. mi ow toenails occurs mainly in elderly people. It can also
(tiny worms) from an de f a
f cro i
o fi affect the fingernails.
nt ria

infested person. The

bi re

o a e.
the a
te

la

worms grow into

by ae

du

onycholysis
skin larv

l ts

larvae inside the fly

whi
m

and are deposited Separation of the nail from its bed: a

Wor

ch

in the skin of a new feature of many skin conditions, includ-

human host when ing psoriasis and dermatitis.
the fly bites. In
the new host, the oocyte
larvae develop One of the cells that are found in the
Fly b and

into adults, which

bloo

ovary that, after undergoing meiosis (a

lin near
ss.

produce micro-
eco ing
d

dne

type of cell division), form ova (egg

e b ie

filariae that migrate

me es

us d d

around the body. cells; see ovum).

s i tin

ca r an
nf

ct t
e
e

g m ed b en oogenesis
icr y su a riae may
o fi ckin i l
crof on The process by which mature ova (egg
lari
ae.
g I f mi reacti
, cells; see ovum) are produced in the
e yes
female’s ovary. At birth, a female has
her entire lifetime’s complement of

563
 OOPHORECTOMY

oogonia (cells that divide by meiosis to -opathy open fracture

develop firstly into oocytes and eventu- A suffix denoting disease or disorder, as A type of fracture, also known as a com-
ally into mature ova). in neuropathy (a disorder of the nerves). pound fracture, in which the broken
bone penetrates the overlying skin. An
oophorectomy open-angle glaucoma open fracture carries a greater risk of
Removal of the ovaries, usually done to An alternative name for chronic simple infection than a closed fracture because
treat ovarian cysts or cancer (see ovary, glaucoma, a gradual buildup of excessive the skin has been punctured.
cancer of). A partial oophorectomy may fluid pressure in the eye.
be performed to preserve ovarian func- open heart surgery
tion in premenopausal women. In a open chest massage Any operation on the heart in which it
hysterectomy, both ovaries may be remov- Rhythmic compression that is applied is stopped temporarily and its function
ed if disease has spread from the uterus, directly to the heart through an incision taken over by a mechanical pump (a
or as a preventive measure. The ovaries in the chest wall in order to restart heart–lung machine). The main forms of
may be removed as part of the treatment arrested heart action (see cardiac arrest). open heart surgery include the correc-
for breast cancer if growth of the tumour Open chest massage, which is also tion of congenital heart defects (see
depends on hormones produced by the known as internal cardiac massage, is an heart disease, congenital), surgery for the
ovary. If both ovaries are removed before emergency measure for the purpose of repair of narrowed or leaky heart valves
the onset of the menopause, hormone maintaining the circulation. It is not (see heart-valve surgery), and coronary
replacement therapy (HRT) may be needed. commonly performed. artery bypass surgery.

OPERATING THEATRE

The operating table can be raised, lowered, and titled in any usually sits. The operating lamp is designed to give brilliant
direction to allow optimum access to the patient. For some focal illumination without causing any shadow. The anaesthetic
operations, it is best for the surgeon to stand but, during apparatus can maintain breathing in patients who have been
delicate procedures, such as microsurgery, the surgeon given a muscle-relaxant drug.

Power supply Assistant surgeon Shadowless Piped anaesthetic

operating lamp gases and suction

Clocks

O Senior
surgeon
Intravenous drip

Lightbox for
viewing X-rays

Patient pulse and

electrocardiograph
(ECG) monitor

Theatre nurse

Scrub nurse
Anaesthetist

Operating table

Bowl of sterile water

Instrument trolley

564
 OPPORTUNISTIC INFECTION

Once the heart–lung machine has been ophthalmitis opiate

connected, the heart is isolated, and A term that is used to describe any Any drug derived from, or chemically
the defects repaired. Surgical hypother- inflammatory eye disorder. Types of similar to, opium.
mia is used to keep the heart cool and ophthalmitis include ophthalmia neonat-
help prevent damage to the heart mus- orum and sympathetic ophthalmitis, a opioid
cle from lack of oxygen (see hypo- rare condition in which a penetrating A type of analgesic drug (painkiller)
thermia, surgical). Various techniques injury to one eye is followed by severe used in the treatment of moderate to
that enable procedures to be performed uveitis (inflammation of the iris and severe pain. Opioids, also known as nar-
on a beating heart without the need choroid) that can lead to blindness in cotic drugs, may be abused for their
to use a heart–lung machine are now the other eye. Sympathetic ophthalmitis euphoric effects; abuse may cause toler-
becoming available. can be treated with corticosteroid drugs, ance (the need for greater amounts of a
but it is sometimes necessary to remove drug to get the same effect), and physi-
operable the injured eye in order to preserve the cal and psychological drug dependence.
A term applied to a condition that is sight of the other. Opioids in common use include codeine,
suitable for surgical treatment, such as diamorphine, morphine, and pethidine.
an accessible noncancerous tumour. (See ophthalmology
also inoperable.) The study of the eye and the diagnosis opisthotonus
and treatment of the disorders that A form of spasm in which the head is
operating theatre affect it. Ophthalmology covers assess- bent backwards and the back is arched.
A specialized room in which surgical ment of vision, prescription of glasses Opisthotonus may occur in people with
procedures are performed. An operating or contact lenses, and surgery for eye tetanus or meningitis or as a result of a
theatre is one of a suite of rooms, disorders, such as cataracts and glauco- severe brain injury.
attached to an anaesthetic room and a ma. (See also eye, examination of; optician;
recovery area. The risk of infection of optometry; orthoptics.) opium
open wounds during surgery is reduced A substance obtained from the unripe
by a ventilation system that continually ophthalmoplegia seed pods of the poppy plant PAPAVER SOM-
provides clean, filtered air, and surfaces Partial or total paralysis of the muscles NIFERUM . Opium has an analgesic (pain-
that are easily washable. Surgeons, assis- that move the eyes. Ophthalmoplegia relieving) effect and may also cause
tants, and nurses use sterile brushes and may be caused by a disease that affects sleepiness and euphoria. Opium and its
bactericidal soaps to scrub their hands the eye muscles themselves, such as derivatives, such as codeine and diamor-
and forearms before putting on sterile Graves’ disease, or by a condition that phine, are known as opiates or opioids.
gowns and gloves. affects the brain or the nerves supplying
The operating theatre has a range of the eye muscles, such as stroke, a brain opportunistic infection
equipment, including shadowless oper- tumour, encephalitis (inflammation of the Infection by organisms that rarely have
ating lights; lightboxes for viewing X-ray
images or scans; anaesthetic machines
brain), or multiple sclerosis. serious or widespread effects in people
of normal health, but which can cause
O
(see anaesthesia, general); and a diather- ophthalmoplegic migraine serious illness or widespread infection
my machine, which is used for the A type of migraine (a severe headache
control of bleeding. A heart–lung machine that is often accompanied by visual
may also be used. disturbances) in which movement of an OPHTHALMOSCOPE
eye is affected. Movement of the pupil
operation An ophthalmoscope allows viewing
may or may not also be affected. of the entire area of the back of the
A surgical procedure usually carried out eye, including the retina.
with specialized instruments; but some- ophthalmoscope
times only the hands are used (as in the An instrument that is used to examine Observer’s eyehole
containing lens and light
manipulation of a simple fracture). the inside of the eye. The ophthalmo-
scope contains a deflecting prism or a
ophryosis perforated angled mirror, which allows Lens selection ring
Spasm (involuntary contraction) of the illumination and viewing of the entire
muscles of the eyebrow. area of the back of the eye, including
the light-sensitive retina.
ophthalmia
An old term for ophthalmitis. ophthalmoscopy
A noninvasive procedure in which a doc-
ophthalmia neonatorum tor uses an ophthalmoscope to examine
A type of eye inflammation and a dis- the inside of the eye. The ophthalmo-
charge (ophthalmitis) that occur in new- scope is used first to direct a beam of Handle containing
born infants, usually as a result of being light into the eye and then to examine battery
infected with the sexually transmitted various structures, such as the light-
diseases gonorrhoea or chlamydia at birth. sensitive retina; the retinal blood vessels;
Treatment of ophthalmia neonatorum is the head of the optic nerve; and the jelly-
with antibiotic drugs. like vitreous humour.

565
 OPPOSITIONAL DEFIANT DISORDER

in a person whose immune system is optic nerve. The optic disc is also known Disease or injury occurring at a particu-
impaired. Malfunction of the immune as the blind spot because of its lack of lar point on an optic nerve leads to loss
system can be caused by diseases such as light-sensitive cells. of a specific part of the visual field.
AIDS and leukaemia or by chemotherapy. Disorders of the optic nerve include
Opportunistic infections include a optician optic atrophy, optic neuritis (nerve inflam-
variety of viral, bacterial, protozoal, and A person who fits and sells glasses and mation) and papilloedema (caused by
fungal infections, including tuberculosis, contact lenses. An ophthalmic optician, pressure on the nerve from disease in
herpes simplex, pneumonia, cryptococcosis, or optometrist, examines the eyes for the eye socket or by a brain tumour).
and candidiasis (thrush). Treatment of myopia (shortsightedness), hypermetropia
the infection is with the appropriate (longsightedness), presbyopia (loss of optic neuritis
antimicrobial drugs. focusing power with age), or astigma- Inflammation of the optic nerve, often
tism (uneven curvature of the cornea). causing sudden loss of part of the visual
oppositional defiant disorder Opticians also screen for eye disorders, field. Attacks are sometimes accompa-
A type of behavioural disorder that usu- such as glaucoma, and refer patients to nied by pain on moving the eyes. Vision
ally appears in childhood or early ophthalmologists. (See also ophthalmol- usually improves within six weeks, but
adolescence. Typically, an affected child ogy; optometry). some optic nerve fibres will be dam-
shows hostile, argumentative behaviour aged. Recurrent attacks usually lead to
that includes loss of temper, defiance of optic nerve permanent loss of visual acuity.
rules, and swearing. While to some The second cranial nerve; the nerve of Most cases are thought to be due to
extent such behaviour is a common fea- vision. The two optic nerves each con- demyelination of the optic nerve fibres
ture of adolescence, when law-breaking sist of about one million nerve fibres in multiple sclerosis. The condition may
or violence occur the condition is con- that transmit impulses from the retina also result from inflammation or infec-
sidered pathological. (the light-sensitive layer at the back of tion of tissues around the optic nerve.
the eye) to the brain. The optic nerves Corticosteroid drugs may help to restore
optic atrophy converge behind the eyes, where fibres vision, but have little effect on long-
A shrinkage or wasting of the optic nerve from the inner halves of the retina term outcome. (See also optic atrophy.)
fibres due to disease of or injury to the cross over. Nerve fibres from the right
optic nerve. The optic nerve is responsi- halves of both retinas go to the right Opticrom
ble for carrying electrical impulses from side of the occipital lobes in the brain; A brand name for eye-drops containing
the light-sensitive layer of the eye, the and those from the left halves of the sodium cromoglicate, an antiallergy drug
retina, to the brain, where the informa- retinas go to the left side. used to treat allergic conjunctivitis.
tion is processed to produce vision.
Damage to the fibres of the optic
nerve leads to blurring of vision and THE FUNCTION OF THE OPTIC NERVE
O may result in total visual loss. Damage
to the optic nerve cannot be reversed.
Each optic nerve is a bundle of long fibres that relays electrical signals from the
nerve cells in one of the retinas towards the brain. The optic nerves meet at the
Optic atrophy may occur without prior optic chiasma, where the information transmitted by both optic nerves is routed
signs of nerve disease. to the appropriate parts of the brain via the optic tracts. The brain coordinates this
Ischaemic optic atrophy is a type of information into a complete visual picture.
optic atrophy in which damage to optic
nerve fibres is caused by an impaired Optic nerve
blood supply. Leber’s hereditary optic
Image Image
atrophy is a rare genetic disorder, most received by received by
common in males, that causes de- left eye right eye
Optic
generation of the optic nerve. The nerve nerve
degeneration first becomes apparent
between 15 and 45 years of age.
Optic atrophy may be diagnosed by
viewing the eye using an ophthalmo-
scope. The optic disc (the point where
the optic nerve leaves the back of the
eye) appears pale or white. Vision tests
may also be performed.
If the underlying cause of the atro-
phy is identified and treated success- Optic Lens
nerve
fully, any further damage to the optic
Optic Retina
nerve can be prevented. tract Binocular vision
Because the eyes are set apart, they form
optic disc Optic
chiasma Coordinated
slightly different images of a nearby object. The
The area on the retina (the light-sensi- image fusion of these two images into one provides
the illusion of solidity. This is called stereopsis.
tive layer at the back of the eye) where
nerve fibres from the eyeball join the

566
 ORAL CONTRACEPTIVES

optimum dose
The amount of an agent, such as a HOW ORAL CONTRACEPTIVES WORK
drug, that will produce a desired effect
Combined pills (including phased pills) Pituitary gland
without causing unwanted side effects. increase the levels of oestrogen and
progesterone in the body, which Gonadotrophin
optometry interferes with the production by the hormones
The practice of assessing vision to estab- inhibited
pituitary gland of two gonadotrophin
lish whether glasses or contact lenses hormones called follicle-stimulating LH Hormonal effects
are needed to correct a visual defect, as hormone (FSH) and luteinizing FSH Each month the
carried out by an optometrist. Disor- hormone (LH). This action in turn pituitary produces
ders of the eye may require treatment prevents ovulation. spurts of FSH and
by an ophthalmologist. (See also oph- The progesterone-only pill (the LH, which act on the
minipill) works partly by making the ovary to cause egg
thalmology; optician.)
mucus that lines the inside of the ripening and
release. Combined
oral cervix (neck of the uterus) so thick
and phased pills
that it is impenetrable to sperm. interfere with
Concerning the mouth.
natural hormone
oral contraceptives production and thus
prevent ovulation.
COMMON DRUGS
OESTROGENS • Ethinylestradiol • Mestranol Ripening and
PROGESTOGENS • Desogestrel • Gestodene release of egg
• Levonorgestrel • Norethisterone prevented

• Norgestimate

A group of oral drug preparations con- Ovary

taining one or more synthetic female
sex hormones that are taken by women Pill packaging Effects on eggs
in a monthly cycle to prevent pregnancy. Most oral contraceptives come in packs, called FSH normally brings about egg ripening and
TYPES calendar packs, that clearly indicate which day LH causes the egg’s release from the ovary;
of the week each pill should be taken. combined pills prevent this.
“The pill” commonly refers to the com-
bined or the phased pill, which both
contain an oestrogen drug and a progesto-
gen drug, and the minipill (or proges-
terone-only pill), which contains only a Combined pill Menstruation
progestogen. The combined pill is taken
for three weeks out of every four; the
These pills contain an oestrogen and a
progestogen drug in fixed doses. A course
followed by seven pill-free days, during which
bleeding may occur. A new course is then
O
minipill is taken continuously. usually consists of one pill per day for 21 days, started, whether or not bleeding has occurred.
EFFECTIVENESS
When oral contraceptives are taken cor-
rectly, the number of pregnancies among
women using them for one year is less Change Change Menstruation
than 1 per cent. However, actual failure Phased pill
rates may be up to four times higher, These are combined pills, containing both an phase to phase (different times during the
particularly for the minipill, which has oestrogen and a progestogen drug. Unlike other month). A course lasts for 21 days followed either
other combined pills, the doses change from by seven pill-free days or by seven inactive pills.
to be taken at the same time each day.
If vomiting or diarrhoea occurs after
a pill has been taken, the woman should
follow the drug manufacturer’s advice
for a missed pill. If a woman taking oral Minipill Menstruation
contraceptives has missed two consecu- These pills contain only a progestogen drug in Bleeding usually occurs during the last few days
tive menstrual periods, she should have a fixed dose. The pills are taken continuously: of each cycle. The minipill has a slightly higher
one every day with no pill-free days in between. failure rate than combined pills.
a pregnancy test.
HOW THEY WORK
Combined and phased pills increase
oestrogen and progesterone levels. This ADVANTAGES POSSIBLE ADVERSE EFFECTS
interferes with the production of two Oestrogen-containing pills can help pro- Possible side effects of oestrogen-con-
hormones, luteinizing hormone (LH) and tect against uterine and ovarian cancer, taining (combined) pills include nausea,
follicle-stimulating hormone (FSH), which ovarian cysts, endometriosis (in which weight gain, depression, breast tender-
in turn prevents ovulation. The minipill fragments of uterine lining are dispersed, ness, increased appetite, reduced sex
works partly by making the mucus lin- usually around the pelvic cavity). They drive, leg cramps, abdominal cramps,
ing of the cervix (the neck of the womb) also tend to make menstrual periods headaches, and dizziness. They can also
too thick to be penetrated by sperm. regular, lighter, and relatively pain-free. cause occasional spotting (slight blood

567
 ORAL HYGIENE

loss) in between periods, early in the oral rehydration therapy wards by protective muscles during
cycle. More seriously, there is a small See rehydration therapy. reflex blinking. Fractures can often heal
increase in the risk of thrombosis (an without treatment, but some may cause
abnormal blood clot) occurring that oral surgery deformity and therefore require correc-
may lead to a stroke or a pulmonary em- The branch of surgery concerned with tive surgery. In rare cases, bacterial
bolism. Oestrogen-containing pills may the treatment of deformity, injury, or infection spreads from a sinus or the
also aggravate heart disease, or they may disease of the teeth, the jaws, and other face to cause orbital cellulitis.
cause gallstones, jaundice, and, very parts of the mouth. Procedures include
rarely, liver cancer. There is a small the extraction of impacted wisdom orbital cellulitis
increase in the long-term risk of breast teeth (see impaction, dental) and alveo- Bacterial infection of the tissues within
cancer occurring for women taking the lectomy (removal of tooth-bearing bone the eye socket, or orbit. Usually, the
combined pill. from the jaw). infection originates in a nearby sinus,
CONTRAINDICATIONS More complicated oral surgery inclu- but sometimes it spreads in the blood
Oestrogen-containing pills are generally des: repair of a broken jaw; orthognathic from a facial infection. The affected eye
not recommended for use by women surgery, (which is carried out to correct protrudes and is extremely painful and
with liver disease, migraine, worsening deformities of the jaw); plastic surgery red. There is also severe swelling of the
otosclerosis (an ear disorder), or women in order to correct cleft lip and palate; lids and conjunctiva (the membrane
at increased risk of thrombosis. They are and the removal of some noncancerous lining the inside of the lids and cover-
not usually prescribed to a woman with tumours from the mouth. ing the white of the eye).
a personal or family history of signifi- Orbital cellulitis is a serious disorder.
cant heart or circulatory disorders or to oral syringe The eye may be damaged; there is also a
a woman who suffers from unexplained See syringe, oral. slight risk that the infection may spread
vaginal bleeding. inwards to involve the brain. Treatment
Combined or phased pills may inter- orange peel effect is with high doses of antibiotic drugs.
fere with milk production and should See peau d’orange.
not be taken during breast-feeding. orchidectomy
Certain drugs, such as some antibiotic orbit The surgical removal of one or both of
drugs or anticonvulsant drugs, may impair The socket in the skull containing the the testes. Orchidectomy may be per-
the effectiveness of oral contraceptives; eyeball, protective fat, blood vessels, formed for testicular cancer (see testis,
a doctor should always be consulted. muscles, and nerves. The optic nerve cancer of) or gangrene caused by torsion
(See also contraception.) passes from the eye to the brain through (see testis, torsion of), or to reduce
an opening in the back of the orbit. production of the male hormone testos-
oral hygiene DISORDERS terone in the treatment of cancer of the
Measures that are used to keep the A severe blow to the face may fracture prostate gland (see prostate, cancer of).
O mouth and teeth clean and to reduce
the risk of tooth decay (see caries, den-
the orbit, but the eyeball is often
undamaged because it is squeezed back-
Removal of only one testis does not
affect sex drive, potency, or the ability
tal), gingivitis and other gum disorders, to have children.
and halitosis (bad breath). Oral hygiene
includes regular, thorough toothbrushing LOCATION OF ORBIT orchidopexy
and flossing (see floss, dental) in order An operation to bring down an unde-
The orbits are the deep cavities in
to remove plaque (a sticky coating that the skull that enclose and protect
scended testis (see testis, undescended)
forms on the teeth and consists of saliva, the eyeballs and the muscles that into the scrotum. Orchidopexy is usu-
bacteria, and food debris). Disclosing move the eyes. ally performed in boys before the age
agents can be used to help to reveal of two in order to reduce the risk of
areas of plaque buildup. Dentures are Orbit Opening for optic nerve later infertility or testicular cancer (see
brushed on all surfaces and soaked in testis, cancer of).
cleansing solution.
Professional treatment to remove cal- orchitis
culus (a mineral deposit that forms on Inflammation of a testis. Orchitis may
teeth) and stubborn plaque by scaling be caused by the mumps virus, particu-
and polishing is usually carried out by a larly if infection occurs after puberty.
dentist or dental hygienist during a rou- Swelling and severe pain in the affected
tine check-up. In periodontal disease, testis are accompanied by high fever. In
treatment may be needed more often. epididymo-orchitis, the tube that carries
sperm from the testis is also inflamed.
oral phase Treatment is with analgesic drugs
A term that is used in psychoanalytic (painkillers) and ice-packs to reduce
theory to refer to the earliest stage of swelling; antibiotic drugs may be given,
a person’s psychosexual development. but not for mumps orchitis. The condi-
The oral phase is thought to last from tion usually begins to subside within
Skull
birth to about 18 months of age. (See seven days but is occasionally followed
also anal phase; genital phase.) by shrinking of the testis.

568
 ORO-

orf organism Orgasm is usually followed by a refrac-

A skin infection occasionally transmit- A general term for an individual animal tory phase during which there is no
ted to humans from sheep. Caused by a or plant. Bacteria and viruses are disease- physical response to further sexual
pox virus, orf usually produces a single causing microorganisms. stimulation. Both men and women may
persistent, fluid-filled blister on the arm experience problems with orgasm (see
or hand. The antiviral drug idoxuridine organ of Corti ejaculation, disorders of; orgasm, lack of).
may hasten recovery. A structure involved in hearing that is
situated in the cochlea of the inner ear. orgasm, lack of
organ Sensory hair cells in the organ of Corti Inability to achieve orgasm during sex-
A collection of various tissues integrated vibrate in response to sounds and trans- ual activity. The problem is more
into a distinct structural unit to perform late them into electrical impulses that common in women than men. In either
specific functions. For example, the travel via the cochlear nerve to the brain. sex, failure to achieve orgasm may be
brain consists of nerve tissue and sup- due to inhibited sexual desire (see sexual
port tissue that is organized to receive, organomegaly desire, inhibited) or inability to become
process, and send out information. Abnormal enlargement of the body’s aroused or maintain arousal (see frigidity;
internal organs, such as hepatomegaly impotence). In men, there may be a
organ donation (enlargement of the liver). problem achieving orgasm despite nor-
The agreement of a person (or of his or mal arousal (see ejaculation, disorders of).
her family) to the surgical removal of organophosphates In women, lack of orgasm is the most
one or more of the organs for use in Highly poisonous agricultural insecti- common sexual problem, affecting up to
transplant surgery. cides that are harmful when absorbed 50 per cent of women at some time in
Most organs that are commonly used through the skin, by inhalation, or by their lives. Some are unable to achieve
for transplantation, such as the heart, swallowing. Among the many possible orgasm under any circumstances, others
lungs, liver, and kidneys, are removed symptoms are nausea, vomiting, abdo- experience orgasm only occasionally.
immediately after death. Heart and minal cramps, diarrhoea, blurred vision, For both sexes, contributory factors
lung function is sometimes maintained excessive sweating, headache, confusion, include problems with sexual technique
by machine after brain death has been and twitching. In cases of severe poison- or a relationship, lack of familiarity
certified until the organs have been re- ing, breathing difficulty, palpitations, with sexual responses, psychological
moved. Living donors may be able to seizures, and unconsciousness may problems (such as anxiety, early sexual
give a kidney, but usually only to a occur. If left untreated, death may result. trauma, or inhibitions), and the fear
close relative (see tissue-typing). Treatment may include washing out of becoming pregnant.
Although it is not legal in the UK, in the stomach (see lavage, gastric) or Sex therapy, relationship counselling,
some countries, organ donors are paid removing soiled clothing and washing and psychotherapy may be helpful.
for their organs. People can facilitate use contaminated skin. Injections of atropine
orifice
of their organs after death by informing
relatives and carrying a donor card. (See
may be administered, and oxygen therapy
and/or artificial ventilation may be A term used in anatomy to refer to any
O
also corneal graft; heart–lung transplant; needed. With rapid treatment, people opening in the body, especially an
heart transplant; heart-valve surgery; kidney may survive doses that would otherwise entrance or outlet of a body cavity. An
transplant; liver transplant.) have been fatal. Long-term effects of example of an orifice is the mouth.
organophosphates in sheep dips are
organelle thought to be responsible for debilitat- orlistat
One of various specialized structures ing illness with neural, muscular, and An anti-obesity drug used with a slim-
contained within a body cell. mental symptoms. ming diet to treat severe obesity. Unlike
appetite suppressants, orlistat acts on the
organic orgasm gastrointestinal tract, preventing the
Related to a body organ; having organs Intense sensations produced by a series digestion of fats by lipases (pancreatic
or an organized structure; or related to of muscular contractions at the peak of enzymes). Instead of being absorbed, the
organisms or to substances from them. sexual excitement. Orgasm usually lasts fats pass out of the body in faeces.
In medicine, the term indicates the for about three to ten seconds but can Side effects are gastrointestinal in
presence of disease in the body. last up to a minute in women. nature and can be minimized by reduc-
In chemistry, the term refers to cer- In men, contractions of the muscles ing fat intake. Flatulence and faecal
tain compounds that contain carbon. of the inner pelvis massage semen into urgency are common. Deficiencies of
(See also inorganic.) the urethra; the semen is then forcefully fat-soluble vitamins may develop with
propelled through the urethral orifice prolonged use of orlistat.
organic brain syndrome (see ejaculation).
See brain syndrome, organic. Orgasm in women is associated with ornithosis
irregular contractions of the voluntary A disease of birds, caused by the
organic disease muscles of the walls of the vagina and, microorganism CHLAMYDIA PSITTACI, that
A term used to refer to any disorder that in some women, of the uterus, followed can cause psittacosis in humans.
is associated with changes in the struc- by relief of congestion in the pelvic
ture of an organ or tissues. (See also area. Some women experience multiple oro-
functional disorder.) orgasms if stimulation is continued. A prefix pertaining to the mouth.

569
 ORPHAN DRUGS

orphan drugs
Drugs that have been developed to treat HOW ORTHODONTIC APPLIANCES WORK
rare conditions but are not manufac-
The tooth sockets are remarkably Overcrowding
tured generally. responsive to sustained pressure against This is frequently
the teeth. Orthodontic appliances, which associated with
orphenadrine may be fixed or removable, provide such malocclusion (poor
A muscle-relaxant drug used to treat the alignment between upper
pressure. Even gentle pressure applied and lower teeth). Some
movement disorder Parkinson’s disease. in a particular direction will move teeth. teeth have to be extracted
Side effects of orphenadrine include a As they move, bone is remodelled so to make room for others to
dry mouth and blurred vision. that the new position is stable. be straightened.

ORT FIXED APPLIANCES REMOVABLE APPLIANCES

The abbreviation for oral rehydration ther-
apy. (See also rehydration therapy.)

ortho-
A prefix meaning normal, correct, or
straight, as in orthopaedics, a branch of
surgery concerned with correcting dis-
orders of the bones and joints. Appearance of brackets and wires
Brackets are fixed appliances cemented to the
orthodontic appliances outer surface of the teeth; they have slots into
which arch wires can be fitted. Arrangement of wires over teeth
Fixed or removable devices, commonly These are easier to keep clean than fixed
known as braces, worn to correct mal- appliances and are less obtrusive, but they may
Repositioning a tooth
occlusion (an abnormal relationship By careful design of the
interfere with speech; their efficiency relies on
between the upper and lower teeth) or patients using them as directed. This type exerts
arrangement of wires and
pressure to push the teeth at the sides outwards.
to reposition overcrowded or buck teeth. spring, force can be exerted in
Usually fitted during childhood and any direction to move a tooth
into the desired position. Bow device
adolescence, a brace moves teeth using This simple wire spring
sustained gentle pressure. acts by exerting force to
A fixed appliance has brackets attach- straighten the tooth. Many
ed to the teeth through which an arch bow devices are more
complicated.
wire is threaded and tightened to exert
pressure. These are usually kept in place Direction of pull

O for about a year, after which time a

retainer plate may be needed to hold
the teeth in place until tooth and jaw 1of theTeeth are removed to create space and an
appliance made to correct the alignment
remaining teeth and to close gaps
growth has finished. between them.
Removable appliances, which consist
of a plastic plate with attachments that
anchor over the back teeth, are used
when only one or a few teeth need cor-
recting. They apply force by means of
springs, wire bows, screws, or rubber A removable bow
bands fitted to the plate. Once the teeth in the upper and lower jaws One of the many forms of orthodontic wire

orthodontics
2 are completely aligned, the appliance is
adjusted to tip or rotate the teeth in order to
appliance, this bow device exerts pressure on
the teeth at the sides, which straightens and
A branch of dentistry concerned with achieve a good appearance and bite. moves them outwards.
prevention and treatment of malocclusion
(an abnormal relationship between the
upper and lower teeth). The procedures orthognathic surgery bone on each side, sliding the front of
are usually performed while teeth are Operations to correct deformities of the the jaw forwards, and inserting bone
developing and relatively manoeuvrable jaw and the severe malocclusion (abnor- grafts (taken from elsewhere in the
but can also be of benefit in adulthood. mal relationship between the upper and body) into the gaps. After reposition-
An orthodontist may first make mod- lower teeth) that is associated with them. ing, the jaw bones often require wiring
els of the teeth (see impression, dental) Orthognathic surgery is performed together (see wiring of the jaws) until
and take X-rays of the head and jaws. under general anaesthesia. A jaw that they have healed.
Certain teeth, often premolars, may be projects too far can be shortened by
extracted to make room for the remain- removing a block of bone from each orthomyxovirus
ing teeth. Poorly positioned teeth are side and manoeuvring the front of One of a family of viruses that includes
then moved by gentle pressure exerted the jaw backwards. A jaw that is too the microorganisms responsible for res-
by orthodontic appliances. short can be reshaped by dividing the piratory tract diseases, especially influenza.

570
 OSTEITIS DEFORMANS

orthopaedics when touched. The disorder often clears osmotic diuresis

The branch of surgery concerned with up without treatment as long as sport- An increased output of urine by the kid-
disorders of the bones and joints and ing activity is restricted; severe pain neys due to the presence of one or more
their associated muscles, tendons, and lig- may require physiotherapy or immobi- substances in the urine that draw water
aments. Orthopaedic procedures include lization in a plaster cast. from the blood into the urine. Excessive
setting broken bones and applying casts; amounts of glucose in the urine, as a
treating slipped discs, dislocations, arth- Osler’s disease result of diabetes mellitus, can produce
ritis, and back problems; treating bone A rare inherited condition in which cap- this effect; another possible cause is
tumours and birth defects of the skele- illaries (tiny blood vessels) in the skin treatment with one of the osmotic
ton; and repairing or replacing hip, and mucous membranes, such as those diuretic drugs, such as mannitol.
knee, or finger joints. (See also brace, lining the mouth and nose, become
orthopaedic; collar, orthopaedic.) dilated, forming red spots. The condi- osseous
tion, which is also known as hereditary Bony or bonelike. The term “osseous” is
orthopnoea haemorrhagic telangiectasia, is an auto- sometimes used to refer to the bony
Difficulty in breathing when lying flat. somal dominant genetic disorder. parts of the inner ear. (See also bone.)
Orthopnoea is a symptom of heart fail- The lesions may bleed easily. Nose-
ure (the heart is no longer pumping bleeds are a common symptom and ossicle
blood efficiently) and pulmonary oedema may begin in childhood. Lesions may A small bone, especially any of the three
(an accumulation of fluid in the lungs), also develop in the digestive tract, caus- tiny bones in the middle ear (malleus,
and also occurs with asthma and chron- ing recurrent bleeding leading to incus, and stapes) that are involved in
ic obstructive pulmonary disease (see anaemia; in the lungs, causing blood to conducting sound from the eardrum to
pulmonary disease, chronic obstructive). be coughed up; or in the brain, causing the inner ear.
tissue damage and seizures.
orthoptics Anaemia can be counteracted with ossification
Techniques used mainly in children to iron supplements. In some cases, laser The process by which bone is formed,
measure and evaluate squint, including treatment is used to seal the lesions. renewed, and repaired, which starts in
eye exercises, assessment of monocular the embryo and continues throughout
and binocular vision, and measures to osmosis a person’s life. There are three main sit-
combat amblyopia (lazy eye). The passage of a solvent from a weaker uations in which ossification occurs:
solution to a more concentrated one bone growth, during which new bone
orthostatic hypotension through a semipermeable membrane. forms at the epiphyses (ends) of bones;
Also called postural hypotension, low All body cells are surrounded by such bone renewal as part of normal regen-
blood pressure that occurs on standing. membranes, which allow water, salts, eration; and bone repair, which occurs
Orthostatic hypotension may be caused simple sugars (such as glucose), and following a fracture.
by treatment with antihypertensive drugs
or the failure of nerves that control the
amino acids (but not proteins) to pass
through. Therefore, osmosis plays an
In newborn babies, the diaphysis
(bone shaft) has begun to ossify and is
O
diameter of the blood vessels, often as a important part in regulating the distri- composed mainly of bone tissue, while
result of diabetes mellitus. bution of water and other substances the epiphyses are made of cartilage that
that are present in body tissues. gradually hardens. In children, growth
orthotics plates produce new cartilage to length-
Use of appliances to support or correct en the bones and further bone forms at
weakened or deformed limbs, joints, or Membrane secondary ossification centres in the
other parts of the body. Solvent
epiphyses. By the age of 18, the shafts,
growth plates, and epiphyses have all
os Solute
ossified and fused into continuous
An anatomical term for a bone. Os also bone, allowing no further growth.
refers to an opening in the body, as in More Less Different
the cervical os (entrance to the uterus). concentrated concentrated concentrations Ossopan
A brand name for hydroxyapatite, a cal-
Osgood–Schlatter disease cium supplement used in the treatment
Painful enlargement and tenderness of Membrane of osteoporosis (loss of bone tissue).
the tibial tuberosity, the bony promi- Solvent
nence of the tibia (shin) just below the osteitis
Solute
knee. The condition occurs most com- Inflammation of bone. The most com-
monly in boys aged between 10 and 14 Same mon cause is infection, usually by
years of age. It may be the result of Same concentration concentration bacteria (see osteomyelitis). Other causes
excessive, repetitive pulling of the quad- Osmosis of osteitis include Paget’s disease and
riceps muscle at the front of the thigh If two solutions, each consisting of different hyperparathyroidism (overactivity of the
due to repeated exercise. There is usu- concentrations of a solute (e.g. salt) in a solvent parathyroid glands).
(e.g. water), are separated by a semipermeable
ally pain above and below the knee, membrane, solvent moves from the weaker to
which is worse during strenuous acti- the stronger solution until the two solutions
osteitis deformans
vity, and the tibial tuberosity is tender attain equal concentration. An alternative term for Paget’s disease.

571
 OSTEO-

osteo- occurs at joint surfaces and changes to Affected joints become enlarged and
A prefix that is used to denote a rela- the bone beneath. This condition is distorted by osteophytes, which are
tionship to bone, as in osteoporosis, most likely to occur in the weight- responsible for the gnarled appearance
which is a condition that causes the bearing joints as well as in any joints of arthritic hands. Weakness and shrink-
bones to become thin and weaken. that have previously suffered some age of surrounding muscles may occur
kind of damage. However, these are not if severe pain prevents the joint from
osteoarthritis the only causes. Genetic factors may be being used regularly.
A common joint disease, osteoarthritis involved in cases in which osteoarthri- TREATMENT
is characterized by degeneration of the tis affects the joints. There is no cure for osteoarthritis. Pain
cartilage that lines the joints or by for- Evidence of osteoarthritis can be seen can be relieved by analgesics and
mation of osteophytes (bony outgrowths), on X-rays of almost everyone over the nonsteroidal anti-inflammatory drugs; in-
leading to pain, stiffness, and occasion- age of 60; however, not all of these peo- jection of corticosteroid drugs into an
ally loss of function. Osteoarthritis is ple have symptoms. Factors that lead to affected joint or of hyaluronic acid into
the most common form of arthritis. Cer- the development of osteoarthritis at an an affected knee may temporarily relieve
vical osteoarthritis is a particular form of earlier age include excessive wear of, or the symptoms; physiotherapy to improve
osteoarthritis that affects mainly the injury to, a joint; congenital deformity muscle strength around the affected
joints between the cervical vertebrae or misalignment of the bones in a joint; joints can help to limit the deterioration
(the bones in the neck). obesity; or inflammation from another that otherwise results from joint instabil-
CAUSES AND SYMPTOMS disease such as gout. Severe osteoarth- ity. In overweight people, weight loss
Osteoarthritis is due to inflammation ritis affects about three times as many often provides relief of symptoms. If the
and destruction of the cartilage that women as men. condition is severe, various aids are
available that can make coping at home
easier. Surgery for osteoarthritis, includ-
OSTEOARTHRITIS ing arthroplasty and arthrodesis, is only
undertaken if the pain and disability are
Osteoarthritis differs from rheumatoid arthritis and has a better outlook. It is
characterized by degeneration of cartilage or by formation of bony outgrowths
too severe to cope with.
(osteophytes). It results from excessive wear on joints or to slight deformity or
misalignment of bones in a joint. Inflammation from a disease, such as gout,
osteoarthropathy, hypertrophic
may also lead to osteoarthritis. Weight-bearing joints, such as those in the neck, pulmonary
the lower back, the knees, and hips, are the areas most commonly affected. A bone disorder almost always associat-
ed with lung cancer. Symptoms include
pain and swelling of the wrists and
ankles, accompanied by clubbing of the
fingers. The condition will disappear if
O Unaffected
the underlying cancer is treated success-
fully. Symptoms can be partially relieved
cartilage
with nonsteroidal anti-inflammatory drugs.
Synovial osteoblastoma
fluid
A painful, noncancerous bone tumour
that is characterized by the formation of
Normal joint surface
The healthy joint (above) is lined with osteoid tissue and primitive bone.
smooth cartilage and lubricated by X-ray signs of osteoarthritis Osteoblastomas most commonly occur
synovial fluid. In this X-ray of a knee joint, there in the spine of a young person.
is narrowing of the joint space with
osteophyte production and an
increase in density of the bone ends. osteochondritis dissecans
Degeneration of a bone just under a
Osteophytes Characteristic joint surface, causing fragments of bone
swelling
and cartilage to become separated; this
may cause the joint to lock. The condi-
Loose tion commonly affects the knee and
bodies
usually starts in adolescence. Symptoms
Degenerated include aching discomfort and inter-
cartilage mittent swelling of the affected joint.
If a fragment has not completely sep-
arated from the bone, the joint may be
immobilized in a plaster cast to allow
Osteoarthritic joint Osteophytes reattachment to occur. Loose bone or
In osteoarthritis (above), the cartilage These are outgrowths of new bone cartilage fragments in the knee are
becomes rough and flaky and small that tend to occur at the margins of removed during arthroscopy. Disruption
pieces break off to form loose bodies. the joint surfaces in osteoarthritis.
to the smoothness of the joint surface
increases the risk of osteoarthritis.

572
 OSTEOMYELITIS

osteochondritis juvenilis bone cysts and bone mass reduction osteomalacia

Inflammation of an epiphysis (growing associated with chronic kidney failure or The softening, weakening, and demin-
end of bone) occurring in children hyperparathyroidism (overactivity of the eralization (loss of essential minerals)
and adolescents. Osteochondritis juve- parathyroid glands). In adults, an of an adult’s bones as a result of a defi-
nilis causes pain, tenderness, and re- osteodystrophy is usually reversible if ciency of vitamin D. Rickets is the
stricted movement if the epiphysis the underlying cause is treated before equivalent disease in children.
forms part of a joint. The inflammation bone deformity occurs. The development and maintenance
leads to softening of the bone, which of healthy bone requires an adequate
may result in deformity. The condition osteogenesis imperfecta intake of calcium and phosphorus from
may be due to disruption of the bone’s A congenital condition characterized by the diet, but these minerals cannot be
blood supply. There are several types of abnormally brittle bones that are unusu- absorbed by the body without a suffi-
osteochondritis juvenilis: Perthes’ dis- ally susceptible to fractures. cient amount of vitamin D. This vitamin
ease; Scheuermann’s disease, which CAUSE AND SYMPTOMS is obtained from certain foods and from
affects several adjoining vertebrae; and The condition is caused by an inherited the action of sunlight on the skin.
other types that affect certain bones in defect in the connective tissue that forms CAUSES
the foot and wrist. the basic material of bone. Severely Osteomalacia can be caused by a variety
The affected bone may need to be affected infants are born with multiple of factors, including: insufficient vita-
immobilized in an orthopaedic brace fractures and a soft skull and they do min D in the diet (for example, due to
or plaster cast. In Perthes’ disease, not usually survive. Other sufferers have lack of butter, fish, eggs, or fish-liver
surgery may be required to prevent many fractures during infancy and oils); insufficient exposure to sunlight;
more deformity. The bone usually childhood, often as a result of normal or inadequate absorption of vitamin D
regenerates within three years and handling and activities, and it may be from the intestine (see malabsorption),
rehardens, but deformity may be per- difficult to distinguish the condition caused by a disorder such as coeliac dis-
manent and increases the risk of from child abuse. ease, or following intestinal surgery.
osteoarthritis in later life. A common sign of osteogenesis im- Rare causes include kidney failure, acido-
perfecta is that the whites of the eyes sis (increased acidity of body fluids),
osteochondroma are abnormally thin, making them and certain inherited metabolic disorders.
A noncancerous bone tumour, which is appear blue. Sufferers may also be deaf Osteomalacia is uncommon in deve-
formed from a stalk of bone capped as a result of otosclerosis. In very mild loped countries, but it may affect
with cartilage, and appears as a hard cases, osteogenesis imperfecta may not people who have poor diets (especially
round swelling near a joint. An osteo- be detected until adolescence or later. dark-skinned people who have little
chondroma develops in late childhood TREATMENT AND OUTLOOK exposure to sunlight).
and early adolescence, usually from the There is no specific treatment for the SYMPTOMS
side of a long bone near the knee or condition. Fractures are immobilized Osteomalacia causes bone pain, espe-
shoulder. The tumour causes problems
only if it interferes with the movement
and usually heal quickly, but they may
cause shortening and deformity of the
cially in the neck, legs, hips, and ribs. In
addition, muscle weakness, particularly
O
of tendons or the surrounding joint, in limbs, resulting in abnormal, stunted at the hips, can make it very difficult to
which case surgical removal may be growth. Skull fractures may cause brain stand up and to climb stairs. If the
necessary. Large osteochondromas can damage or death. Parents may have blood calcium level is very low, there
interfere with skeletal growth, and may genetic counselling to estimate the risk of may be tetany (muscle spasms) in the
cause deformity. the condition occurring in future chil- hands, feet, and throat. Weakened bones
dren. Severe cases can be diagnosed are vulnerable to distortion and frac-
Head of prenatally by ultrasound scanning. tures, which are often painless.
femur TREATMENT
X-ray of osteogenic sarcoma Treatment is with a diet rich in vitamin
osteochondroma See osteosarcoma. D and regular supplements. Calcium
The X-ray shows the
fluffy outline of an
supplements may also be given.
osteochondroma
osteoid osteoma
that is surrounding A bone disorder in which a tiny abnor- osteomyelitis
the head of the mal area of bone, usually in a long Infection, usually by bacteria, of bone
femur. These bone, causes deep pain, which is typi- and bone marrow. It is relatively rare in
benign tumours
are composed of cally worse at night. The condition is developed countries but is more com-
cartilage-forming cured by removing the area of bone. mon in children, most often affecting
cells. (See also osteoma.) the long arm and leg bones and
vertebrae; in adults, it usually affects the
osteochondrosis osteoma vertebrae. The condition may be either
See osteochondritis juvenilis. A hard, noncancerous, usually small acute or chronic.
tumour that may occur on any bone in ACUTE OSTEOMYELITIS
osteodystrophy the body. Surgical removal of the osteo- In acute osteomyelitis, the infection
Any generalized bone defect caused by ma may be necessary if it causes (which is usually caused by the bacter-
metabolic disorders. Types of osteodys- symptoms through pressing on sur- ium STAPHYLOCOCCUS AUREUS) enters the
trophy include rickets; osteomalacia; and rounding structures. bloodstream via a skin wound or as a

573
 OSTEOPATHY

result of infection elsewhere in the osteopetrosis Bisphosphonate drugs may be used to

body. The infected bone and marrow A very rare inherited disorder in which prevent and treat bone loss following the
become inflamed; pus forms, causing bones harden and become denser. Defi- menopause. Long-term hormone replace-
fever, severe pain and tenderness in the ciency of one of the two types of bone ment therapy (HRT) is now usually only
bone, and inflammation and swelling of cell responsible for healthy bone growth advised for women who cannot take
the skin over the affected area. results in a disruption of normal bone other treatments or in whom other treat-
Prompt treatment with high doses of structure. In its mildest form, there may ments have been unsuccessful. Women
antibiotic drugs, initially given intra- be no symptoms. More severe forms who have gone through a premature
venously and continued over several result in abnormally high susceptibility to menopause before the age of 40 may be
weeks or months, usually cures acute fractures; stunted growth; deformity; and advised to have HRT until the age of 50
osteomyelitis. If the condition fails to anaemia. Pressure on nerves may cause to protect them against osteoporosis;
respond, surgery has to be performed blindness, deafness, and facial paralysis. for these women, the health risks of
to remove infected and dead bone and Most treatments for osteopetrosis aim HRT are thought to be less than normal.
drain away any pus. to reduce the severity of symptoms.
CHRONIC OSTEOMYELITIS Bone marrow transplants of cells from osteosarcoma
Chronic osteomyelitis may develop if which healthy bone cells might develop A cancerous tumour of the bone that
acute osteomyelitis is neglected or fails are undertaken in some cases. can spread to the lungs and, less com-
to respond to treatment; after a com- monly, to other areas. An osteosarcoma
pound fracture; or due to infection of osteophyte usually develops in people between the
the bone with MYCOBACTERIUM TUBERCULO- An outgrowth of bone at the boundary ages of ten and 25, generally in a long
SIS , which causes tuberculosis. of a joint. The formation of osteophytes bone of the arm or leg, often around
The condition causes constant pain in is a characteristic feature of osteoarthritis the knee. Osteosarcomas may also be
the affected bone. Complications include that contributes to the deformity and seen in elderly people as a rare compli-
persistent deformity and, in children, restricted movement of affected joints. cation of Paget’s disease or of previous
arrest of growth in the affected bone. treatment with radiotherapy. The tumour
Involvement of the spine can result in osteoporosis causes pain and swelling of the affected
damage to the spinal cord if the con- A disease in which there is loss of bone bone if it occurs near the surface.
dition is not treated. In the later stages tissue (and so loss of bone density), In the past, amputation of the affect-
of the disease, amyloidosis (abnormal causing bones to become brittle and ed limb was inevitable. However, the
deposits of a starchy substance in vital fracture easily. outlook has improved due to a combi-
organs) may develop. CAUSES nation of chemotherapy and surgery in
Chronic osteomyelitis requires sur- Thinning of the bones is a natural part of which the diseased bone is replaced
gical removal of all affected bone, the aging process. However, women are with a custom-made prosthesis.
sometimes followed by a bone graft; anti- especially vulnerable to loss of bone den-
osteosclerosis
O biotic drugs are also prescribed. sity after the menopause, because their
ovaries no longer produce oestrogen hor- Increased bone density, which is visible
osteopathy mones, which help maintain bone mass. on X-rays as an area of extreme white-
A system of diagnosis and treatment Other causes of osteoporosis include ness. Localized osteosclerosis may be
that recognizes the role of the musculo- premature removal of the ovaries; a diet caused by a severe injury that com-
skeletal system in the healthy functioning that is deficient in calcium; certain hor- presses the bone, the joint disorder
of the body. The basic principle of oste- monal disorders, such as an overactive osteoarthritis, chronic osteomyelitis (bone
opathy is that all body systems operate thyroid gland (see hyperthyroidism); long- infection), or an osteoma (noncancerous
in unison, and that disturbances in one term treatment with corticosteroid drugs; bone tumour). Osteosclerosis occurs
system can alter the functions of some and prolonged immobility. Osteoporo- throughout the body in the inherited
others. The osteopath uses manipula- sis is most common in heavy smokers bone disorder osteopetrosis.
tion, rhythmic stretching, and pressure and drinkers, and in very thin people.
to restore movement to the joints. He or SYMPTOMS osteotomy
she also uses traditional diagnostic and Osteoporosis may go undiagnosed for Surgery to alter the alignment or length
therapeutic procedures to diagnose and many years.The first sign is often a frac- of a bone, by cutting it. Osteotomy is
treat dysfunction. ture, typically at the wrist or the top of used to correct hallux valgus (a deformity
the femur (thigh bone), after what may of the big toe) that has caused a bunion;
osteopenia have been a trivial injury. One or several coxa vara (a deformity of the hip); or
Any decrease in bone mass below the vertebrae may fracture spontaneously and deformity caused by congenital hip dis-
normal level. The term is used particu- cause the bones to crumble, leading to location (see hip, congenital dislocation of).
larly to refer to a decrease in mass that progressive height loss and/or pain due Osteotomy is also used to straighten a
occurs when the body makes too little to compression of spinal nerve roots. long bone that has healed crookedly after
new bone to compensate for normal DIAGNOSIS AND TREATMENT a fracture, or to shorten the uninjured
bone lysis (breakdown or destruction). Osteoporosis is confirmed by the use of leg if a fractured leg has shortened dur-
Osteopenia can occur throughout the bone densitometry. Bone loss can be ing healing (see leg, shortening of).
skeleton or may be confined to a specif- minimized by adequate dietary calcium
ic area, such as the bones adjacent to a and regular, sustained exercise to build ostium
diseased or damaged joint. the bones and maintain their strength. An anatomical term for an opening.

574
 OTOACOUSTIC EMISSION

OSTEOPOROSIS

In osteoporosis, the density of bones

decreases, and their brittleness Bone marrow
increases, although there is no
change in size or composition. Soft, spongy
Women past the menopause are the bone
Less dense
most commonly affected because bone
their ovaries no longer produce Hard, dense
oestrogen, which helps to maintain bone
bone mass. The risk of the condition
is greater in a woman who undergoes Osteoporotic bone
the menopause early, or whose Normal bone cross-section Thinning is mainly due to loss of collagen, which
Bone consists of fibres of collagen (a protein), which takes calcium with it. Both hard and spongy bone
mother had osteoporosis. tissues are affected.
give elasticity, and calcium, which gives hardness.

Bone loss with age Decrease %

The graph on the right
shows how the
percentage of bone Women
lost increases in both 30
sexes from age 50
onwards, with the
losses particularly Men
marked in women 20
after the menopause.
By age 80, up to half
of all women have 10
sustained at least
one fracture due to Bone tissue affected by osteoporosis
osteoporosis, a much When compared with normal bone tissue (left), the
higher proportion osteoporotic bone (right) is far less dense and
than in men. Age 10 20 30 40 50 60 70 80 90 appears thin and brittle.

-ostomy infection has cleared. Locally acting eardrum may burst, discharging pus
A term that is used to describe a surgi- preparations that contain antibiotic and relieving pain, in which case heal-
cal opening (for example, colostomy) or
a junction of two hollow organs.
drugs, antifungal drugs, or corticosteroid
drugs may be used. Oral antibiotics may
ing usually occurs within a few weeks.
DIAGNOSIS AND TREATMENT
O
be given to treat bacterial infections if The condition is diagnosed by examina-
otalgia they are severe. tion of the middle ear with an otoscope;
The medical term for earache. the eardrum appears red and may bulge
otitis media outwards. Treatment is with analgesic
OTC drug Inflammation of the middle ear, the cav- drugs (painkillers). Antibiotic drugs may be
See over-the-counter drug. ity between the eardrum and the inner prescribed if the infection is bacterial.
ear, (see Ear infections box, overleaf). COMPLICATIONS
otitis externa CAUSES A complication of otitis media is glue
Inflammation of the outer-ear canal, com- This condition is due to a viral or bacter- ear, in which a thick fluid builds up in
monly due to infection (see Ear infections ial infection that has usually travelled up the ear and affects hearing. Glue ear
box, overleaf). It usually causes swelling, the eustachian tube, the passage that runs may follow severe or recurrent otitis
a discharge, and, in some people, eczema from the back of the nose to the middle media, which occurs mainly in children.
around the opening of the ear canal. ear. The tube may become blocked by In rare cases, the infection spreads
The ear may be itchy and painful and inflammation or enlarged adenoids, caus- inwards to cause mastoiditis (inflamma-
blocked with pus, causing deafness. ing fluid and/or pus to accumulate in tion of the mastoid bone in the skull).
CAUSES the middle ear rather than draining away
Generalized infection of the canal, and through the tube. Children, particularly oto-
sometimes of the pinna (external ear), those under seven years, are especially Pertaining to the ear, as in otorrhoea
may be due to a fungal or bacterial susceptible to otitis media because of (discharge from the ear).
infection. The ear may also sometimes the shortness of their eustachian tubes;
become inflamed as part of a gen- some children have recurrent attacks. otoacoustic emission
eralized skin disorder such as atopic SYMPTOMS An echo emitted by the inner ear in
eczema or seborrhoeic dermatitis. Acute otitis media can cause sudden response to sound. The emission is pro-
TREATMENT severe earache, a feeling of fullness in duced only by a normally functioning
Often, the only treatment required is to the ear, deafness, tinnitus (ringing or ear and is recorded in a test to detect
keep the ear clean and dry until the buzzing in the ear) and fever. The impaired hearing.

575
 OTOMYCOSIS

freely, it can transmit sound vibrations

EAR INFECTIONS: OTITIS MEDIA AND OTITIS EXTERNA to the inner ear. Alternatively, a hearing-
aid can markedly improve hearing.
Inflammation of the middle ear (otitis
media) or ear canal (otitis externa) otoscope
usually results from infection and may
cause earache. Otitis media is more An instrument, also called an auroscope,
common in children and may be acute for examining the outer-ear canal and
(with sudden onset of pain) or chronic the eardrum. An otoscope illuminates
(continuing over a long period). and magnifies the inside of the ear.
Otoscopy (examination using an oto-
scope) is performed in order to detect
physical abnormalities such as inflam-
mation or pus in the outer-ear canal
Eardrum (see otitis externa) and distortion or rup-
ture of the eardrum.

Middle ear OTOSCOPE

Otitis media – Viewing lens

infection may
spread up
eustachian tube
Lightbulb
container
Ear canal Otitis externa – infection
spreads from outside Ear
speculum
Otitis media Otitis externa
This usually occurs through spread of infection The ear canal is susceptible to infection if it is
from the back of the nose to the middle ear via moist (after swimming) or damaged by attempts
the eustachian tube. to remove earwax.
On/off switch
and dimmer

otomycosis CAUSES AND INCIDENCE

A fungal ear infection that causes inflam- Otosclerosis occurs when overgrowth Handle/battery
container
mation of the ear canal and the external of bone immobilizes the stapes (the
O ear (see otitis externa). innermost one of the three tiny bones
in the middle ear). As a result, sound
otoplasty vibrations are prevented from passing ototoxicity
Cosmetic surgery on the external ear along the bone to the inner ear. Toxic damage to the structures of the
usually carried out to make protruding Otosclerosis frequently runs in fami- inner ear. High doses of certain drugs,
ears lie closer to the head. Otoplasty may lies, and symptoms usually start to such as aminoglycoside antibiotics, may
also be performed to construct a missing appear in early adulthood. The condi- cause this type of ear damage, resulting
ear in a child born with part or all of one tion affects more women than men, and in impaired hearing and balance.
missing, or to reconstruct a damaged ear. often develops during pregnancy.
SYMPTOMS AND SIGNS Otrivine
otorhinolaryngology To an affected person, sounds are muf- A brand name for xylometazoline, a de-
A surgical speciality, also known as ENT fled but can be distinguished more congestant drug that is used in the
surgery, concerned with diseases of the easily if there is background noise. treatment of allergic rhinitis to relieve
ear, nose, and throat. ENT specialists treat Hearing loss progresses slowly over nasal congestion. Otrivine is available as
sinus problems, otitis media, tonsillitis, 10 to 15 years and is often accompa- a nasal spray or drops.
minor hearing loss, otosclerosis, Ménière’s nied by tinnitus (ringing in the ears)
disease, airway problems in children, and, more rarely, vertigo (a spinning out-of-body experience
uncontrollable nosebleeds, and cancer of sensation). A degree of sensorineural A feeling of leaving one’s body and
the larynx (voicebox) and sinuses. deafness may develop, making high observing oneself from another dimen-
tones difficult to hear and causing the sion. The experience, which is thought
otorrhoea sufferer to speak loudly. to be due to disturbance of brain func-
A discharge of pus or other fluid from DIAGNOSIS AND TREATMENT tion, is reported by some patients
the ear (see ear, discharge from). The condition is diagnosed by hearing following a general anaesthetic or a
tests. It can be cured by stapedectomy, a medical emergency.
otosclerosis surgical procedure in which the stapes
A disorder of the middle ear that causes is replaced by a tiny piston, which outpatient treatment
progressive deafness.The condition usu- moves through a hole created in the Medical care on a same-day basis in a
ally develops in both ears. inner ear. Because the piston can move hospital or clinic.

576
 OVERBITE

ovarian cyst the guidance of ultrasound, or during

An abnormal, fluid-filled swelling in laparoscopy, may be possible. If an ovar- ANATOMY OF THE OVARY
an ovary. Ovarian cysts are common ian cyst is particularly large, the ovary
Each ovary consists
and, in the majority of cases, non- may need to be removed by surgery
of glandular cells
cancerous; however, the likelihood of a (see oophorectomy). and egg-producing
cyst being cancerous increases with follicles. After
age. In some cases, both of the ovaries ovary ovulation, each
have multiple cysts due to a hormonal One of a pair of almond-shaped glands follicle forms a
disorder (see ovary, polycystic). situated on either side of the uterus corpus luteum.
TYPES immediately below the opening of the
The most common type, a follicular fallopian tubes. Each ovary contains
Fallopian tube
cyst, is one in which the egg-producing numerous cavities called follicles, in
follicle enlarges and fills with fluid. which egg cells (see ovum) develop. The
Egg released
Cysts may also occur in the corpus ovaries also produce the female sex hor-
luteum, a mass of tissue that forms mones oestrogen and progesterone. Maturing
from the follicle after ovulation. Other follicle
types of cysts include dermoid cysts and ovary, cancer of
mucous or serous cystadenomas (see A malignant growth of the ovary. The
adenoma), which can become very large. cancer may be primary (arising in the
In some cases, an ovarian cyst may be ovary) or secondary (due to the spread
due to ovarian cancer, particularly in of cancer from another part of the body).
Ovary
postmenopausal women. INCIDENCE AND CAUSES
SYMPTOMS Ovarian cancer can occur at any age but Corpus Immature
luteum follicle
Ovarian cysts often produce no symp- is most common in women over 50 and
toms, but some may cause abdominal in those who have never had children. A
swelling or discomfort, pain on inter- family history of cancer of the ovary,
course, or irregularities of menstruation breast, or colon, especially in close rela- ovary, disorders of
including amenorrhoea, menorrhagia, and tives under 50, is an important risk Diseases and abnormalities of the
dysmenorrhoea. Severe abdominal pain, factor. Having taken oral contraceptives in ovaries can occur for various reasons.
nausea, and fever may develop if twist- the past substantially reduces the risk. Absence of ovaries, or their failure to
ing or rupture of a cyst occurs. Surgery SYMPTOMS develop normally, is rare and is usually
is required to treat these conditions. In most cases, ovarian cancer causes no due to a chromosomal abnormality (see
DIAGNOSIS AND TREATMENT symptoms until it is widespread. The Turner’s syndrome). Oophoritis (inflam-
An ovarian cyst may be discovered dur- first symptoms may include vague dis- mation of an ovary) may result from
ing the course of a routine pelvic
examination and its position and size
comfort and swelling in the abdomen;
nausea and vomiting; and abnormal
infections such as gonorrhoea or pelvic
inflammatory disease. Ovarian cysts are
O
confirmed by ultrasound scanning. In vaginal bleeding. The swelling may be common and usually noncancerous.
many cases, simple ovarian cysts (thin- due to the tumour itself or to ascites Polycystic ovary syndrome is due to an
walled or fluid-filled cysts) disappear (excess fluid in the abdominal cavity). imbalance of sex hormones. Ovarian
without treatment. Complex cysts (such DIAGNOSIS AND TREATMENT cancer (see ovary, cancer of) occurs
as dermoid cysts) usually require surgi- Diagnosis of ovarian cancer involves a mainly in women over 50. Ovarian fail-
cal removal. In some cases, aspiration physical examination, ultrasound scan- ure causes premature menopause in
(withdrawal by suction) of fluid under ning, and blood tests to measure levels of about 5 per cent of women.
Ovarian a substance produced by the tumour.The
cyst Instrument tumour is usually surgically removed, ovary, polycystic
along with the uterus (see hysterectomy) An ovary with multiple ovarian cysts.
and the unaffected ovary. In younger Symptomless ovarian cysts are present
women whose cancer is found early, it in about a quarter of the female popula-
is sometimes possible to perform less tion. In some women, however, ovarian
radical surgery and preserve fertility. cysts are associated with menstrual dis-
The extent of spread within the abdo- orders and/or other symptoms; in these
men is assessed during surgery. cases the condition is known as poly-
Surgery is followed by chemotherapy, cystic ovary syndrome.
unless the cancer was found at a very
early stage. Platinum-based drugs, overbite
which are combined with paclitaxel, are Overlapping of the lower front teeth by
usually given. Survival rates depend on the upper ones. A slight degree of over-
the type of tumour and how advanced bite is normal as the upper jaw is larger
Laparoscopic view of an ovarian cyst
This photograph shows an ovarian cyst (centre it is at the time of diagnosis; as the dis- than the lower jaw. In malocclusion,
left) that has formed at the ovary as a result of ease is often quite advanced, less than overbite may be greater than normal or
endometriosis, a condition in which fragments one in four women survive for more the lower teeth may project in front of
of uterine tissue locate in other parts of the body. than five years. the upper teeth (prognathism).

577
 OVERBREATHING

overbreathing commonly occurs in cases of long- ovum

A common name for hyperventilation. term urinary retention, which is caused The egg cell (the female cell of repro-
by an obstruction at the outlet of the duction). An ovum contains a nucleus
overcrowding, dental bladder. Treatment is generally of the suspended in cytoplasm (a gel-like sub-
Excessive crowding of the teeth so that underlying problem. stance) and it is surrounded by a
they are unable to assume their normal protective layer that is known as the
positions in the jaw. over-the-counter (OTC) drug zona pellucida.
CAUSES A drug that can be bought without a About one million immature ova are
Dental overcrowding is commonly in- prescription at a pharmacy or other present in each ovary at birth, but only
herited and may occur because the teeth shop, such as a supermarket. about 200 per ovary mature to be
are too large for the jaw or the jaw is released at ovulation. A fertilized ovum
too small to accommodate the teeth. overuse injury develops into an embryo.
Overcrowding may also be caused, or Also called repetitive strain injury, a term
aggravated, by premature loss of prim- for any injury caused by repetitive ovum, blighted
ary molar (back) teeth; this can cause movement of part of the body. Symp- A zygote (a fertilized egg cell) in which
the permanent teeth replacing them to toms include pain and stiffness in the development has stopped at an early
move out of position and crowd the affected joints and muscles. stage. This condition results in the
teeth further forward. Examples include epicondylitis: painful appearance of an empty sac in the
SYMPTOMS inflammation of one of the bony uterus, with no fetus visible on ultra-
Overcrowded teeth may lead to maloc- prominences at the elbow, caused by sound scanning; blighted ovum is a
clusion (abnormal relationship between the pull of the attached forearm muscles common cause of miscarriage.
the upper and lower teeth) or may pre- during strenuous activities (see golfer’s
vent certain teeth from erupting elbow; tennis elbow). Overuse injuries of Ovysmen
through the gum (see impaction, dental). the fingers, thumb, and wrist joints A brand-name oral contraceptive contain-
The teeth can be difficult to clean, may affect assembly-line and keyboard ing ethinylestradiol (a synthetic form of
increasing the risk of dental decay (see workers, and musicians; injuries of the the female sex hormone estradiol) and
caries, dental) and periodontal disease. neck may affect violinists. levonorgestrel (a progestogen drug).
TREATMENT Rest usually relieves the symptoms. A
Teeth may need to be extracted to allow change in the technique used during oxalate
room for others or for cosmetic rea- the activity may prevent recurrence. A substance that is synthesized by the
sons. Usually, an orthodontic appliance is body as well as being derived from cer-
fitted to the remaining teeth until they overweight tain foods, such as spinach, rhubarb,
are positioned correctly. Weighing more than the recommend- and tea. When blood oxalate levels are
ed weight for a particular height. (See raised, kidney stones (see calculus, uri-
O also obesity.) nary tract) may develop.

ovulation oxazepam
The development and release of an ovum A benzodiazepine drug used as a short-
(egg; the female reproductive cell) from term treatment for anxiety. Oxazepam
a follicle within an ovary. During the may cause dependence if it is taken reg-
first half of the menstrual cycle (see ularly for more than two weeks (see
menstruation), follicle-stimulating hormone drug dependence).
(FSH) causes several ova to mature in
the ovary. At mid-cycle, luteinizing hor- oximeter
mone (LH) causes one ripe ovum to be An instrument that measures the
released for potential fertilization. amount of oxygenated haemoglobin
Signs of ovulation include a rise in (see oxyhaemoglobin) in the blood. A
Overcrowded teeth
The top and bottom front teeth are crowded
body temperature, changes in the con- pulse oximeter is a photoelectric sensor
together because the molars, just behind them, sistency of the cervical mucus, and attached either to a finger or to an ear
have grown too far forward. sometimes mild abdominal pain (see to measure oxygen saturation continu-
mittelschmerz). A yellow mass of tissue ously. Oximetry is used to monitor
overdose known as the corpus luteum develops a patient during certain procedures, and
See drug poisoning. from the follicle after ovulation and always during general anaesthesia; it is
releases progesterone during the second also used to help diagnose and monitor
overflow incontinence half of the cycle. many lung diseases.
A type of incontinence (see inconti- After the release of the ovum, it trav-
nence, urinary) in which urine leaks els along the fallopian tube and, if oxprenolol
from the bladder, or a type of faecal fertilization does not occur, it soon A beta-blocker drug that is used in the
incontinence in which semi-liquid fae- degenerates. Regular menstruation usu- treatment of hypertension (high blood
ces leak out around impacted faeces in ally means that ovulation is occurring; pressure), angina (chest pain due to
constipation (see incontinence, faecal). exceptions to this occur around puberty insufficient blood supply to the heart),
Overflow urinary incontinence most and approaching the menopause. and cardiac arrhythmias (irregular heart-

578
 OZONE

beat). Oxprenolol may also be used to with the patient’s needs. Piped oxygen oxyuriasis
relieve symptoms of anxiety and control is used in hospitals; oxygen in cylinders An alternative name for enterobiasis or
those of hyperthyroidism (overactivity of can be used when the patient is moving threadworm infestation.
the thyroid gland). from place to place. Long-term therapy
for people with persistent hypoxia, ozena
oxybutynin which results from diseases such as A severe and rare form of rhinitis, in
A drug used to treat frequent urination chronic obstructive pulmonary disease which the mucus membrane in the
(see urination, frequent) and urge incon- (see pulmonary disease, chronic obstruc- nose wastes away and a thick nasal dis-
tinence (see incontinence, urinary) by tive) or pulmonary fibrosis, may involve charge dries to form crusts. Ozena often
relaxing bladder muscle and increasing the use of an oxygen concentrator. (See causes severe halitosis (bad breath).
bladder capacity. Common side effects also hyperbaric oxygen treatment.)
include dry mouth and blurred vision. ozone
oxyhaemoglobin A form of oxygen, ozone (O3) is a poi-
oxygen The substance formed when the iron in sonous, faintly blue gas that is produced
A colourless and odourless gas that haem, the pigment in the haemoglobin by the action of electrical discharges
makes up 21 per cent of the Earth’s of red blood cells, combines chemically (such as lightning) on oxygen mole-
atmosphere. Oxygen is essential for with oxygen. Oxyhaemoglobin gives cules (O2) and by interactions between
almost all forms of life, including the blood in the arteries its bright red hydrocarbon pollutants and sunlight.
humans, because it is necessary for the colour. This compound is the form in Ozone occurs naturally in the upper
metabolic “burning” of foods to pro- which oxygen is transported from the atmosphere, where it screens the Earth
duce energy. This is a process that takes lungs to the tissues, where the oxygen from most of the sun’s harmful ultravi-
place in body cells and is known as aer- is released (see respiration). olet radiation. The ozone layer is being
obic metabolism. depleted by atmospheric pollutants,
Oxygen is absorbed through the oxymetazoline allowing increasing amounts of ultravi-
lungs and into the blood, where it binds A decongestant drug used in the treat- olet radiation to reach the Earth’s
to the haemoglobin in red blood cells. As ment of allergic rhinitis (hay fever), surface. This increases the risk of affect-
oxygen-rich blood circulates around the sinusitis, and the common cold. ed populations developing higher rates
body, the oxygen is released from the of certain diseases and conditions, such
red blood cells into the body tissues. oxytetracycline as skin cancer and cataracts (see sunlight,
Additional supplies of oxygen are A tetracycline antibiotic drug that is used adverse effects of).
used to treat conditions such as severe to treat chlamydial infections such as Increased levels of ozone near the
hypoxia (inadequate oxygen in the body nongonococcal urethritis. It is also used ground are an indicator of poor air
tissues) or bronchitis. High-pressure for a variety of other infective condi- quality. In these circumstances, the
oxygen (see hyperbaric oxygen treatment) tions, including bronchitis and pneu- raised levels make the breathing prob-
is sometimes used to treat decompres-
sion sickness or carbon monoxide
monia; the drug may also be used to
treat severe acne.
lems of people with allergic lung
diseases increasingly likely to worsen,
O
poisoning. (See also ozone.) Side effects may include nausea, particularly if they exercise.
vomiting, diarrhoea, skin rash, and
oxygen concentrator increased sensitivity of the skin to
An appliance used in oxygen therapy that sunlight. Oxytetracycline may discolour
separates oxygen from the air and developing teeth and is not given to
mixes it back in at a greater concen- children under 12 or pregnant women.
tration. This oxygen-enriched air is
delivered through a tube for prolonged oxytocin
inhalation. The appliance is used by A hormone produced by the pituitary
people who have persistent hypoxia gland. Oxytocin causes uterine contrac-
(inadequate oxygen in body tissues) tions during labour and stimulates
due to severe chronic obstructive pul- milk-flow in breast-feeding women.
monary disease (see pulmonary disease, Synthetic oxytocin is used for induc-
chronic obstructive). (See also hyperbaric tion of labour. It is given by intravenous
oxygen treatment.) infusion to produce uterine contrac-
tions. It is also often given with ergo-
oxygen therapy metrine as a single dose after delivery
The process of supplying a person with to prompt placental separation and
oxygen-enriched air to relieve severe expulsion, to reduce blood flow, or to
hypoxia (inadequate oxygen in body tis- empty the uterus after an incomplete
sues). The oxygen is usually delivered miscarriage or a fetal death.
through a face-mask or a nasal cannula A possible adverse effect of synthetic
(a length of narrow plastic tubing with oxytocin is abnormally strong, painful
two prongs that are inserted into the contractions. Rare side effects include
nostrils). The oxygen concentration of nausea, vomiting, palpitations, and al-
the air may be varied in accordance lergic reactions.

579
 PACEMAKER

P
heart rate during exercise or change an newborn; if a smaller volume of blood is
abnormal rhythm into a normal one. transfused, there is less risk of overload-
Internal pacemakers are also either ing the circulation.
single-chambered or dual-chambered.
Single-chamber pacemakers work by paclitaxel
passing a single wire into the right atri- An anticancer drug that is used to treat cer-
um or right ventricle; dual-chamber tain types of cancer, such as ovarian cancer
pacemakers have two wires, one that (see ovary, cancer of) and breast cancer.
passes into the right atrium, and the The possible side effects of paclitaxel
other into the right ventricle. include nausea, vomiting, anaemia, and
increased susceptibility to infection.
pacemaker pachyderma
A small device that supplies electrical Abnormal thickening of the skin. (See paediatrics
impulses to the heart in order to main- also elephantiasis.) The branch of medicine that concen-
tain a regular heartbeat. trates on the development of children
WHY IT IS USED Pacinian corpuscle and with the diagnosis, treatment, and
A pacemaker is needed when the heart’s A specialized form of sensory nerve prevention of childhood diseases and
sinoatrial node malfunctions (see sick sin- ending (see receptor) found in the der- other conditions.
us syndrome), when the passage of the mis (the lower layer of the skin).
electrical impulses that stimulate heart Pacinian corpuscles detect deep pres- paedophilia
contractions is impaired (see heart block), sure and vibration. Persistent sexual attraction to, often lead-
or when the heart rate is intermittently ing to abuse of, children. Paedophilia is
slow and fast or the rhythm is irregular. packed red blood cells most often seen in men. It is thought to
TYPES A blood product comprising blood from result from a combination of psycholog-
Pacemakers may be fitted externally, as a which 70 per cent of the plasma (the ical and social factors that affect sexuality.
temporary measure until a permanent fluid that carries blood cells and other Paedophiles often show personality dis-
pacemaker can be fitted. They can also substances) has been removed to leave a orders such as antisocial personality
be internal (surgically implanted in the high concentration of red blood cells. In disorder, and have little concern for the
chest). Internal pacemakers can either blood transfusions, packed red blood effect of their behaviour on the child.
discharge impulses at a steady (fixed) cells are used much more commonly Paedophilic activity is illegal; many
rate or discharge only at times when the than “whole” blood (blood that has had affected people are only identified once
heart rate slows or a beat is missed nothing removed), especially to treat they have been arrested. Treatments are
(demand); some types can increase the anaemia and haemolytic disease of the designed to reduce the urge to have sex-
ual relations with children; they include
cognitive–behavioural therapy and drug
INTERNAL PACEMAKER treatment to reduce sexual urges. (See
also child abuse; incest.)
P An internal pacemaker is inserted just beneath the skin in
the chest wall, usually under local anaesthetic. The device
weighs only 20–50g, and most are powered by a lithium
Paget’s disease
battery that lasts on average between six and 10 years A common disorder that occurs in
before needing to be replaced. Each electrical impulse that middle-aged and elderly people that is
the pacemaker discharges stimulates the heart into characterized by the disruption of bone
contracting and producing a heartbeat. Some pacemakers formation. The affected bones become
deliver continuous impulses: others deliver an impulse only weak, enlarged and thickened, and de-
when the heart rate falls too low or in order to override an Site of incision formed. Paget’s disease is sometimes
excessively fast rate. called osteitis deformans,
Paget’s disease usually affects the pelvis,
Dual-chamber pacemaker skull, collarbone, vertebrae, and long
Electrical wires bones of the leg. Normally, the mainte-
nance of healthy bones involves a balance
between the actions of cells that break
Superior
vena cava
down bone tissue and the activity of cells
Internal
pacemaker that create new tissue. In Paget’s disease,
however, this balance is disturbed. The
disorder is thought to be caused by a viral
Wire passing infection; it may run in families.
into right
atrium SYMPTOMS
Wire There are often no symptoms. If symp-
passing
into right toms do occur, the most common ones
ventricle are bone pain and deformity, especially
bowing of the legs. Affected bones are
susceptible to fracture.

580
 PAIN RELIEF

Skull changes may lead to leontiasis heat; others respond to warning stimuli painful arc syndrome
ossea (distortion of the facial bones pro- such as firm pressure or stretching. Sig- A condition in which pain occurs when
ducing a lionlike appearance) and cause nals that arise from the nociceptors are the arm is raised between 45 and 160
damage to the inner-ear bones, some- transmitted via nerves to the brain. In degrees from the side.The usual cause is
times resulting in deafness, tinnitus addition, chemicals called prostaglandins an inflamed tendon or bursa in the
(ringing in the ears), vertigo (a spinning trigger inflammation and swelling, and shoulder joint that is being squeezed
sensation), or headaches. further stimulate the nerve endings. between the scapula (shoulderblade)
In the spine, enlarged vertebrae may Pain that may be felt at a point some and humerus (upper-arm bone). Treat-
press on the spinal cord, causing pain distance from the cause is known as ment includes physiotherapy and in-
and sometimes paralysis of the legs. If referred pain (see pain, referred). jections of corticosteroid drugs. (See also
the disease affects the pelvis, it may PSYCHOLOGICAL ASPECTS OF PAIN subacromial bursitis.)
cause severe arthritis of the hip joints. Pain is usually associated with distress
Occasionally, bone cancer may devel- and anxiety, and sometimes with fear. painful heel
op. In rare cases, when many bones are People vary tremendously in their pain See heel, painful.
involved, increased blood flow through thresholds (the level at which the pain is
affected bones may cause heart failure. felt and the person feels compelled to painkillers
DIAGNOSIS AND TREATMENT act). The cause and circumstances of the See analgesic drugs.
Paget’s disease is diagnosed by X-rays, pain may also affect the way it is per-
which show areas of porous and thick- ceived by the sufferer. The pain of painless haematuria
ened bone, and blood tests, which reveal cancer, because of fear of the disease, A form of haematuria (blood in the
abnormal levels of the substances involved may seem much greater and cause more urine) that is not associated with pain
in bone formation and breakdown. suffering than similar pain that results when urine is passed (see urination,
Most people do not need treatment, or from persistent indigestion. Unexplained painful). Common causes of painless
need only analgesic drugs (painkillers). In pain is often worse because of the anxi- haematuria include kidney tumours;
more severe cases, treatment with drugs ety it can cause; once a diagnosis is tumours in the ureters; bladder tumours;
such as bisphosphonates or calcitonin may made and reassurance given, the pain or glomerulonephritis (inflammation in
be prescribed to control the rates of may be perceived as less severe. In some the tiny filtering units of the kidneys).
bone breakdown and renewal. The drugs cases, pain may be felt due to emotional
will not reverse any existing deformity, reasons rather than any obvious physical pain, psychogenic
but will slow the progression of the dis- cause (see pain, psychogenic). Pain that occurs in response to a mental
ease. Surgery may be needed to correct The experience of pain may be or emotional stimulus rather than hav-
deformities or treat arthritis. reduced or blocked by arousal or strong ing a physical cause. Persistent pain that
emotion; for example, an injury sus- has no obvious physical cause may be
Paget’s disease of the nipple tained during competitive sport or on the due to a psychological disorder (see
A rare type of breast cancer in which a battlefield may go unnoticed in the heat somatization disorder).
tumour develops in the nipple. The dis- of the moment. Some people believe that
ease resembles eczema and can cause mental preparation for pain, in advance pain, referred
itching and a burning feeling. A non- of situations such as childbirth or in Pain that is felt in a site other than the P
healing sore may develop. Without experiments to test pain, can greatly affected part of the body. This form of
treatment, the tumour may spread into reduce the response. pain occurs when the brain cannot dis-
the breast. Diagnosis is made with a A person’s response to pain is also tinguish the correct source of the pain
biopsy (sample of tissue). greatly modified by past experience; the signals (see the illustrated box overleaf).
outcome of previous episodes of pain Examples of referred pain are pain in
pain may affect the way in which the indivi- the left shoulder or the arm, related to
A localized, unpleasant sensation that can dual copes with subsequent pain. angina pectoris (chest pain due to insuf-
range from a feeling of mild discomfort Factors such as insomnia, anxiety, and ficient blood supply to the heart
to an excruciating experience. Pain depression, which often accompany in- muscle) and sciatica (pain that radiates
serves the function of alerting the body capacitating chronic illness, lower along the sciatic nerve in the leg).
to possible causes of injury, or making an tolerance to pain. Many hospitals now
affected person (or animal) withdraw have specialist pain clinics, in which pain relief
from a source of harm. It may be acute people with severe pain that has proved The treatment of pain, usually with
(in which it appears and disappears sud- difficult to control may be assessed and analgesic drugs. Paracetamol, aspirin and
denly) or chronic (in which it persists treated. Such patients include those codeine are among the most widely used
for days, weeks, or even longer). with advanced cancer and poorly under- drugs in this group. Pain accompanied
MECHANISM OF PAIN stood conditions such as facial pain and by inflammation is often alleviated by non-
Pain results from the stimulation of sen- various types of neuralgia. steroidal anti-inflammatory drugs (NSAIDs).
sory nerve endings called nociceptors in TREATMENT Severe pain may require treatment with
the skin. Pain receptors are also present Treatment is for the underlying cause of opioids, such as morphine. Other types of
in other structures, such as the blood the pain. It may involve analgesic drugs, drug may be used to treat nerve pain,
vessels and tendons. Some nociceptors electrical stimulation (TENS), surgery, or such as trigeminal neuralgia or the burn-
respond only to severe stimulation, therapies such as acupuncture. (See also ing sensation in the feet that may be a
such as cutting, pricking, or extreme pain relief; endorphins.) feature of diabetes mellitus. Examples are

581
 PAIN RELIEF

PAIN

Pain mechanisms exist to provide a useful Brain region

Pain message
warning of possible injury or to caution concerned with
pain perception Nerve ending
against repeating an action that has led to
injury. Certain diseases, such as arthritis Prostaglandin
and extensive cancer, may set off these
same mechanisms, causing chronic pain
that has no apparent function. Damaged cell
Pathway of
pain signals
Sensory
nerve Initiation of pain signals
Pain signals are set off by stimulation of special
nerve endings – by pressure, heat, or the
release of chemicals, including prostaglandins,
by cells that have been damaged.

Nerve cell

Chemical
Receptors
transmitter
Sensory
nerve
Pain signal

Reflex action Perception of pain

The nerve pathways that warn of noxious When an injury occurs, signals pass along nerve Signal transmission to brain
stimuli (through the sensation of pain) may pathways concerned with pain, first to the Within the brain and spinal cord, pain signals
also initiate automatic, reflex actions that spinal cord and then to the thalamus in the pass between nerve cells by means of chemicals
help prevent harm. brain; there the pain is perceived. that cross the gaps between the cells.

1to theReceptors in the fingertip detect heat.

Signals are sent along a sensory nerve
spinal cord.
REFERRED PAIN
A referred pain is one felt in a
Spinal site other than an injured or
cord diseased part. Sensory nerves
Motor from certain body areas
nerve converge before they enter the
brain, causing confusion about
P the source of pain signals.
Teeth

Sensory
nerve Tooth to ear region
A toothache may be felt in the ear,
because the same sensory nerve
supplies both parts.

Diaphragm
Spinal Diaphragm to right shoulder
cord
Inflammation of the diaphragm,
Ganglion often due to pneumonia, may be
felt as a pain in the right shoulder.
Sensory
nerve

Heart to left arm

Finger Angina, a pain caused by reduced Heart
blood supply to the heart muscle, is
often felt in the left shoulder or arm.
Muscle Motor nerve

The signals arriving in the spinal cord pass

2 instantaneously to a motor nerve that
connects to a muscle in the arm. The signals
Hip to knee
Disorders that affect the hip, such
received via the motor nerve cause the muscle as arthritis, may be felt as pain in
in the arm to contract, moving the arm away the knee rather than in the hip. Hip
from the source of danger (the flame).

582
 PANCREAS

tricyclic antidepressants (such as ami- and to provide a comfortable, reassuring (irregularities of the heartbeat; see
triptyline) and anticonvulsant drugs (such environment for the last days or weeks arrhythmia, cardiac); anaemia
(a reduced
as carbamazepine or gabapentin). of life. (See also palliative treatment.) level of the oxygen-carrying pigment
Other methods of pain relief include haemoglobin in the blood); or hyperthy-
massage, ice-packs, poultices, TENS, acu- palliative treatment roidism (overactivity of the thyroid
puncture, and hypnosis. Surgery to destroy Treatment that relieves the symptoms of gland), which speeds up the heartbeat.
pain-transmitting nerves (such as a sym- a disorder but does not cure it.There is a DIAGNOSIS AND TREATMENT
pathectomy) is occasionally performed wide variety of palliative treatments. Recurrent palpitations, or those causing
in cases where all other appropriate Examples are pain relief; antiemetic drugs chest pain, breathlessness, or dizziness,
treatments have failed. to relieve nausea and vomiting; sedative may indicate an underlying disorder,
drugs to relieve insomnia; and other and need prompt medical attention.
palate therapies, such as massage and coun- They may be investigated by a 24-hour
The roof of the mouth, which sepa- selling. (See also dying, care of the.) ECG and thyroid function tests. Treatment
rates the mouth from the nasal cavity. depends on the cause.
The palate is covered with a mucous pallor
membrane. At the front is the hard Abnormal paleness of the skin and mucous palsy
palate, which is a plate of bone form- membranes, particularly noticeable in the A term applied to certain forms of para-
ing part of the maxilla (upper jaw). At face. Pallor may have many possible causes lysis, such as Bell’s palsy (the most
the rear is the soft palate, which is a and is not always a symptom of disease. common form of facial palsy).
flap of muscle and fibrous tissue that Pallor may be caused by constriction
projects into the pharynx (throat). of small blood vessels in the skin, Paludrine
During the process of swallowing, the which may occur in response to shock, The brand name for the antimalarial
soft palate presses against the rear wall severe pain, injury, heavy blood loss, or drug proguanil.
of the pharynx, thereby preventing fainting. This restriction of blood flow
food from escaping into the nose. (See to the skin ensures that the brain and panacea
also cleft lip and palate.) other vital organs are adequately sup- A remedy that is claimed to cure all dis-
plied with blood and that body heat is eases. No such remedy is known.
conserved (at least temporarily).
LOCATION OF THE PALATE Less commonly, pallor may be due to Panadol
a deficiency of the skin pigment melanin A brand name for the analgesic (pain-
The palate forms the floor of the that may result from spending too little killing) drug paracetamol.
nasal cavity and the roof of the time in daylight. Abnormally pale skin
mouth, providing a surface against is also a feature of albinism. Pancoast’s syndrome
which the tongue can push during
chewing and swallowing.
Disorders that cause pallor include A collection of symptoms that occurs
anaemia, kidney failure, and hypothyroidism when a growth presses on the brachial
(underactivity of the thyroid gland). plexus (the group of major nerves con-
Lead poisoning is a rare cause. trolling the arm and hand). These
symptoms include pain and paralysis in P
palmar erythema the arm or hand, as well as Horner’s syn-
See liver palms. drome if the growth presses on the
sympathetic cervical (neck) nerves. Pan-
palpation coast’s syndrome is commonly due to a
A technique used in physical examination tumour called Pancoast’s tumour, which
in which parts of the body are felt with develops in the upper part of the lung
the hands to assess the condition of the in people with lung cancer.
skin and underlying organs.
pancreas
palpitation A tapered gland that lies across the back
Hard An awareness or feeling in the chest of of the abdomen, behind the stomach.
palate Soft the heartbeat or a sensation of having a The broadest part (which is called the
Tonsil palate
Nasal rapid and forceful heartbeat. head) is on the right-hand side, in the
cavity Tongue
CAUSES loop of the duodenum (the first part of
Palpitations are usually felt in tense or the small intestine). The main part
frightening situations, or following (which is called the body) tapers from
palliative care strenuous exercise. When experienced the head and extends horizontally. The
Nursing or medical care that is given to at rest or during a period of calm, they narrowest part (the tail) extends left-
relieve the symptoms of illness rather are usually due to ectopic heartbeats and wards, towards the spleen.
than to treat the cause. Palliative care is are felt as fluttering or thumping in the STRUCTURE AND FUNCTION
often given to people who are in the chest. This condition is usually due to The major part of the pancreas is made
last stages of a terminal illness (see alcohol or caffeine consumption, or smok- up of exocrine tissue, which release
dying, care of the). In these cases, the aim ing, rather than disease. Palpitations may chemicals through ducts. Embedded
is to minimize unpleasant symptoms also be due to cardiac arrhythmias within these tissues are “nests” of

583
 PANCREAS, CANCER OF

loss; jaundice (yellowing of the skin) if heavy drinking, and gallstones. Less com-
LOCATION OF THE PANCREAS the tumour obstructs the bile ducts; and mon causes are injury (such as a violent
possibly even diabetes mellitus. There may blow to the abdomen), viral infections
This organ lies behind
and under the stomach,
also be indigestion, nausea, vomiting, (such as mumps), surgery on the biliary
except for its head, diarrhoea, and tiredness. In many cases, system, or certain drugs, such as immuno-
which lies within the symptoms do not appear until the cancer suppressants and thiazide diuretic drugs.
curve of the duodenum. has spread (typically to the liver and the Chronic pancreatitis is usually due to
lymph nodes in the abdomen). long-term alcohol abuse. Less common
DIAGNOSIS AND TREATMENT causes include hyperlipidaemia (a high
Diagnosis usually requires ultrasound level of fat in the blood), cystic fibrosis,
Liver
scanning, CT scanning or MRI of the haemochromatosis (a condition in which
upper abdomen, or ERCP (endoscopic there is excess iron in the body), and
Stomach examination of the pancreatic ducts). severe acute pancreatitis.
In the early stages, Whipple’s operation SYMPTOMS
Gallbladder (surgical removal of cancerous tissue), An attack of acute pancreatitis usually
radiotherapy, and anticancer drugs may lasts about 48 hours. Symptoms are a
Duodenum
provide a cure. In the later stages, little sudden attack of severe upper abdominal
Tail of
pancreas
can be done apart from provision of pal- pain, which may spread to the back,
liative treatment, such as pain relief, a often accompanied by vomiting. Move-
bypass operation to treat obstruction of ment often makes the pain worse, but
the duodenum, or insertion of a stent sitting may help to relieve it. In severe
(rigid tube) to relieve jaundice. Most cases, inflammation may affect the
Common Head of Pancreatic people with advanced pancreatic cancer whole abdomen (see peritonitis); there is
bile duct pancreas duct survive for less than one year. also a risk of shock (failure of blood cir-
culation), which may be life-threatening.
pancreatectomy Chronic pancreatitis usually develops
endocrine cells (known as the islets of Removal of all or part of the pancreas, over several years, and may be symp-
Langerhans), which secrete hormones which may be performed as treatment tomless in the early stages. When
into the bloodstream. for pancreatitis (inflammation of the symptoms do appear they are usually
The exocrine cells secrete digestive pancreas). In rare cases, pancreatectomy the same as those of acute pancreatitis,
enzymes into a network of ducts that is performed as a treatment for insulino- although the pain may last from a few
meet to form the main pancreatic duct. mas (insulin-producing tumours). hours to several days, and attacks may
This duct joins the common bile duct Pancreatectomy may cause a deficien- become more frequent over time. If
(which carries bile from the gall- cy of pancreatic hormones and digestive there is no pain, the principal signs may
bladder) to form a small chamber, the enzymes. This situation may lead to dia- be of malabsorption or diabetes mellitus
ampulla of Vater, which opens into the betes mellitus, which needs to receive due to reduced levels of pancreatic
duodenum. Also secreted is sodium bicar- treatment with insulin therapy, and mal- enzymes and insulin, respectively.
P bonate, which neutralizes stomach acid absorption, which requires oral supp- COMPLICATIONS
entering the duodenum. lements of pancreatin. Acute pancreatitis may recur repeatedly.
The islets of Langerhans are surround- Severe acute pancreatitis may damage
ed by many blood vessels, into which pancreatin the pancreas and lead to hypotension
they secrete the hormones insulin, gluca- An oral preparation of pancreatic enzy- (low blood pressure), heart failure, kid-
gon, and somatostatin. These hormones mes required for digestion. It is used to ney failure, respiratory failure, pancreatitic
regulate the level of glucose in the blood. prevent malabsorption, and it may be cysts, and ascites (accumulation of fluid
(See also Disorders of the pancreas box.) needed after pancreatectomy or by people in the abdomen).
who have disorders affecting the pan- Chronic pancreatitis leads to permanent
pancreas, cancer of creas, such as chronic pancreatitis, cancer damage to the gland; the tissue is dam-
A malignant tumour of the pancreas. (see pancreas, cancer of), or cystic fibrosis. aged and gradually replaced by scar tissue,
Pancreatic tumours usually arise in the and normal function is progressively
exocrine tissue, which is responsible for pancreatitis impaired. Other possible complications
producing digestive juices. They may also Inflammation of the pancreas, a con- include the development of ascites and
occasionally arise from parts of the endo- dition that may be acute or chronic. cysts, as well as bile duct obstruction.
crine system or from the ampulla of In acute pancreatitis, the pancreas sud- DIAGNOSIS AND TREATMENT
Vater (the junction of the common bile denly becomes inflamed, causing severe A diagnosis may be made using abdo-
duct and the pancreatic duct). The cause abdominal pain. This condition can be minal X-rays, ultrasound scanning, or CT
of cancer of the pancreas is unknown, life-threatening if left untreated. In scanning or MRI (techniques that pro-
but smoking, chronic pancreatitis, and a chronic pancreatitis, the pancreas is per- duce cross-sectional or three-dimen-
high alcohol intake may contribute. sistently inflamed; this condition leads sional images of body structures). In
SYMPTOMS to a progressive loss of function. addition, blood tests may be used in
Symptoms and signs of pancreatic cancer CAUSES cases of suspected acute pancreatitis, to
include upper abdominal pain that radi- The main causes of acute pancreatitis detect pancreatic enzymes that have
ates to the back; loss of appetite; weight are alcohol abuse, typically a bout of leaked directly into the blood.

584
 PANIC ATTACK

DISORDERS OF THE PANCREAS

Serious disruption of pancreatic the mumps or hepatitis viruses. Other thiazide diuretic drugs; corticosteroid drugs
function occurs only when the viruses, such as coxsackievirus, may may also cause pancreatitis.
secretory tissue of the gland has been also cause pancreatitis. In some cases,
damaged or destroyed in advanced coxsackievirus infection may contribute Autoimmune disorders
disease. The most common pancreatic to the development of diabetes. The cause of the damage to the pancreas
disorder is diabetes mellitus, in which in diabetes mellitus remains controversial.
the insulin-producing cells in the Tumour However, there is increasing evidence
gland are destroyed. Pancreatic cancer is one of the fairly that, possibly in response to a viral
common cancers (see pancreas, cancer of). infection, the body’s immune system
Congenital and genetic disorders It is difficult to diagnose and, in most produces antibodies (proteins made by
About 85 per cent of people with the cases, has spread extensively by the the immune system) that inappropriately
genetic disorder cystic fibrosis produce time it is detected. attack and destroy the pancreatic cells.
totally inadequate quantities of
pancreatic digestive enzymes, which Trauma Other disorders
results in malabsorption of fats and Injury to the pancreas – as a result of a The condition most often associated with
proteins. This, in turn, may produce blow to the abdomen, for example – may pancreatitis, other than alcohol overuse,
steatorrhoea (excess fat in the faeces) cause acute pancreatitis. The mechanism by is gallstones. These occasionally block
and muscle wasting. which this occurs is not fully established, the exit of the pancreatic duct into the
Genetic factors are thought to play but it is believed that pancreatic enzymes duodenum, leading to inflammation of
some part in diabetes mellitus, (most of which are inactive until they the pancreas.
although they are not the primary reach the intestine) are released within
cause of the disease. the gland and then activated, with the INVESTIGATION
Chronic pancreatitis (inflammation result that they digest the pancreas.
of the pancreas) may, in rare cases, be Diagnosis of pancreatic disorders may
hereditary; chronic pancreatitis often Poisons and drugs involve ultrasound scanning, CT scanning,
causes diabetes. Excessive alcohol intake is a common or MRI of the abdomen; tests to measure
cause of pancreatitis. It can also be caused levels of pancreatic enzymes in the
Infection by various drugs, such as sulphonamides, blood or duodenum; and endoscopic
Acute pancreatitis may result from oestrogen drugs (including oestrogen- examination of the gland (see ERCP).
certain viral infections, especially with containing contraceptive pills), and

Acute pancreatitis is treated with intra- This condition may be a result of last for only a few minutes, cause no
venous infusion of fluids and salts and damage to the bone marrow, where physical harm, and are rarely associated
opioid analgesic drugs (painkillers). In blood cells are made; such damage may with any serious physical illness. P
some cases, the abdominal cavity may be due to cancer in the marrow, or to Panic attacks are generally a feature of
be washed out with sterile fluid; ERCP destruction of the marrow by radiother- an anxiety disorder, agoraphobia, or other
(an endoscopic X-ray procedure) may apy or anticancer drugs. Pancytopenia phobias. In some cases, however, such
be used to find and remove gallstones; may also be due to hypersplenism (over- attacks are associated with a somatization
or a pancreatectomy (surgical removal of activity of the spleen), in which the disorder or schizophrenia.
damaged tissue) may be performed. spleen destroys excessive numbers of Attacks are unpredictable at first, but
Treatment for the chronic form is blood cells. (See also aplastic anaemia; tend to become associated with specific
with painkillers, insulin, pancreatin, and, Fanconi’s anaemia.) situations, such as being in a cramped
in some cases, pancreatectomy. lift. Symptoms begin suddenly. They
pandemic include a sense of breathing difficulty,
pancreatography A medical term that is applied to a dis- chest pains, palpitations, feeling light-
Imaging of the pancreas or its ducts ease that occurs over a large geo- headed, dizziness, sweating, trembling,
using CT scanning, MRI, ultrasound scan- graphical area and that affects a high and faintness. Hyperventilation often also
ning, X-ray (after a radiopaque contrast proportion of the population; a wide- occurs. This condition results in carbon
medium is injected into the ducts during spread epidemic. dioxide levels in the blood becoming
exploratory surgery), or with ERCP (an abnormally low, which leads to a pins-
endoscopic X-ray procedure). panencephalitis and-needles sensation and feelings of
See subacute sclerosing panencephalitis. depersonalization and derealization. The
pancytopenia attacks end quickly.
A simultaneous and severe reduction in panic attack The symptoms of hyperventilation
the numbers of red blood cells (causing A brief period of acute anxiety, often may be relieved quickly by covering the
anaemia); white blood cells (a condi- dominated by an intense fear of dying or mouth and nose with a small paper bag
tion called leucopenia); and platelets, losing one’s reason. Although unpleasant and breathing into the bag for a few
involved in clotting (thrombocytopenia). and frightening, panic attacks usually minutes; this measure restores carbon

585
 PANIC DISORDER

dioxide levels to normal. In the longer disease) causes the milk teeth to be lost paraesthesia
term, cognitive–behavioural therapy and prematurely, and may cause all the adult Altered sensation in the skin without
relaxation exercises may be used to help teeth to be lost by age 20. any stimulus (see pins-and-needles).
affected people control their anxiety.
papovavirus paraffinoma
panic disorder A family of viruses that includes papil- A tumourlike swelling under the skin
A type of anxiety disorder characterized lomaviruses (see human papillomavirus). caused by prolonged exposure to paraf-
by recurrent panic attacks that are of fin. Paraffinomas may form in the lungs
intense anxiety and accompanied by pap smear if paraffin is inhaled.
distressing physical symptoms. See cervical smear test.
paraffin, white soft
panniculitis papule See petroleum jelly.
Inflammation occurring in subcuta- A small, solid, slightly raised area of
neous fat (the layer of fatty tissue just skin. Papules are usually less than 5 mm paraldehyde
beneath the skin). The inflamed fatty in diameter. They may be raised or flat; A sedative drug used to stop prolonged
tissue forms multiple tender nodules rough or smooth; and pigmented or the epileptic seizures. Paraldehyde can be
under the skin. One form of this condi- colour of the surrounding skin. administered as an enema or by injec-
tion is erythema nodosum, in which tion into a muscle.
swellings develop on the legs. par-/para-
Prefixes that have several meanings. paralysis
pantothenic acid They may mean “beside or beyond”, as Complete or partial loss of controlled
A vitamin of the vitamin B complex. in the parathyroid glands (which lie movement caused by the inability to
behind the thyroid); “closely resem- contract one or more muscles. Paralysis
papain bling or related to”, as in paratyphoid may be temporary or permanent, and
A naturally occurring mixture of en- fever (a disease that is very similar to can affect areas of varying sizes, from a
zymes, including chymopapain, which typhoid fever); or “faulty or abnormal”, small facial muscle to many of the
is found in pawpaws. Papain breaks as in paraesthesia (abnormal sensation). major muscles in the body. There may
down proteins and has been used to also be loss of feeling in affected areas.
remove clotted blood and dead tissue para-aminobenzoic acid (PABA) Paralysis is also known as palsy.
from wounds and ulcers. A biochemical that used to be the active TYPES
ingredient of many sunscreen prepara- The types of paralysis are classified by
papilla tions, but is now rarely used. the areas of the body that are affected
Any small, nipple-shaped projection and by the effect on the muscles. Para-
from a tissue’s surface, such as the paracentesis lysis of one half of the body is called
mammary papilla (the breast nipple). A procedure in which a body cavity is hemiplegia. If corresponding areas on
punctured with a needle to remove both sides of the body (such as the legs)
papilloedema fluid for analysis, to relieve pressure are affected, it is known as diplegia. If all
P Swelling of the head of the optic nerve. from excess fluid, or to instil drugs. four limbs and the trunk are affected,
This condition is also known as optic the paralysis is called quadriplegia or
disc oedema. The nerve swelling is visi- paracetamol tetraplegia. Paraplegia is the paralysis of
ble with an ophthalmoscope. It usually An analgesic drug that is used to treat both legs and sometimes part of the
indicates a dangerous rise in the pres- mild pain and to reduce fever. Paraceta- trunk. In addition, paralysis may be clas-
sure within the skull, which may some- mol may, in rare cases, cause nausea or a sified as flaccid, causing floppiness, or
times be caused by a brain tumour. rash. An overdose may cause liver dam- spastic, causing rigidity.
age and can be fatal. An antidote is CAUSES
papilloma available, but must be given early. The muscles that control body move-
A noncancerous growth of the epitheli- ments are stimulated to contract by
um (the cell layer that forms the surface impulses originating in the motor cor-
of the skin and mucous membranes) tex of the brain. These impulses travel
that resembles a wart and most com- via the spinal cord and peripheral
monly affects the skin, tongue, larynx, nerves to reach the muscles. Paralysis
and urinary and digestive tracts. If it may be caused by any form of injury or
does not disappear spontaneously it can disorder anywhere along this nerve
be surgically removed. pathway. Alternatively, it may result
from a disorder in the muscle.
Papillon–Lefevre syndrome Brain disorders A common cause of
A rare genetic disorder affecting the skin paralysis is a stroke, in which brain tis-
and gums. Papillon–Lefevre syndrome sue is damaged by bleeding from a
results in areas of thickened, cracked ruptured blood vessel, or an area of the
Papilloma on the tongue
skin. In addition, it makes the gums This harmless growth, which resembles a wart, brain is starved of oxygen due to a clot
prone to infection from very early in may disappear spontaneously but may need to in the blood vessel supplying that
life. Severe gum disease (see periodontal be removed under local anaesthetic. region. The paralysis will occur on the

586
 PARAPSYCHOLOGY

opposite side of the body to the site of paralysis, periodic amines, manic–depressive illness, or schiz-
the brain damage because the motor A rare, inherited condition that causes ophrenia. It is also a feature of paranoid
nerves cross over in the brainstem. intermittent phases of muscle weakness, personality disorder, which is a psycho-
Hemiplegia may be caused by any often associated with raised or lowered logical condition that causes people to
brain disorder in which the portion of blood levels of potassium. The disorder be constantly suspicious of the motives
the brain that controls movement is shows an autosomal dominant pattern of other people.
damaged. Examples of such disorders of inheritance (see genetic disorder). Acute paranoia, lasting for less than
include a brain tumour, brain abscess, or Periodic paralysis affects young peo- six months, may occur in people who
brain haemorrhage. ple, with attacks usually beginning in have experienced radical life changes,
Some types of paralysis are caused by childhood or adolescence. Episodes of such as refugees. In shared paranoia (see
damage to parts of the nervous system muscle weakness vary in frequency folie à deux), delusion develops because
concerned with fine movement control, from daily to once every few years and of a close relationship with someone
such as the cerebellum and the basal gan- last from a few minutes to a few hours. else who has a delusion.
glia. Parkinson’s disease is caused by a Lowered potassium levels may occur SYMPTOMS
lack of dopamine in the basal ganglia. after a high-carbohydrate meal or dur- There are usually no other symptoms of
Cranial nerve damage may affect a ing a period of rest following physical mental illness apart from occasional hal-
variety of muscles and functions. For exertion. The diuretic drug acetazolamide lucinations. In time, however, the anger,
example, damage to the facial nerve (the may be used to prevent attacks; potassi- suspicion, and social isolation may
seventh cranial nerve) causes weakness um is often given orally to restore muscle become severe.
of the facial muscles (see facial palsy) strength when an attack occurs. TREATMENT AND OUTLOOK
and loss of taste. In other cases, potassium levels are If acute illness is treated early with
Spinal cord disorders If the spinal cord raised; triggers include being cold, hav- antipsychotic drugs, the outlook is good.
becomes damaged or diseased, paralysis ing a rest after physical exertion, and In long-standing cases of paranoia,
will develop in muscles that are supplied pregnancy. Diuretic drugs may be given as however, the delusions are usually firm-
by nerves below the affected area. Dam- preventive treatment; a sugary drink ly entrenched, but antipsychotic drugs
age to, or pressure on, the spinal cord may help to relieve an attack. may make them less debilitating.
may result from fracture of one or more The condition often clears up with-
vertebrae (which may result from severe out treatment by the age of 40. paraparesis
injury, as in a road traffic accident) or Partial paralysis or weakness of both legs
disc prolapse (slipped disc). Diseases paralytic ileus and sometimes part of the trunk.
affecting the spinal cord include multiple See ileus, paralytic.
sclerosis and poliomyelitis. paraphimosis
Peripheral nerve disorders Certain nerve paramedic Constriction of the penis behind the
disorders, called neuropathies, affect the A term for any health-care worker who glans (head) by an extremely tight fore-
peripheral nerves and may cause varying is trained to work in an auxiliary capac- skin that has been pulled back, causing
degrees of paralysis. Neuropathies may ity to medical professionals such as swelling and pain. Paraphimosis often
be caused by a variety of conditions, doctors and nurses. The term usually occurs as a complication of an abnor-
such as diabetes mellitus (see diabetic refers to ambulance staff who attend mally tight foreskin (see phimosis). P
neuropathy), vitamin deficiency, liver dis- accidents or medical emergencies. The problem can often be remedied
ease, cancer, and the toxic effects of manually by applying an ice-pack to
some drugs or metals (such as lead). paramyxovirus reduce swelling and then squeezing the
Muscle disorders Certain disorders arising One of a family of viruses that includes glans to return the foreskin to its nor-
in the muscles, such as muscular dystrophy, the microorganisms responsible for mal position. Otherwise, an injection or
may cause paralysis. Temporary paralysis croup, mumps, measles, and parainfluenza an operation to cut the foreskin may be
sometimes occurs in myasthenia gravis. (a mild form of influenza). necessary. Circumcision (surgical removal
TREATMENT of the foreskin) may be performed to
The underlying cause is treated, if pos- paranoia prevent recurrence.
sible. Physiotherapy is given for both A condition in which the central feature
temporary and permanent paralysis, to is the delusion that people or events are paraplegia
prevent joints from becoming locked in especially connected to oneself. The term Weakness or paralysis of both legs and
awkward positions. In addition, it re- “paranoia” may also be used to describe sometimes of part of the trunk as well,
trains and strengthens the muscles and feelings of persecution. A paranoid per- often accompanied by loss of feeling
joints in people with temporary paraly- son builds up an elaborate set of beliefs and by loss of urinary control. Paraple-
sis, so that some degree of mobility will based on the interpretation of chance gia is a result of nerve damage in the
be possible after recovery. remarks or events.Typical themes are per- brain or spinal cord.
For paralysed people who are con- secution, jealousy (see jealousy, morbid),
fined to a bed or a wheelchair, nursing love, and grandeur (belief in one’s own parapsychology
care is essential to avoid the complica- superior position and powers). The branch of psychology dealing with
tions that can result from prolonged TYPES AND CAUSES experiences and events that cannot be
immobility, such as bedsores, deep vein Paranoia may be chronic or acute. Chro- explained by scientific knowledge. Such
thrombosis, urinary tract infections, consti- nic paranoia may be caused by brain phenomena include extrasensory per-
pation, and limb deformities. damage, abuse of alcohol or amphet- ception (ESP), telepathy (communication

587
 PARAQUAT

pathetic system controls everyday func-

PARASITES: ECTOPARASITES (present in skin or on body surface) tions such as breathing, digestion, and
excretion of waste products.
Common examples Activities How acquired
parathion
• Head lice Suck host’s blood Through contact with other
An agricultural organophosphate insecti-
• Ticks people (lice, scabies mites,
warts), animals (ringworm fungi, cide that is highly poisonous.
• Bedbugs
ticks), vegetation (ticks, mites),
• Cat/Dog fleas or water (aquatic leeches). parathyroidectomy
• Aquatic leeches Bedbugs live in bedroom walls or Surgical removal of abnormal tissue from
mattresses and visit humans at
• Scabies mites Burrow in skin night. Cat and dog fleas may visit the parathyroid glands. Parathyroidectomy
humans when the pet is absent. may be performed to treat hyperparathy-
• Ringworm fungi Multiply in skin
roidism (excess secretion of parathyroid
• Wart viruses
hormones). Less commonly, it may be
used to treat parathyroid cancer.
If hyperparathyroidism is caused by an
adenoma (a small, benign tumour), usu-
PARASITES: ENDOPARASITES (live within body) ally only one of the parathyroid glands is
involved and needs to be removed. If all
Common examples Activities How acquired
the glands are enlarged and overactive,
more parathyroid tissue may be removed.
• Tapeworms Adults live in human By eating infected meat,
• gut, blood vessels, bile swallowing eggs on food,
Flukes
ducts, or elsewhere and contaminating fingers with parathyroid glands
• Roundworms
produce eggs that are faecal material, or contact with Two pairs of oval, pea-sized glands that
• Threadworms passed out of the body. infected water. lie behind the thyroid gland in the neck.
• Hookworms
The glands produce parathyroid hor-
• Various disease- Organisms multiply By inhalation, water- or food-borne mone (PTH), which helps to regulate
causing protozoa, locally or spread transmission, sexual transmission, the level of calcium in the blood.
fungi, bacteria, and throughout the body, or blood-borne infection, among Blood calcium levels are monitored
viruses causing disease. other mechanisms.
continuously by the body because even
small variations can impair muscle and
nerve function. If the calcium levels
of thoughts), telekinesis (movement of Parasites obtain nourishment from the drop too low, the parathyroid glands
objects with the mind), and precogni- host’s blood, tissues, or ingested food.
tion (being able to see into the future). The organisms may spend only part of
Many “paranormal” experiences can their life-cycle with the host or remain LOCATION OF THE
PARATHYROID GLANDS
probably be explained by mental distur- there permanently. Some cause few
P bances; others are probably due to symptoms, while others cause disease These glands are
coincidence, self-deception, or fraud. or even death. embedded in the
Animal parasites of humans include back of the thyroid
paraquat protozoa, worms, flukes, leeches, lice, ticks, gland, in the front
A weedkiller, available in high concentra- and mites. Viruses and disease-causing of the neck, and are
tions for agricultural use, which can be fungi and bacteria are also parasites. situated on either
fatal if swallowed, inhaled, or absorbed side of the trachea.
through the skin. Paraquat poisoning parasitology
requires urgent medical attention. Symp- The scientific study of parasites. Although
toms may include breathing difficulty, viruses and many types of bacteria and Thyroid
cartilage
mouth ulcers, nosebleeds, diarrhoea, and fungi are parasites, their study is conduct-
later, respiratory and kidney failure. ed under the title of microbiology.
Treatments include eating activated
charcoal or Fuller’s earth. Haemodialysis parasuicide Thyroid
gland
(removal of toxic substances from the See suicide, attempted.
blood) may also be used. Superior
parasympathetic nervous parathyroid
parasite system glands
Any organism living in or on another One of the two divisions of the auto- Inferior
living creature (the host) and deriving nomic nervous system, which controls the parathyroid
advantage from it, while causing the host automatic activities of organs, glands, glands

disadvantage. In contrast, some organ- blood vessels, and other tissues through-
isms live on other creatures but have a out the body. In contrast to the function Trachea Parathyroid glands
symbiotic, or mutually beneficial, rela- of the sympathetic system, which pre- viewed from behind
tionship with their host (see commensal). pares the body for action, the parasym-

588
 PARKINSONISM

release more PTH (see feedback). This parity from the slowness of movement. These
response causes the bones to release A term used to indicate the number of features include a masklike face, a festi-
more calcium into the blood, the pregnancies a woman has undergone nating gait (a shuffling, unbalanced style
intestines to absorb more from food, that have resulted in the birth of a baby of walking), a monotonous style of
and the kidneys to conserve calcium; as capable of survival. speech, and reduced blinking. The most
a result, calcium levels rise rapidly. If the common type of parkinsonism is known
blood level of calcium is too high, the parkinsonism as Parkinson’s disease.
glands reduce their output of PTH. Any neurological disorder that is char- The known causes of parkinsonism
Some people have only one parathy- acterized by tremor (typically, this is a include cerebrovascular disease (prob-
roid gland or have extra glands in the “pill-rolling” tremor, which occurs lems involving the blood vessels in the
neck or chest. Rarely, the parathyroid when the thumb is rubbed over the brain); the use of antipsychotic drugs, or
glands may become overactive (a condi- index finger); slow movements; and the abuse of certain designer drugs; car-
tion called hyperparathyroidism), which rigidity. The other characteristic features bon monoxide poisoning; and, rarely, the
causes erosion of the bones and stones of the disorder of parkinsonism result infection encephalitis lethargica.
in the kidneys, ureters, or bladder (see
calculus, urinary tract). Alternatively, the
glands may become underactive (see CAUSE OF PARKINSON’S DISEASE
hypoparathyroidism), resulting in tetany
This disorder results from damage, of unknown origin, to the basal ganglia (nerve
(painful muscle spasms) or seizures. cell clusters in the brain). The difference between the healthy state and that of
Parkinson’s disease is shown in the diagrams below.
parathyroid tumour
A growth within a parathyroid gland. The Motor Motor
tumour may cause excess secretion of cortex cortex
parathyroid hormone (PTH), leading to Basal Basal
ganglia ganglia
hyperparathyroidism. Parathyroid cancers
are very rare; most parathyroid tumours
are noncancerous adenomas. An adeno-
ma that causes hyperparathyroidism
Motor cortex Motor cortex
will be surgically removed (see parathy-
roidectomy).This usually provides a cure.
B A B A
paratyphoid fever
An illness identical in most respects to
Dopamine Lack of
typhoid fever, except that it is caused by a
stimulates dopamine
different bacterium, SALMONELLA PARATYPHI,
and is usually less severe.
paraumbilical hernia
Basal
ganglia
Reticular
formation
Basal
ganglia
Reticular
formation P
A hernia occurring near the navel.
Paraumbilical hernias may occur in obese DAMPING EFFECT
women who have had several children.
Acetylcholine Acetylcholine
parenchyma inhibits inhibits
The functional (as opposed to support-
ing) tissue of an organ.
Spinal cord Spinal cord
parenteral
The administration of drugs or other
substances by any route other than via
Controlled muscle activity Increased muscle tension
the gastrointestinal tract (for example, and tremor
by injection into a blood vessel).
Healthy state Parkinson’s disease
parenteral nutrition During movement, signals pass from the brain’s In Parkinson’s disease, degeneration of parts
Intravenous feeding (see feeding, artificial). cortex, via the reticular formation and spinal of the basal ganglia causes a lack of dopamine
cord (pathway A), to muscles, which contract. within this part of the brain. The basal ganglia
paresis Other signals pass, by pathway B, to the basal are thus prevented from modifying the nerve
ganglia; these damp the signals in pathway A, pathways that control muscle contraction.
Partial paralysis or weakness affecting reducing muscle tone so that movement is not As a result, the muscles are too tense, causing
one or more muscles. jerky. Dopamine, a nerve transmitter made in tremor, joint rigidity, and slow movement.
the basal ganglia, is needed for this damping Most drug treatments increase the level of
parietal effect. Another transmitter, acetylcholine, dopamine in the brain or oppose the action
inhibits the damping effect. of acetylcholine.
A medical term that is used to refer to
the wall of a part of the body.

589
 PARKINSON’S DISEASE

Parkinson’s disease effects such as nausea and vomiting;

A neurological disorder that is the most therefore, the dose is increased gradually, LOCATION OF THE
common cause of parkinsonism. and the drug may be given in combina- PAROTID GLANDS
CAUSES AND INCIDENCE tion with benserazide or carbidopa. The glands are situated deep in the
Parkinson’s disease is caused by degen- Levodopa is usually effective for several angle of the jaw and secrete saliva
eration of, or damage to, cells in the years, but the effects gradually wear off. into the mouth. Mumps may affect
basal ganglia of the brain. As a result, Drugs that may be used in conjunction other salivary and exocrine glands.
there is a deficiency of the neurotrans- with it, or as substitutes for it, include
mitter dopamine (which is needed for amantadine and bromocriptine.
the control of movement).The condition Surgical operations on the brain are
occurs mainly in elderly people and is occasionally performed, if the affected
more common in men. person is young and otherwise in good
For further information on the health. New therapies that are still being
processes leading to Parkinson’s disease, assessed include replacement of dam-
see the illustrated box, previous page. aged tissue with transplanted brain cells,
SYMPTOMS AND SIGNS and deep brain stimulation with electri-
The main symptoms develop gradually, cal impulses to reduce tremor.
over several months or even years. The OUTLOOK
disease usually begins as a slight tremor If left untreated, the disease progresses
Parotid duct Parotid gland
of one hand, arm, or leg, which is over 10 to 15 years, leading to severe
worse when the hand or limb is at rest. weakness and incapacity. Some sufferers
Later, both sides of the body are eventually develop dementia. Modern
affected, causing stiffness, weakness, and drug treatments, however, can provide affects these glands is mumps, which
trembling of the muscles. Symptoms considerable relief from the symptoms causes inflammation of one or both
include a stiff, shuffling walk that may and give affected people a much im- glands. Another is a form of noncancer-
break into uncontrolled, tiny running proved quality of life. ous tumour, pleomorphic adenoma,
steps; constant hand tremors, sometimes which is slow-growing and painless but
accompanied by shaking of the head; a paronychia may rarely become cancerous.
permanent rigid stoop; and an unblink- An infection of the skin fold at the base
ing, fixed expression. Everyday activities or side of the nail. The affected area parotitis
such as eating, washing, and dressing becomes swollen and painful, and there Inflammation of the parotid glands,
become very difficult. may be a buildup of pus. which is often due to infection with the
The intellect is unaffected until late in Paronychia may be acute (caused by mumps virus.
the disease, although the affected per- bacteria) or chronic (usually caused by
son’s speech may become slow and CANDIDA ALBICANS). The condition is most paroxetine
hesitant, and the handwriting usually common in women, particularly those A selective serotonin reuptake inhibitor
becomes very small. Depression is a with poor circulation and whose work antidepressant drug. Possible side effects
P common complication. involves frequent contact with water. It of paroxetine include nausea, indiges-
TREATMENT also affects people with skin disease tion, and appetite loss.
There is no cure, but drug treatment, involving the nail fold.
physiotherapy, and, rarely, surgery can Treatment is with antifungal drugs or paroxysm
help to relieve symptoms. In the early antibiotic drugs. If pus has collected in A sudden attack, worsening, or recur-
stages of Parkinson’s disease, exercises, the area, it may need to be drained sur- rence of symptoms or of a disease; a
special aids in the home (see disability), gically. To prevent the occurrence of spasm or seizure.
and support can improve the affected paronychia, gloves should be worn for
person’s morale and mobility. Drug all tasks that involve putting the hands paroxysmal nocturnal dyspnoea
treatment is used to minimize symp- in water, and the hands should be dried Acute breathing difficulty that occurs
toms in later stages. These treatments thoroughly after washing. suddenly at night, usually waking the
cannot halt the degeneration of brain person from sleep. The condition most
cells, but can minimize the symptoms parotid glands commonly affects people suffering
by helping to correct the chemical The largest of the three pairs of salivary from congestive heart failure with pul-
imbalances in the brain. glands.The parotid glands are situated on monary oedema (a buildup of fluid in the
In some cases, an anticholinergic drug each side of the face, just above the angle lungs); in these cases, it is caused by
such as trihexyphenidyl (benzhexol) of the jaw and in front of the ear. They fluid leaking out of the blood vessels
may initially be given to reduce tremor. secrete saliva into the mouth through a into the air spaces of the lungs once the
Anticholinergic drugs can be effective duct that opens into the inner cheek, person is lying down. It may also occur
for several years, but may cause side level with the second molar tooth. in people with chronic lung diseases.
effects such as dry mouth, blurred The parotid glands may develop vari-
vision, and difficulty in passing urine. ous disorders that can affect all of the paroxysmal tachycardia
Levodopa, which the body converts salivary glands, such as infections, ab- A form of tachycardia (abnormally
into dopamine, is usually the most effec- scesses (collections of pus), or calculi rapid heartbeat) that usually comes on
tive drug. It may, however, cause side (stones). One disorder that specifically abruptly and stops just as suddenly. It

590
 PATHOGNOMONIC

may be due to irregular muscle contrac- Most children with Patau’s syndrome die DIAGNOSIS AND TREATMENT
tions in one of the chambers of the before two years of age, and those that Diagnosis is made from hearing a heart
heart (see arrhythmia, cardiac). survive have learning difficulties. Some- murmur, from chest X-rays, and from an
times, affected children may have a ECG and echocardiography. The drug
parrot fever mixture of normal and abnormal cells indometacin or surgery may be used to
The common name for psittacosis. (see mosaicism), and they may have close the duct.
milder forms of the condition.
parturition The condition may be diagnosed at paternity testing
See childbirth. an early stage of pregnancy by a test The use of tests, including DNA tests and
such as chorionic villus sampling or amnio- blood tests, to help decide whether a par-
parvovirus centesis. In addition, genetic counselling ticular man is the father of a certain child.
The former name for erythrovirus. may be offered. This procedure may be requested, or
ordered by a court, in legal situations in
passive movement patch test which the paternity of a child is disputed.
Movement of a person’s limbs or body A method that is used to diagnose the Blood samples or buccal swabs (cell
by another person. Passive movement is substances that are responsible for the samples taken from rubbing the inside
used in physiotherapy to exercise the body skin disorder allergic contact dermatitis. of the cheek) are taken from the child,
if a person has nerve or muscle disorders A selection of possible allergens are put from the man who is believed to be the
that prevent voluntary movements. on a patch and taped to the skin. A skin father, and from the mother. There are
reaction indicates that there is a sensiti- various methods of testing for paterni-
passive smoking vity to a particular allergen. ty: blood samples may be tested for
Involuntary inhalation of tobacco smoke blood groups, histocompatibility antigens
by people who do not smoke. Passive patella (proteins that normally exist within
smoking has been shown to increase risks The kneecap (see knee). body tissues, and whose form is inher-
of chest and ear infections in children ited from the parents), and/or short
and of tobacco-induced cancers in adults. patent lengths of DNA (a technique known as
A term meaning “open” or “unob- genetic fingerprinting); buccal swabs may
passivity structed” (such as in patent ductus only be used for DNA tests.
In psychology, a persistent unwillingness arteriosus). The term “patent medicine” Genetic fingerprinting is the most
or inability to take responsibility for is sometimes used to refer to propri- conclusive method of paternity testing.
oneself and one’s everyday life. Passivity etary drugs protected by a patent. Particular regions of DNA are examined
may be a feature of disorders such as for structures called genetic markers. If
depression or dependent personality disor- patent ductus arteriosus certain markers are present in the child’s
der. The term has a specific meaning A defect of the heart in which the duc- blood but not in the mother’s blood, it
when used in reference to schizophrenia: tus arteriosus (a channel between the follows that they must be determined by
it describes a patient’s belief that his or pulmonary artery and the aorta in the genes inherited from the child’s biologi-
her thoughts, feelings, or actions are fetus) fails to close at birth. cal father. If the man being tested shows
controlled by others. CAUSE the markers in his blood, there is a high P
In the fetus, blood that is pumped by the probability that he is the biological
pasteurization right side of the heart flows through the father; if he does not, he can be exclud-
The process of heating foods to destroy ductus arteriosus and bypasses the lungs ed from the paternity of the child. No
disease-causing microorganisms, and to (see fetal circulation). Normally, the duc- form of paternity testing is 100 per cent
reduce numbers of microorganisms that tus arteriosus closes at or shortly after accurate in confirming or excluding
cause fermentation and putrefaction. birth, and blood passes from the right someone as the father of a child.
ventricle (lower chamber) of the heart to
Patau’s syndrome the lungs. In some babies this closure patho-
A chromosomal abnormality in which may fail to happen, producing a patent A prefix denoting a relationship to
there are three copies of chromosome ductus arteriosus. In this condition, disease.
13 rather than the normal two. Patau’s some of the blood that is pumped by the
syndrome is a congenital condition (one left side of the heart, and which should pathogen
that is present from birth). It causes go to the rest of the body, is directed via Any agent, but particularly a micro-
low birth weight and a range of defor- the ductus to the lungs. As a result, the organism, that causes disease.
mities including cleft palate or hare lip; heart has to work harder than normal to
eye deformities; micrognathia (under- pump sufficient blood to the body. pathogenesis
sized jaw); low-set ears; extra digits (see SYMPTOMS The processes by which a disorder orig-
polydactyly); and malformation of the Patent ductus arteriosus usually causes inates and develops.
genitalia. There may also be serious no symptoms, unless a large amount of
deformities of the internal organs, such blood is misdirected, in which case the pathognomonic
as heart defects, meningomyelocele (see baby fails to gain weight, becomes short A medical term applied to a sign or symp-
neural tube defects), and exomphalos (in of breath on exertion, and may have fre- tom that is characteristic of a disease or
which part or all of the intestines pro- quent chest infections. Eventually, heart disorder and is therefore sufficient by
trude through the navel). failure may develop. itself to make a diagnosis.

591
 PATHOLOGICAL

inations of dead people) to determine

PATERNITY TESTING USING DNA ANALYSIS causes of death and to determine the
effects that a disease or a treatment has
DNA analysis (commonly referred to as genetic fingerprinting) is replacing older
techniques of paternity testing because it gives a decisive result in more cases.
had on the body.
Blood samples are taken from the mother, child, and possible father, and some
DNA (hereditary material) from each is specially processed.
pathology, cellular
Also called cytopathology, the branch
PATERNITY ESTABLISHED of cytology concerned with the effects of
M C F M C F M C F disease on cells.
pathology, chemical
Another name for clinical biochemistry,
which is the study of abnormalities that
occur in the chemistry of diseased body
tissues and fluids.
pathophysiology
The study of the effects of disease on
body functions.
Each person’s DNA has a A child’s DNA bands The other bands are
1“fingerprint”,
unique banding pattern, or 2 come from the biological 3 compared with the
-pathy
detectable by parents. First the bands from suspected father’s bands. Here A suffix that is used to denote a disease
X-rays after the processing. the mother are identified. they match, proving paternity. or disorder.

PATERNITY DISPROVED Paul–Bunnell test

M C F M C F M C F A type of blood test, also called the het-
erophil agglutination test, that is used to
detect infection with the Epstein–Barr
virus, which causes glandular fever (see
mononucleosis, infectious). The Paul–Bun-
nell test involves detecting particular
antibodies (proteins produced by the
immune system to combat the virus) in
a sample of blood.
PCR
The abbreviation for polymerase chain
P The mother’s, the child’s, Half the child’s DNA bands The other bands are not reaction.
1 and the suspected father’s 2 can be seen to have come 3 shared by the suspected
DNA have different banding from the mother, as in the father, meaning he is not the peak-flow meter
patterns, shown above. example above. biological father.
A piece of equipment that measures the
maximum speed at which air can flow
Key M = Mother C = Child F = Father out of the lungs. A peak-flow meter is
useful in assessing the severity of bron-
chospasm (constriction of the airways in
pathological pathology the lungs), because narrowed airways
Relating to disease or to its study (see The study of disease, and specifically slow the rate at which air can be
pathology). its causes, mechanisms, and effects on expelled from the lungs. A peak-flow
the body. The study of disease-induced meter is most commonly used to diag-
pathological diagnosis changes in cells is called cytopathology; nose asthma. In people who already
A method of diagnosis in which the study of such changes in body tis- have the disorder, it is used to monitor
diseases are identified through exami- sues is called histopathology. A doctor their condition and assess how they
nation of cells (see cytopathology), who specializes in these subjects is respond to treatment.
tissues (see histopathology), or body called a pathologist. The peak flow is measured by taking
fluids. A clinical diagnosis, based on a Pathologists carry out laboratory in a deep breath and breathing out with
patient’s symptoms and a physical studies of cells and tissues that help the maximum force possible through
examination, is also undertaken. other doctors to reach accurate diag- the mouthpiece. The meter has a point-
noses, and they also supervise other er and a scale on the side; the expelled
pathological fracture laboratory personnel in the testing and breath moves the pointer to give a read-
Fractureof a bone weakened by disease, microscopic examination of blood and ing on the scale – the higher the
such as by certain forms of cancer, other body fluids. In addition, patholo- reading, the greater the speed at which
osteoporosis, and Paget’s disease. gists conduct autopsies (physical exam- the air is travelling.

592
 PELVIC INFLAMMATORY DISEASE

peau d’orange CAUSES AND INCIDENCE pelvic floor muscles and ligaments is
A condition in which the skin is a nor- Pellagra occurs primarily in poor rural common following childbirth, and is a
mal colour but looks like orange peel. communities in parts of the world, such part of the aging process.
The skin’s dimpled appearance is due to as areas of India, where people subsist WHY THEY ARE DONE
fluid retention in the nearby lymph ves- on maize. The body is unable to absorb Performing pelvic floor exercises, espe-
sels. Peau d’orange is not necessarily a most of the niacin in maize unless the cially during pregnancy and after
sign of disease, although it is, for exam- maize is first treated with an alkali such childbirth, may help to prevent prolapse
ple, one of the features of breast cancer. as limewater. Maize is also low in tryp- of the uterus (see uterus, prolapse of) and
tophan, an amino acid that is converted urinary stress incontinence (see inconti-
pectin into niacin in the body. nence, urinary).The exercises may also be
A form of polysaccharide found in Disorders such as carcinoid syndrome of help to women who find achieving
apples and in the rinds of citrus fruits. (which increases the breakdown of orgasm difficult.
Preparations containing pectins may be tryptophan) and Crohn’s disease (which HOW THEY ARE DONE
used to relieve diarrhoea. impairs absorption of tryptophan from The pelvic floor muscles are those that
the small intestine) may cause pellagra. tighten if urine flow is stopped in mid-
pectoral SYMPTOMS stream. The exercises involve contract-
A medical term that means “relating to The first symptoms are weakness, weight ing and relaxing the muscles several
the chest”, as in the pectoral muscles on loss, lethargy, depression, irritability, and times. They can be carried out while
either side of the chest. The pectoralis inflammation and itching of skin that is standing, sitting, or lying down, by
major is a large muscle covering much exposed to sunlight. In acute attacks, imagining that urine is being passed,
of the upper front of the chest. The weeping blisters may develop on the contracting and holding the muscles for
smaller pectoralis minor lies beneath it. affected skin, and the tongue becomes ten seconds, and then slowly releasing
bright red, swollen, and painful. them. This action should be repeated
DIAGNOSIS AND TREATMENT five to ten times, as often as possible;
PECTORAL MUSCLES Diagnosis is made from the patient’s ideally, the exercises should be perfor-
condition and dietary history. Daily med for five minutes in every hour
The major pectoral
draws the arm across
intake of niacin and a varied diet usu- throughout the day. Weighted pessaries
the body. The minor, ally bring about a cure. may also be used; these help the patient
which lies beneath it, to perform the exercise correctly.
moves the shoulder pelvic abscess
and raises some ribs. An abscess (a collection of pus formed pelvic infection
after infection with microorganisms) An infection that affects the female
Sternum that develops in one of the structures reproductive system. Severe or recurrent
within the pelvis. Pelvic abscesses may pelvic infection is referred to as pelvic
Clavicle Humerus be due to peritonitis (inflammation of inflammatory disease (PID).
the membrane lining the abdominal
cavity) or to localized inflammation pelvic inflammatory disease
resulting from disorders such as pelvic Inflammation of the internal female P
inflammatory disease. reproductive organs. Pelvic inflammatory
disease (PID) is usually due to an infec-
pelvic examination tion. It is most common in young,
Examination of a woman’s external and sexually active women. PID is a com-
internal genitalia. After examination of mon cause of lower abdominal pain in
the external genitalia, a speculum is in- women. In some cases, however, there
serted into the vagina to allow a clear are no obvious symptoms, and affected
view of the cervix. A cervical smear test women may be unaware that they have
Pectoralis major Pectoralis minor
may be performed. The doctor also car- had the condition until they undergo an
ries out a bimanual examination: he or examination to assess their fertility.
she inserts two fingers into the vagina, CAUSES
pediculosis feeling the abdomen with the other Pelvic inflammatory disease may not
Any type of louse infestation (see lice; hand to evaluate the position and size of have any obvious cause, but it usually
pubic lice). the uterus and the ovaries and to detect occurs as a result of a sexually transmit-
any tenderness or swelling (see Procedure ted infection, such as a chlamydial
peer review for a pelvic examination box, overleaf). infection. It may also occur after a miscar-
Processes by which doctors and scien- riage, abortion (see abortion, induced), or
tists review the work of colleagues in pelvic floor exercises childbirth. Use of an IUD increases the
the same field, to maintain standards. A programme of exercises to strengthen risk of infection, particularly soon after
the muscles and tighten the ligaments insertion of the device.
pellagra at the base of the abdomen. These tis- SYMPTOMS AND COMPLICATIONS
A potentially fatal disorder due to niacin sues make up the pelvic floor, which Common symptoms of PID include pain
deficiency (see vitamin B complex) result- supports the uterus, vagina, bladder, and tenderness in the lower abdomen,
ing in dermatitis, diarrhoea, and dementia. urethra, and rectum. Slackening of the fever, and irregular menstrual periods.

593
 PELVIC PAIN

birth, to determine whether a woman is

PROCEDURE FOR PELVIC EXAMINATION likely to have difficulty in delivering a
baby vaginally.The procedure may also be
The examination is usually
performed with the woman lying
performed after a vaginal delivery has
on her back with her knees bent. been unsuccessful and a caesarean section
If the examination is carried out has been carried out, to assist in planning
because of uterine prolapse or a future pregnancy and delivery.
incontinence, the woman may Medical staff can obtain a rough indica-
be asked to lie on her side. tion of the size of the pelvic outlet by
The doctor usually begins by manually checking the distance between
inspecting the external genitals the ischial tuberosities (the prominent
for ulceration or swelling and then bones in the lower pelvis) during a pelvic
does an internal examination. examination. More precise information
may be obtained by taking an X-ray of the
pelvis and then making measurements
from the resulting image. However, exces-
sive exposure to X-rays in pregnancy may
increase the risk of subsequent leukaemia
or other cancers in the unborn child, and
therefore this procedure is carried out
only in rare circumstances.
pelvis
The ring of bones in the lower trunk
that supports the trunk, protects the
lower abdominal organs, and forms part
of the hip joints. Attached to the pelvis
are the muscles of the abdominal wall,
the buttocks, the lower back, and the
insides and backs of the thighs.
Bladder STRUCTURE
Speculum
Uterus
The pelvis consists of two innominate
Spatula
bones (hip-bones). At the back, the hip-
Vagina Cervix Cervix Vagina bones are joined by rigid joints (the
sacroiliac joints) to the sacrum (the trian-
Use of speculum Manual examination
A speculum is inserted into the vagina to hold The doctor inserts two fingers into the vagina gular spinal bone below the lumbar
vertebrae). At the front, they curve for-
P the vaginal walls apart; this gives the doctor
a clear view of both the vagina and cervix. A
and palpates (feels) the abdomen with the other
hand to evaluate the size and position of the wards to join at a central point known
cervical smear test, in which cells are removed uterus and ovaries, and to detect any abnormal as the pubic symphysis.
with a spatula, may also be performed. pelvic swelling or tenderness.
Each innominate bone consists of
three fused bones: the ilium, ischium,
and pubis. The ilium, the largest and
There may also be a profuse vaginal dis- OUTLOOK uppermost of these bones, consists of a
charge consisting of blood and/or pus. If PID is detected and treated early, the wide, flattened plate with a long,
Pain often occurs after menstruation and patient should recover fully. Some curved ridge (the iliac crest) along its
may be worse during sexual intercourse affected women, however, have repeated upper border. The ischium is the bone
(see intercourse, painful). There may also attacks with or without reinfection. A that bears much of the body weight
be malaise, vomiting, or backache. PID pelvic abscess may develop as a compli- when sitting. The pubis is the smallest
may be acute or chronic. cation of the condition. PID may cause of the pelvic bones; from the ischium it
DIAGNOSIS AND TREATMENT infertility or increase the risk of ectopic extends forwards and round to the
A diagnosis is usually made by an pregnancy; this is primarily due to scar- pubic symphysis, where it is joined to
internal pelvic examination and exami- ring of the fallopian tubes, which the other pubis bone by tough fibrous
nation of swabs from the vagina or prevents eggs from travelling down the tissue. All three bones meet in the
cervix to look for infectious organisms. tubes to the uterus. acetabulum, the cup-shaped cavity that
Laparoscopy (examination of the abdo- forms the socket of the hip joint.
minal cavity using a viewing instru- pelvic pain In women, the pelvis is generally
ment) can confirm the diagnosis. See abdominal pain. shallow and broad, and the pubic
Antibiotic drugs are prescribed to clear symphysis joint is less rigid than a
the infection, and sometimes analgesic pelvimetry man’s. These differences facilitate child-
drugs (painkillers) may be given. If an Assessment of the shape and dimensions birth. In men, the greater body weight
IUD is the suspected cause of PID, the of a woman’s pelvis. Pelvimetry may be needs a larger and more heavily built
device may need to be removed. carried out a couple of weeks before child- pelvis for support.

594
 PENICILLIN DRUGS

STRUCTURE OF THE PELVIS

A basin-shaped bony Male pelvis Sacroiliac joint

structure at the base
of the trunk, the
pelvis consists of the Iliac crest
sacrum and coccyx at Ilium
the back and, on
either side, the hips Sacrum
(each comprising Coccyx
three fused bones: Ileofemoral
the ilium, ischium, ligament
and pubis), which Pemphigus
Pubis The fragile blisters, as seen in this photograph,
curve round to meet
break down, leaving numerous large, raw areas of
at the front. The pelvis Ischium skin that are typical of this condition.
supports the upper Femur Pubic symphysis
half of the body and penciclovir
protects the lower Female pelvis
abdominal organs. An antiviral drug. Penciclovir is com-
The female pelvis is monly used in the form of a cream to
shallower and wider. treat cold sores (see herpes simplex).
Wider, penicillamine
rounder
pelvic inlet An antirheumatic drug sometimes used to
treat rheumatoid arthritis. Penicillamine is
also used to treat copper or lead poison-
ing; it is a chelating agent, which binds
to these metals to form a less harmful
compound that can be safely excreted.
In addition, it is used to treat Wilson’s
disease (a rare brain and liver disorder
DISORDERS pemphigoid caused by a buildup of copper in the tis-
Fractures of the pelvis may be caused An uncommon, chronic skin disease, sues), and primary biliary cirrhosis (a
by a direct blow, or by a force transmit- mainly affecting elderly people, in which liver disorder).
ted through the femur (thigh-bone). large, sometimes itchy, blisters form on The possible adverse effects of peni-
Considerable force is required to cause the skin. Pemphigoid is thought to be an cillamine can include allergic rashes,
such a fracture, and it is usually the autoimmune disorder (one in which the itching, nausea, vomiting, abdominal
result of a road traffic accident; motor- body reacts against its own tissues). pain, loss of taste, blood disorders, and
cycle riders are particularly at risk. The Diagnosis is made with a skin biopsy. impaired kidney function. P
fracture itself often heals without any Treatment of the disease is usually with
problems, but it is frequently accompa- a long-term course of corticosteroid or penicillin drugs
nied by damage to internal organs immunosuppressant drugs. COMMON DRUGS
within the pelvis, and especially to the • Amoxicillin • Ampicillin • Benzylpenicillin
bladder; such damage may require pemphigus • Co-amoxiclav • Co-fluampicil • Flucloxacillin
immediate surgical treatment. A rare, serious skin disease in which • Phenoxymethylpenicillin
Osteitis pubis (inflammation of the numerous blisters develop on the skin
pubic symphysis) is usually caused by and in the mouth. Pemphigus primarily A group of antibiotic drugs. Natural peni-
repeated stress on the pelvis. It occurs in affects people aged between 40 and 60. cillins are derived from the mould
soccer players due to continually kick- The blisters usually develop in the PENICILLIUM; others are synthetic prepara-
ing a ball. The symptoms include pain mouth, then appear on the skin. They tions. Penicillins are used to treat many
in the groin and tenderness over the rupture to form raw areas that may infective conditions, including tonsillitis,
front of the pelvis. In most cases, the become infected and later crust over. bronchitis, bacterial endocarditis, syphilis,
condition clears up with rest. Skin that appears unaffected may also and pneumonia. They are also given to
blister after gentle pressure is applied. If prevent rheumatic fever from recurring.
pelviureteric junction a large area of the body is affected by Penicillins destroy bacteria by preventing
The point at which the renal pelvis (the the disease, there may be severe skin them from forming normal cell walls.
main collecting duct of the kidney) nar- loss, which can lead to bacterial infec- POSSIBLE ADVERSE EFFECTS
rows to become the ureter (the tube that tion and, sometimes, death. Diarrhoea is a common adverse effect of
carries urine from the kidney to the The diagnosis is confirmed by a skin penicillin drugs. Penicillins may also pro-
bladder). Obstruction to the flow of biopsy. Treatment of pemphigus is with voke an allergic reaction (see allergy) in
urine may occur at the pelviureteric a long-term course of corticosteroid drugs susceptible individuals. Allergic symp-
junction, and this can result in damage and, in some cases, with immunosuppres- toms appear immediately after the drug is
to the kidneys. sants. Antibiotics may also be prescribed. taken and include urticaria (nettle rash),

595
 PENILE IMPLANT

wheezing, and angioedema (swelling of form the glans. Around the erectile tis- cauliflowerlike mass. The growth usual-
body tissues, occurring especially around sue is a sheath consisting of fibrous ly spreads slowly, but in some cases it
the mouth and eyes). In rare cases, peni- connective tissue that is enclosed by can spread to the lymph nodes in the
cillins may cause the life-threatening skin. Over the glans, the skin forms a groin within a few months.
allergic reaction anaphylactic shock. Reac- fold called the foreskin. Diagnosis is made by a biopsy (tissue
tion to a penicillin drug requires im- Through the centre of the corpus sample). If the tumour is detected early,
mediate discontinuation of the drug; spongiosum runs the urethra, which is a surgical removal is usually successful.
urgent medical advice should be sought. narrow tube that carries urine and Otherwise, removal of part or all of the
semen out of the body through an penis may be necessary. Radiotherapy and
penile implant opening at the tip of the glans. chemotherapy may also be used.
A prosthesis inserted into the penis to The principal functions of the penis
help a man suffering from permanent are the excretion of urine and the dis- pentamidine
impotence to achieve sexual intercourse. charge of semen during sexual inter- An antiprotozoal drug (see protozoa)
The various types include a silicone course (see erection; ejaculation). administered by intravenous infusion or
splint inserted in the tissues of the DISORDERS nebulizer to prevent and treat pneumo-
upper surface of the penis, and an One common problem is impotence cystis pneumonia in immunosuppressed
inflatable prosthesis that is inflated by (failure to attain or maintain an erec- people. Pentamidine is also used to treat
squeezing a small bulb in the scrotum. tion). This condition affects most men the tropical disease leishmaniasis. Side
at some point in their lives, and is usu- effects of the drug may include nausea
penile warts ally psychological in origin. However, and vomiting, dizziness, flushing, rash,
See warts, genital. persistent impotence may be caused by and taste disturbances.
nerve damage associated with diabetes
penis mellitus, alcohol dependence, atheroscle- pentazocine
The male sex organ, through which rosis, or spinal cord injury. An opioid analgesic drug used to relieve
urine and semen pass. Balanitis (inflammation of the glans moderate or severe pain caused by injury,
STRUCTURE AND FUNCTION and foreskin) is usually caused by candidi- surgery, cancer, or childbirth. It is rarely
The penis consists of three cylindrical asis, although other organisms, including used because of its adverse affects, which
bodies of erectile tissue (spongy tissue those that cause gonorrhoea and syphilis, include dizziness, drowsiness, nausea,
full of blood vessels) that run along its may cause inflammation. Balanitis may vomiting, and, rarely, hallucinations. Drug
length. Two of these bodies, the corpora lead to phimosis, in which the foreskin is dependence may develop if high doses are
cavernosa, lie side by side along the abnormally tight, or paraphimosis, in taken for prolonged periods.
upper part of the penis. The third body, which the foreskin retracts at erection but
the corpus spongiosum, lies centrally is too tight to move back over the glans. peppermint oil
beneath them and expands at the end to Penile warts (see warts, genital) are An oil obtained from the peppermint
caused by a sexually transmitted virus. plant MENTHA PIPERITA. It is prescribed to
Cancer of the penis (see penis, cancer relieve abdominal colic but may cause
ANATOMY OF THE PENIS of) is a rare disorder; the incidence is heartburn. Peppermint oil is also used as
P The corpora cavernosa and the
higher in men who have not been cir- a flavouring in some drug preparations.
spongiosum are the erectile tissues
cumcised than in those who have.
The most common congenital abnor- peptic ulcer
of the penis. A network of nerves
controls the blood flow into them. mality of the penis is hypospadias, a A raw area that develops in the gastro-
condition in which the opening to the intestinal tract due to erosion by acidic
urethra is located on the underside of gastric juice. A peptic ulcer most com-
Penis the penis. In male pseudohermaphro- monly occurs in the stomach, where it is
ditism, which is also congenital, the called a gastric ulcer, or the duodenum
Urethra
penis is very small and there is usually (the first part of the small intestine),
also hypospadias. where it is known as a duodenal ulcer.
Foreskin
Other disorders of the penis include CAUSES
priapism, in which an erection is pain- The lining of the stomach and duo-
Glans ful and abnormally prolonged, and a denum is usually protected from the
condition called Peyronie’s disease, in acid gastric juice by a layer of mucus. If
Scrotum which the erect penis bends. this layer is damaged, the acid can come
into contact with the tissues, causing
penis, cancer of inflammation and erosion. Ulcers can
Cross-section of penis A rare type of cancerous tumour that is also form in the oesophagus, when
Corpora more common in uncircumcised men acidic juice from the stomach enters it
cavernosa with poor personal hygiene. Viral infec- (see acid reflux).
Corpus tion and smoking have both been The major cause of peptic ulcers is
spongiosum shown to be additional risk factors. The infection with HELICOBACTER PYLORI bacteria,
Urethra tumour usually starts on the glans or on which can damage the lining of the stom-
the foreskin as a painless, wartlike lump ach and duodenum, allowing the acid
or a painful ulcer, and develops into a stomach contents to attack it. The long-

596
 PEPTIC ULCER

term use of nonsteroidal anti-inflammatory SYMPTOMS COMPLICATIONS

drugs (NSAIDs), smoking, alcohol con- There may be no symptoms, or there The most common complication of a
sumption, and excess acid production can may be burning or gnawing pain in the peptic ulcer is bleeding as the ulcer
also damage the stomach lining. A stress upper abdomen when the stomach is penetrates deeper and damages blood
ulcer is a peptic ulcer caused by severe empty. The pain of a duodenal ulcer is vessels. If severe, bleeding may result in
physiological stress, such as that due to often relieved by eating, but usually haematemesis (vomiting of blood) and
neurosurgery or to burns (for example, recurs a few hours later. The pain of a melaena (black faeces) and is a medical
a Curling’s ulcer). Psychological stress is gastric ulcer may be worsened by food. emergency. Chronic bleeding may cause
thought to aggravate an existing ulcer. Other possible symptoms of a peptic iron-deficiency anaemia. Rarely, an ulcer
For further information on how an ulcer include a loss of appetite, a bloat- may perforate the wall of the digestive
ulcer forms and the sites where ulcers ed or full feeling in the abdomen, tract and lead to peritonitis (inflamma-
may develop, see the illustrated box. nausea, and, sometimes, vomiting. tion of the abdominal cavity’s lining).

SITES AND CAUSES OF PEPTIC ULCER

A peptic ulcer develops in about one in eight people the stomach and duodenum. A sample of the stomach
in the UK at some time in their lives. Some of the lining may be taken at the same time to look for
mechanisms that are involved in causing ulcers are evidence of HELICOBACTER PYLORI infection, the major
shown below. A peptic ulcer is investigated using cause of peptic ulcers; blood tests (to check for
endoscopy, which involves passing a gastroscope antibodies against HELICOBACTER PYLORI) and breath tests
(a type of endoscope) through the mouth to view are also used to confirm its presence.
Stomach

Duodenum

Gastric ulcer Duodenal ulcer Site of ulcers

This photograph of an ulcer in the wall of the
stomach was taken using a gastroscope passed
In this gastroscopic view of the top of the
duodenum, an ulcer is clearly visible as a
Peptic ulcers are most common in the first part
of the duodenum or lower half of the stomach; P
through the mouth into the stomach. smooth white area. oesophageal ulcers also occur.

HOW AN ULCER IS FORMED

Acid and pepsin Mucus Stomach lining irritated by bacteria (mostly Protective wall of epithelial
HELICOBACTER PYLORI), NSAIDs (e.g. aspirin), cells broken by acid
bile, alcohol, and caffeine

Reduced mucus
production
Gastric Epithelial Increased Ulcer
gland cells acid secretion
Gastric glands in the lining of the Most peptic ulcers are due to bacterial infection If damaging influences overcome the
1pepsin,
stomach secrete acid and the enzyme
which help to break down food.
2mucous
of the stomach lining, which damages its
layer (making it vulnerable to acid) and
3 protective factors in the stomach or
duodenal lining, the mucous layer and
The acid and pepsin would quickly eat the cells that control excess acid production. mucus-secreting cells are eroded and an
away the stomach and duodenum if other Ulcers can also be caused by NSAIDs or excess ulcer forms. Stress is probably not a prime
cells in the lining did not secrete a alcohol combined with excess production of acid. cause of ulcers but it is possible it may
protective mucus. Smoking is another important irritant factor. aggravate an existing ulcer.

597
 PEPTIDE

Another rare complication is scarring of percutaneous DIAGNOSIS AND TREATMENT

the tissues that occurs as a result of A term meaning “through the skin”. Diagnosis is made from a physical exam-
chronic ulcers. Scar tissue around the ination, from an ECG (which records the
pyloric sphincter (the outlet where the perforation electrical activity in the heart) and chest
stomach opens into the duodenum) A hole made in an organ or tissue by X-rays or echocardiography, which will
may cause narrowing of the outlet. This disease or injury. show any excess fluid around the heart.
condition, which is called pyloric sten- If possible, treatment is aimed at the
osis, may obstruct the passage of food pergolide cause. Analgesic drugs (painkillers) or
from the stomach to the duodenum, A drug used to treat parkinsonism, a type anti-inflammatory drugs may be given.
resulting in vomiting and weight loss. of neurological disorder resulting from If there is an effusion, the excess fluid
DIAGNOSIS AND TREATMENT a lack of dopamine. It acts by stimulating may be drawn off through a needle.
An ulcer is usually diagnosed by endos- the receptors for dopamine in the brain. In severe constrictive pericarditis, the
copy of the stomach and duodenum, or, thickened part of the pericardium may
less commonly, a barium meal (see bar- peri- be surgically removed so that the heart
ium X-ray examination). Tests are carried A prefix meaning “around”, as in peri- can pump freely.
out to see whether the individual is cardium, the membranous sac that
infected with the HELICOBACTER bacteri- surrounds the heart. pericardium
um. If so, a combination of antibiotics The membranous bag that surrounds
and an ulcer-healing drug will be given as perianal haematoma the heart and the roots of the major
treatment. A further test may be carried A haematoma (collection of blood) under blood vessels that emerge from it.
out to check that the treatment has been the skin around the anus. A perianal The pericardium is made up of two
successful. If HELICOBACTER is not detect- haematoma is painful and of sudden layers. The outer layer is tough, inelas-
ed, however, (for example, in cases onset. It usually disappears with no tic, and fibrous. It is attached to the
where the ulcer was due to the use of treatment, but minor surgery may be diaphragm below and to the sternum
NSAIDs), the NSAIDs will be stopped required to drain the blood. (breastbone) in front. The inner layer is
and treatment with proton pump inhib- separated into two sheets; the inner-
itors or H2-blockers will be given. periapical abscess most one is firmly attached to the heart,
Surgery is now rarely needed for pep- See abscess, dental. and the outer one is attached to the
tic ulcers, except to treat complications fibrous layer. The smooth inner surfaces
such as bleeding or perforation. pericarditis of these sheets are separated by a space
Inflammation of the pericardium (the called the pericardial space, which con-
peptide double-layered membrane surrounding tains a small amount of fluid that
A protein fragment consisting of two the heart). This disorder often leads to lubricates the heart.
or more amino acids. Peptides that con- chest pain and fever. There may also be
sist of very many linked amino acids are an increased amount of fluid (see effu- perimenopause
called polypeptides; chains of polypep- sion) in the pericardial space, which The period immediately preceding the
tides are called proteins. In the body, separates the two smooth layers of the menopause (when the ovaries stop pro-
P peptides occur in forms such as hor- pericardium. The excess fluid may com- ducing eggs and menstruation ceases).
mones and endorphins. press the heart and restrict its action. During the perimenopause, levels of
Long-term inflammation can cause a oestrogen begin to fall. Fluctuations in
perception condition called constrictive pericardi- hormone levels cause menstrual periods
The interpretation of a sensation. Infor- tis, in which the pericardium becomes to become irregular and results in
mation is received through the five scarred, thickens, and contracts, and as a symptoms such as hot flushes.
senses (taste, smell, hearing, vision, and result impedes the heart’s action.
touch), then identified and organized CAUSES perimetry
into a pattern by the brain. Factors such Causes of pericarditis include infection; A visual field test to determine the
as attitude, mood, and expectations myocardial infarction (heart attack); can- extent of peripheral vision. (See eye,
affect the final interpretation; for exam- cer spreading from another site; and examination of).
ple, a person who is hungry is more injury to the pericardium. The disorder
likely to notice the sight and smell of may accompany the autoimmune con- perinatal
food than someone who has just eaten. ditions rheumatoid arthritis and systemic Relating to the period that extends from
Hallucinations are false perceptions lupus erythematosus, or kidney failure. just before the birth of a baby to just
that occur in the absence of any type SYMPTOMS after. The perinatal period is often
of sensory stimuli. Pain, behind the sternum (breastbone) defined as the period from the 24th
and sometimes in the neck and shoul- week of pregnancy to the end of the
percussion ders, may be more severe if the person first week after birth.
A diagnostic technique that involves tap- takes a deep breath, changes position,
ping the chest or abdomen with the or swallows. Pain may be relieved by perinatology
fingers and listening to the sound that is sitting up and leaning forward. There A branch of obstetrics and paediatrics
produced. From this sound, the doctor may also be fever. Constrictive peri- concerned with the study and care of
can deduce the condition of the internal carditis causes oedema (fluid swelling) the mother and baby during pregnancy
organs. (See also examination, physical.) of the legs and abdomen. and just after birth.

598
 PERIOSTITIS

Perinatologists are specialists in the In marginal periodontitis there are signs

management of high-risk pregnancies of gingivitis, such as red, soft, shiny,
and births, and in the investigation and tender gums that bleed easily. There is
treatment of prenatal conditions that also an unpleasant taste in the mouth
might endanger the life or health of the and bad breath. The deepening pockets
fetus, such as Rhesus incompatibility, in the gums gradually expose the sensi-
spina bifida, or biochemical disorders. tive dentine in the roots of the teeth,
These doctors are also skilled in assess- causing the teeth to ache when hot,
ing the function of the placenta and cold, or sweet foods or liquids are con-
maintaining the health of an expectant sumed. Occasionally, there is a discharge
Periodontal disease
mother who may herself be at risk of The gums are inflamed and have receded. Many
of pus from the gums, or a periodontal
health problems. of the teeth are eroded at the base; and the tooth abscess develops.
sockets may also be decayed. DIAGNOSIS AND TREATMENT
perindopril The diagnosis of periodontitis is by a
One of a class of drugs called ACE periodontics dental examination to find any pockets
inhibitors, which act by widening the The branch of dentistry concerned with and assess their size and depth, and
blood vessels and thereby ease the work- the structures that surround and sup- dental X-rays to check for bone loss.
load on the heart. Perindopril may be port the teeth, particularly the gums. Periapical periodontitis is treated by
used to relieve hypertension (high blood draining the pus and filling the tooth or
pressure) or congestive heart failure. periodontitis alternatively by root-canal treatment, in
The drug may have side effects relat- Inflammation of the periodontium (the which decayed pulp is removed from a
ed to widening of the blood vessels, tissues surrounding the teeth). There are tooth and its root and the cavity is then
such as hypotension (low blood pres- two types: periapical and marginal. filled. If the tooth cannot be saved, how-
sure), leading to dizziness or fainting; CAUSES ever, extraction is performed .
flushed skin; and headaches. Periapical periodontitis results from In the early stages of marginal peri-
neglected tooth decay (see caries, dental). odontal disease, regular, scrupulous teeth
perineum If dental caries is left untreated, areas of cleaning can prevent further plaque and
The area that is bounded internally by enamel and the dentine (softer tissue) calculus formation and thus halt destruc-
the bony structures that surround the beneath them are eventually destroyed, tion of the tissues surrounding the teeth.
pelvic floor (the muscles that support allowing bacteria to enter the tooth For more severe periodontitis, the dentist
the pelvis). Internally, the perineum pulp. From there, the bacteria spread to will remove existing plaque and calculus
extends from the coccyx at the back to the root tip and into the surrounding by scaling and root planing (smoothing
the public symphysis at the front of the tissues, sometimes causing the forma- the surface of an exposed root). In some
body and incorporates the lower parts tion of an abscess (see abscess, dental), cases, gingivectomy (surgical trimming of
of the genitourinary and gastrointesti- granuloma, or cyst. the gums) may be performed to reduce
nal tracts. Outside the body, the peri- Marginal periodontitis is the major the size of gum pockets. Surgery may also
neum is the area that extends from the cause of tooth loss in adults. It is a result be carried out in order to remove the dis-
genitals to the anus. of untreated gingivitis (gum disease), eased lining from the pocket (see P
which in turn is usually due to poor oral curettage, dental), so that healthy underly-
periodic fever hygiene. In this condition, neglected, ing tissue will reattach itself to the tooth;
An inherited condition that causes inflamed gum tissue at the base of the and the damaged, irregular bone is
recurrent bouts of fever (see familial teeth becomes damaged, and pockets smoothed. Loose teeth can sometimes be
Mediterranean fever). form between the gums and the teeth. A anchored to firmer ones by a method
sticky deposit of mucus, food particles, called splinting (see splinting, dental).
periodic paralysis and bacteria (see plaque, dental) and a
See paralysis, periodic. hard, mineralized coating formed from period pain
plaque and saliva (see calculus, dental) See dysmenorrhoea.
period, menstrual then collect in these pockets. The bacteria
See menstruation. in the plaque and calculus attack the peri- periosteum
odontal tissues, causing them to become The layer of connective tissue that coats
periodontal abscess inflamed and then detached from the all of the bones in the body except the
See abscess, dental. teeth. The bacteria also eventually erode joint surfaces. The periosteum contains
the bones surrounding the teeth. As a small blood vessels and nerves. It pro-
periodontal disease result, the teeth become loose in their duces new bone in the initial stages of
Any disorder of the periodontium (the sockets and fall out. healing following a fracture.
tissues that surround and support the SYMPTOMS
teeth). The most common type of peri- Periapical periodontitis may cause local- periostitis
odontal disease is gingivitis (gum inflam- ized toothache, especially on biting. An Inflammation of the periosteum (connec-
mation). Gingivitis can lead to marginal abscess may damage bone and peri- tive tissue covering bone). The usual
periodontitis, which often causes the odontal ligaments, causing the tooth to cause is a blow that presses directly on to
development of a periodontal abscess become loose; a large dental cyst may bone. Symptoms include pain, tender-
(see abscess, dental). cause swelling of the jaw. ness, and swelling over the affected area.

599
 PERIPHERAL NERVES

peripheral nerves Diseases of the peripheral arteries that pain. The affected limb becomes cold
Nerves that run between the central ner- are not caused by atherosclerosis include and pale or blue, with no pulse. Move-
vous system (CNS, the brain and spinal Buerger’s disease and Raynaud’s disease. ment and feeling in the limb are lost.
cord) and particular body tissues. Of SYMPTOMS AND COMPLICATIONS DIAGNOSIS AND TREATMENT
these, 12 pairs are cranial nerves and 31 The first symptom of narrowed arteries A diagnosis is often based on the res-
pairs are spinal nerves. Some peripheral due to atherosclerosis is usually an ults of Doppler ultrasonography, which
nerves are sensory, carrying messages aching feeling in the leg muscles (usu- shows the flow of blood through the
from sensory organs and nerve endings ally in the calf) when walking. The pain affected vessels, or angiography, which
(see receptor) towards the brain and may be relieved by resting for a few will reveal signs of narrowing or other
spinal cord; others are motor nerves, minutes, but recurs after the same structural abnormalities.
carrying signals away from the CNS to amount of walking as before. Prolonged Exercise and giving up smoking are
stimulate responses in the tissues. use of the arms may also cause pain. important aspects of treatment. For
Symptoms then become worse until, peripheral vascular disease of the legs,
peripheral nervous system eventually, pain is present even when the affected person needs to take scrupu-
The system of peripheral nerves, which the person is at rest. The pain may be lous care of the feet in order to prevent
fan out from the central nervous system severe and continuous, even disrupting infection and minimize the risk of gan-
(the brain and spinal cord) to the mus- sleep. By this stage, the blood supply to grene. Arterial reconstructive surgery, by-
cles, skin, internal organs, and glands. the affected leg is dangerously low. The pass surgery, or balloon angioplasty may
affected limb is cold and numb, with be needed to widen or bypass the affect-
peripheral vascular disease dry, scaly skin, and leg ulcers may devel- ed blood vessels. Amputation is necessary
Narrowing of arteries in the legs, and op after even minor injuries. In the final if gangrene has developed.
sometimes in the arms, which restricts stage, gangrene (tissue death) develops,
blood flow and causes pain. In severe initially appearing in the toes and then peristalsis
cases, gangrene (death of tissues sup- spreading up the leg. Wavelike movement caused by the
plied by the vessels) may develop. Sudden arterial blockage sometimes rhythmic contraction and relaxation of
CAUSES occurs, causing acute ischaemia (insuffi- the smooth muscles in the walls of the
In most affected people, peripheral vas- cient blood supply to an organ or tissue). digestive tract and the ureters. Peristalsis
cular disease is caused by atherosclerosis, This arterial blockage may be due to the is responsible for the movement of food
in which fatty deposits form on the inner rapid development of a clot on top of a and waste products through the diges-
walls of arteries. The greatest risk factor plaque of atherosclerosis, by a dissecting tive system and for transporting urine
for developing atherosclerosis is smoking. aneurysm (splitting of an arterial wall), from the kidneys to the bladder.
Other risk factors include hypertension or by an embolism arising from a clot In the digestive system, peristalsis in
(high blood pressure), a high-fat diet, formed in the heart and carried to a the oesophagus (gullet) moves food
and poorly controlled diabetes mellitus. peripheral artery. It causes sudden, severe towards the stomach, even if the body is

PERIPHERAL PERISTALSIS
P VASCULAR DISEASE
The walls of many body passages Oesophagus
The disease usually starts with the contain a special type of muscle
formation of atheroma (fatty plaques) called smooth muscle. The muscle
in the lining of artery walls. Smokers fibres contract in sequence, sending Stomach
are among those at highest risk. waves of contraction along the walls
of the passage.

Normal artery Relaxed muscle

Direction of
blood flow

Duodenum

Possible
site of
clot
Small
intestine
Food Muscle
bolus contraction
Atheroma
Effect of peristalsis Large
As each group of muscle fibres in the wall of intestine
Clot formation the intestinel contracts, it narrows that part Sites of peristaltic action
Clots may form on top of the atheroma of the passage, squeezing the food bolus Peristalsis occurs most obviously in the
(plaques), restricting blood flow to tissues, into an adjoining section where the muscle digestive tract, shown above, but it also moves
which may lead to pain and tissue death. fibres are relaxed. urine through the ureters.

600
 PERSISTENT VEGETATIVE STATE

turned upside down. In the stomach, SYMPTOMS pernio

similar muscle movements help to mix There is usually severe abdominal pain An alternative term for chilblain.
food with gastric juices and move the over part or all of the abdomen. After
partly digested food into the duodenum a few hours, the abdomen feels hard, peroneal muscular atrophy
(the first part of the small intestine). and peristalsis (wavelike contractions of A rare, inherited disorder characterized
The muscles of the small intestine move the intestinal muscles) stops (see ileus, by muscle wasting in the feet and calves
in a slow, back-and-forth churning paralytic). Other symptoms are fever, and then in the hands and forearms.
motion that allows more time for the bloating, nausea, and vomiting. Dehydra- The condition, which is also known as
intestine to absorb nutrients. In the tion and shock may occur. Charcot–Marie–Tooth disease, is caused
large intestine, peristaltic contractions DIAGNOSIS AND TREATMENT by degeneration of some peripheral
occur only about once every 30 min- Diagnosis is made from a physical exami- nerves. It usually appears in late child-
utes. Two or three times a day, however, nation. The affected person will need to hood or adolescence.
usually following a meal, a strong, sus- be admitted to hospital without delay. Muscle wasting stops halfway up the
tained wave of peristalsis in the colon Surgery may be necessary to deal with arms and legs, making them look like
forces the contents into the rectum, and the cause. If the cause is unknown, a inverted bottles; sensation may be lost.
may prompt the urge to defaecate. (See laparoscopy or an exploratory laparotomy There is no treatment for the disorder,
also the illustrated box.) may be performed. Antibiotic drugs are but it is rare for the sufferer to become
often given to destroy bacteria, and intra- totally incapacitated because the disease
peritoneal dialysis venous infusions of fluid may be given to usually progresses at a very slow rate.
See dialysis. treat dehydration. Life expectancy is normal.
OUTLOOK
peritoneum In most cases, a full recovery is made. perphenazine
The two-layered membrane that forms a Rarely, however, intestinal obstruction, A phenothiazine-type antipsychotic drug
lining in the abdominal cavity and cov- caused by adhesions (bands of scar tis- that is used to relieve symptoms in psy-
ers and supports the abdominal organs. sue between loops of intestine), may chiatric disorders, such as schizophrenia;
The peritoneum contains blood vessels, occur at a later stage. to sedate agitated or anxious patients;
lymph vessels, and nerves. The surface and sometimes for the relief of severe
area of the peritoneum is equal to that peritonsillar abscess nausea and vomiting.
of the entire skin. An abscess (collection of pus) in the Possible adverse effects include ab-
The peritoneum produces a lubrica- soft tissue around the tonsils that occurs normal movements of the face and
ting fluid that allows the abdominal as a complication of tonsillitis. A peri- limbs, drowsiness, blurred vision, stuffy
organs to glide smoothly over each other. tonsillar abscess, also known as quinsy, nose, and headache. Long-term use of
It also protects the organs against infec- causes pain, swallowing difficulties, and the drug may cause the movement dis-
tion. In addition, the membrane absorbs jaw stiffness. The tonsils appear asym- order parkinsonism.
fluid and acts as a natural filtering sys- metrical. Antibiotic drugs and analgesic
tem; this function is utilized in one form drugs (painkillers) are usually given to Persantin
of dialysis. The peritoneum may become help relieve the symptoms, and, in some A brand name for dipyridamole, an anti-
inflamed as a complication of an ab- cases, a small surgical incision may be platelet drug. Persantin prevents abnormal P
dominal disorder (see peritonitis). made to drain the abscess. blood clotting by inhibiting the activity
of platelets (tiny blood cells that aid
peritonitis permanent teeth clotting). The drug is used to prevent
Inflammation of the peritoneum (the The second set of teeth, which usually recurrence of a stroke or transient isch-
membrane lining the abdominal wall start to replace the primary teeth at aemic attack or to prevent the dev-
and covering the abdominal organs). about the age of six. There are 32 per- elopment of blood clots in people with
Peritonitis is a serious condition. manent teeth: 16 in each jaw. Each set prosthetic heart valves.
CAUSES of 16 consists of four incisors, two
The inflammation is almost always due to canines, four premolars and six molars. persistent vegetative state
irritation and bacterial infection caused by (See also eruption of teeth.) A term used to describe a type of indef-
another abdominal disorder. The most inite, deep coma (unconsciousness and
common cause is perforation of the stom- permethrin unresponsiveness to stimuli). The con-
ach or intestine wall, which allows bac- A drug included in preparations used dition is caused by damage to areas of
teria and digestive juices to move into the to treat lice and scabies. the brain that control higher mental
abdominal cavity. Perforation is usually functions. Although the eyes may open
the result of a peptic ulcer, appendicitis pernicious anaemia and close and there may be random
(acute inflammation of the appendix), or A type of anaemia (reduced blood levels movements of the head and limbs, there
diverticulitis (inflammation of abnormal of the oxygen-carrying pigment haemo- is no response to stimuli such as pain.
pouches in the wall of the intestine). globin) caused by the stomach lining Only basic functions, such as breathing
Peritonitis may also be associated failing to produce intrinsic factor – and heartbeat, are maintained due to
with acute salpingitis (inflammation of necessary for vitamin B12 absorption. functioning of the brainstem.There is no
a fallopian tube), cholecystitis (inflam- Deficiency of vitamin B12 prevents bone treatment to reverse the situation; with
mation of the gallbladder), or septi- marrow from producing normal red good nursing care, survival for several
caemia (blood poisoning). blood cells (see anaemia, megaloblastic). years is possible.

601
 PERSONALITY

personality counselling, psychotherapy, and behaviour worse. Whooping occurs in most cases.
A term that is used to describe the sum therapy. The treatment may need to be Sometimes the cough can cause vomiting.
of a person’s traits, habits, and ex- prolonged, however, and affected peo- In infants, there is a risk of temporary
periences. Temperament, intelligence, ple may not always comply with apnoea (cessation of breathing) following
emotion, and motivation are important guidance from doctors or therapists. a coughing spasm. The illness may last
aspects. The development of personality anything from a few weeks up to three
seems to depend on the interaction of personality tests months, although the child is usually only
heredity and environment. Questionnaires designed to define vari- infectious for about three weeks.
ous personality traits or types. Tests may COMPLICATIONS
personality disorders be used to detect psychiatric symptoms, Coughing may cause nosebleeds and
A group of conditions characterized by various underlying traits, how outgoing bleeding from ruptured blood vessels
a failure to learn from experience or to or reserved a person is, and predisposi- on the surface of the eyes or petechiae
adapt appropriately to changes, resulting tion to developing neurotic illness. (red, flat, pinhead spots) on the face.
in distress, impaired social functioning, Other possible complications include
and, in some cases, occupational prob- perspiration dehydration from repeated vomiting;
lems. Personality disorders are patterns of The production and excretion of sweat pneumonia; pneumothorax (a form of col-
abnormal behaviour that may become from the sweat glands. Perspiration is lapsed lung); bronchiectasis (permanent
especially obvious during periods of another name for sweat. widening of the airways); and seizures.
stress. They are usually first recognizable Untreated, pertussis may prove fatal.
in adolescence and may continue Perthes’ disease DIAGNOSIS AND TREATMENT
throughout life, often leading to depres- Inflammation of an epiphysis (growing Pertussis is usually diagnosed from the
sion or anxiety. Personality disorders are area) of the head of the femur (thigh symptoms. In the early stages of the ill-
not the result of another psychiatric dis- bone). The disease is a type of osteo- ness, the antibiotic erythromycin is often
order or a result of substance abuse. chondritis juvenilis, thought to be due to given to reduce the child’s infectivity.
TYPES disrupted blood supply to the bone. Treatment consists of keeping the child
Specific types of personality disorders The condition is most common in warm, giving small, frequent meals and
are divided into three groups, but there boys aged between five and ten years, plenty to drink, and protecting him or her
is often overlap between them. and usually affects one hip. Symptoms from stimuli, such as smoke, that can pro-
The first group is characterized by include pain in the thigh and groin, and voke coughing. If the child becomes blue
eccentric behaviour. Paranoid people a limp on the affected side. Movement or persistently vomits after coughing, he
show suspicion and mistrust of others; of the hip is restricted and painful. or she must be admitted to hospital.
schizoid people are cold emotionally; Diagnosis is made with X-rays, which PREVENTION
and schizotypal personalities have behav- may show flattening, fragmentation, and In the UK, vaccination against pertussis
ioural oddities similar to, but less severe (in later stages) shrinking of the head of is usually given at two, three, and four
than, those of schizophrenia. the femur. Treatment of the disease may months of age, with a booster dose at
In the second group, behaviour tends be rest for a few weeks, followed by three to five years.
to be dramatic. Histrionic people are ex- splinting of the hip, or surgery to fit the Possible complications of vaccination
P citable and constantly crave stimulation. head of the femur more securely into include mild fever and fretfulness. Very
Narcissists have an exaggerated sense of the pelvis. The disease usually clears up rarely, an infant may react severely, with
self-importance (see narcissism). People by itself within three years, but the hip high-pitched screaming or seizures.
with antisocial personality disorder may be permanently deformed. Communities need to maintain a
(formerly called psychopaths) disregard high level of immunity, through immu-
accepted standards of behaviour and pertussis nization, to protect infants. It should be
show no concern for other people’s feel- A highly contagious infectious disease, remembered that the risks from the dis-
ings and rights. As a result, they often also called whooping cough. It mainly ease itself are far greater than any risk
come into contact with the police. Peo- affects infants and young children and is from the pertussis vaccine.
ple with borderline personality disorder most dangerous in newborn babies. The
behave very impulsively; their self-image, main features are bouts of coughing, perversion
relationships, and emotions are unstable. often followed by a “whoop” as air is See deviation, sexual.
People in the third group show anxi- drawn back into the lungs.
ety and fear. Dependent personalities CAUSE pes cavus
lack the self-confidence to function in an The main cause is infection with BORDE- See claw-foot.
independent way (see dependence). Peo- TELLA PERTUSSIS bacteria, which are spread
ple who have avoidant personalities are in airborne droplets. In affluent coun- pessary
hypersensitive to criticism and rejection tries such as the UK, however, the Any of a variety of devices placed in the
and cautious about new experiences. incidence of pertussis has been greatly vagina. Some types are used to correct the
Those with obsessive–compulsive per- reduced by immunization. position of the uterus (see uterus, prolapse
sonalities are very rigid in their habits SYMPTOMS of); others are used as contraceptive
(see obsessive–compulsive disorder). After an incubation period of seven to ten devices. The term “pessary” is also used
TREATMENT days, the illness starts with a mild cough, to refer to a dose of medication, in solid
Personality disorders are generally diffi- sneezing, nasal discharge, fever, and sore form, that is inserted into the vagina,
cult to treat. Treatment options include eyes. After a few days, the cough becomes where it dissolves to release the drug.

602
 PHAEOCHROMOCYTOMA

pesticides PET scanning portion of the small intestine). Peyer’s

Poisonous chemicals used to eradicate The abbreviation for positron emission patches form part of the lymphatic sys-
pests. Different types of pesticide include tomography. This imaging procedure is tem, which helps to fight infection.
herbicides, insecticides, and fungicides. a diagnostic technique that is based on
Pesticide poisoning, particularly in chil- the detection of positrons (a type of peyote
dren, may result from swallowing an subatomic particle) emitted by radioac- A cactus plant found in northern Mex-
insecticide or a garden herbicide (see tively labelled substances introduced ico and the southwest of the United
chlorate poisoning). Poisoning may also into the body. PET scanning produces States. Dried blossoms are used to pre-
occur in agricultural workers, often as a images of the metabolic and chemical pare the hallucinogenic drug mescaline.
result of inhalation or of absorption of activity of tissues.
the chemical through the skin. Exposure HOW IT WORKS Peyronie’s disease
to pesticides can also occur indirectly, Certain substances used in biochemical A disorder of the penis in which part of
through eating food in which chemicals processes in the body, such as glucose or the sheath of fibrous connective tissue
have accumulated as a result of crop oxygen, are labelled with radioisotopes thickens, causing the penis to bend dur-
spraying. (See also DDT; defoliant poisoning; and then injected into the bloodstream. ing erection. The problem commonly
lindane; paraquat; parathion.) They are taken up in greater concentra- makes intercourse difficult and painful.
tions by tissues that are more active or The thickened area can be felt as a firm
petechiae overactive metabolically. The substances nodule when the penis is flaccid. Even-
Red or purple, flat, pinhead-sized spots emit positrons, which release photons tually, some of the erectile tissue may
that occur in the skin or mucous mem- that are detected by the scanner. A com- also thicken. Men over 40 are most
branes. They do not blanch (go pale) puter then converts this information often affected. The cause is unknown.
when pressure is applied to them. into images, which are colour-coded to The disease may improve without treat-
Petechiae are caused by a localized show different levels of tissue activity. ment. Otherwise, surgical removal of the
haemorrhage (leakage of blood) from WHY IT IS DONE thickened area and replacement with nor-
small blood vessels.They occur in purpu- PET scans are used to detect brain mal tissue may be carried out.
ra (a group of bleeding disorders) and, tumours, locate epileptic activity within
sometimes, in bacterial endocarditis the brain, and examine brain function pH
(infection of the inner lining of the in Alzheimer’s disease and in mental ill- A measure of the acidity or alkalinity of
heart). Petechiae may also arise after nesses such as depression. a solution. The pH scale ranges from
periods of excessive straining; in con- 0–14, 7 being neutral; values smaller
ditions such as pertussis (whooping than this are acid, and values that are
cough), for example. larger are alkaline.
The pH of body fluids must be close
pethidine to 7.4 for metabolic reactions to pro-
A synthetic opioid analgesic drug similar ceed normally (see acid–base balance).
to, but less powerful than, morphine. If it falls lower than 7.35, the resulting
Pethidine is used as a premedication and acidity is called acidosis; if it rises above
to relieve severe pain after operations or 7.45, the result is alkalosis. P
during childbirth. The drug may cause
nausea and vomiting, so it is usually phacoemulsification
Normal brain Alzheimer’s disease
given with an antiemetic drug. Pethidine A surgical procedure used to treat
can be addictive, making it unsuitable PET scans of the brain cataract (an opacity in the lens of the
A scan of a normal brain (left) can be compared to
for treating continuing pain. that of a patient with Alzheimer’s disease, in which eye). In this procedure, ultrasound waves
the dark areas on both sides of the brain indicate are used in order to break down the
petit mal reduced function and blood flow. lens tissue, and then the broken-down
A type of generalized seizure that occurs material is removed through a tiny inci-
in epilepsy. Petit mal attacks affect chil- Peutz–Jeghers syndrome sion in the eye. An artificial lens implant
dren and adolescents but rarely persist A rare, inherited condition in which may then be inserted to improve vision.
into adulthood. Attacks may take place polyps occur in the gastrointestinal tract (See also cataract surgery.)
many times a day, and they may some- and small, flat, brown spots appear on
times last as long as 30 seconds each. the lips and in the mouth. Occasionally, phaeochromocytoma
The signs include a momentary loss the polyps bleed, or cause abdominal A rare, usually noncancerous, tumour
of awareness, occasionally with droop- pain or intussusception (the intestine tele- arising in cells in the medulla (core)
ing eyelids. Treatment for petit mal scopes in on itself causing obstruction). of the adrenal glands. These cells secrete
attacks is with an anticonvulsant drug. Tests for the condition include barium the hormones adrenaline (epinephrine)
X-ray examination and endoscopy. Bleed- and noradrenaline (norepinephrine). The
petroleum jelly ing polyps may be removed. tumour causes increased production
A greasy substance, also known as pet- of the two hormones, which leads to
rolatum or soft paraffin, that is obtained Peyer’s patches hypertension (high blood pressure) and
from petroleum. The jelly is commonly Areas of mucosa-associated lymphoid signs of stress, such as anxiety. The dis-
used as an ointment base, a protective tissue (MALT) situated in the mucous order is most common in young to
dressing, and an emollient. membrane lining the ileum (the last middle-aged adults.

603
 PHAGOCYTE

SYMPTOMS AND SIGNS pharmacognosy Swallowing substances that can scald,

Hypertension is usually the only sign. The study or knowledge of the pharma- corrode, or scratch the lining of the
However, certain conditions or situa- cologically active ingredients of plants. throat, smoking, and excessive con-
tions (such as pressure on the tumour, sumption of alcohol may also be the
emotional upset, change in posture, or pharmacokinetics causes of pharyngitis.
taking beta-blocker drugs) can cause a The term that is used to describe how SYMPTOMS
surge of hormones. This surge brings the body deals with a drug. It covers the As well as a sore throat, there may
on a sudden rise in blood pressure, pal- way in which the drug is absorbed into be discomfort when swallowing, slight
pitations, headache, nausea, vomiting, the bloodstream, how the drug is dis- fever, earache, and swollen lymph nodes
facial flushing, sweating, and, some- tributed to different body tissues, and in the neck. In severe cases of pharyn-
times, a feeling of impending death. how the drug is broken down for gitis, there may be a high fever, and the
DIAGNOSIS AND TREATMENT excretion from the body. soft palate and throat may swell so
Blood tests and urinalysis are used to much that breathing and swallowing
detect excessive levels of epinephrine pharmacology can become difficult.
and norepinephrine and thus make a The branch of science that is concerned TREATMENT
diagnosis. CT scanning, MRI, and radioiso- with the discovery and development of Gargling with warm salt water and tak-
tope scanning may be used to locate the drugs; their chemical composition; their ing analgesic drugs (painkillers) is usually
tumours, and they are then usually re- actions; their uses; and their toxicity. the only treatment needed. If the sore
moved surgically. Follow-up medical Pharmacodynamics involves the study throat is severe or prolonged, a doctor
checks are required because the condi- of the drugs’ interactions with, and may take a throat swab and prescribe
tion occasionally recurs. effects on, living organisms. antibiotic drugs.

phagocyte pharmacopoeia pharynx

A cell in the immune system that can Any book that lists and describes most The passage that connects the back of
surround, engulf, and digest micro- medicinal drugs, especially an official the mouth and nose to the oesophagus.
organisms, foreign particles, and cellular publication. One such example is the The upper part of the passage, or naso-
debris. Phagocytes are found in the British Pharmacopoeia (BP). pharynx, connects the nasal cavity to the
blood, spleen, lymph nodes, and alveoli A pharmacopoeia provides a descrip- area situated behind the soft palate. The
(small air sacs) within the lungs. Some tion of the sources, preparations, and middle part, the oropharynx, runs from
types of white blood cell, especially doses of drugs. There may also be infor- the nasopharynx to below the tongue.
granulocytes and some monocytes, are mation on how drugs work and on The lower part, called the laryngo-
“free” phagocytes, which are able to possible adverse effects. pharynx, lies behind and to each side of
migrate through the tissues and engulf the larynx (voicebox).
harmful organisms and debris. pharmacy
The practice of preparing drugs, and
phalanges making up and dispensing prescrip- LOCATION OF THE PHARYNX
The small bones that make up the fin- tions. The term is also used to describe
P gers, thumb, and toes. The thumb and the place, in a hospital for example,
The pharynx, or throat, plays an
essential part in breathing and
big toe have two phalanges; all the where these activities are carried out. eating and can change shape to
other fingers and toes have three. help form vowel sounds in speech.
pharyngeal diverticulum It has a mucous membrane lining.
phalanx An alternative term for a pharyngeal
A term for any of the bones in the fin- pouch (see oesophageal diverticulum).
gers or the toes.
pharyngeal pouch
phallus See oesophageal diverticulum.
Any object that may symbolize the penis.
pharyngitis
phantom limb pain Acute or chronic inflammation of the
The perception that a limb is still present pharynx (the part of the throat that is
after it has been amputated. The sensa- situated between the tonsils and the
tion occurs because impulses from the voicebox), causing a sore throat.
Nasopharynx
nerves in the stump are interpreted by CAUSES
the brain as coming from the limb. The most common cause is a viral infec- Oropharynx
tion. Pharyngitis often occurs as part of a
phantom pregnancy cold (see cold, common) or influenza. It
Epiglottis

See pregnancy, false. may also be an early feature of glandular Laryngopharynx

fever (see mononucleosis, infectious) or Vocal cord
pharmaceutical scarlet fever. Sometimes, the condition is
Trachea
Any medicinal drug. The term is also due to a bacterial infection, such as a Oesophagus
used with reference to the manufacture streptococcal infection; a rare but serious
and sale of drugs. bacterial cause is diphtheria.

604
 PHENYLKETONURIA

DISORDERS depression. Coordination, speech, and phenotype

The most common disorder affecting thinking are impaired; the user may The physical appearance, form, and bio-
the pharynx is acute pharyngitis (inflam- have hallucinations, and may become chemical make-up of an individual. (In
mation of the pharynx), which causes a violent. Other possible effects include contrast, the genotype is an individual’s
sore throat. Another common problem increases in blood pressure and heart genetic make-up.) The phenotype is
is choking due to the presence of a for- rate, dilated pupils, tremor, and reduced influenced by the genes that a person
eign body, such as a fish-bone, that has sensitivity to pain. High doses of phen- possesses and by environmental factors
become lodged in the pharynx. cyclidine may cause coma. (such as diet).
A rare disorder is oesophageal divertic- Long-term effects include violent
ulum. In this condition, a small sac (a behaviour, anxiety, and mental disorders phenoxymethylpenicillin
pharyngeal pouch) develops in the rear such as severe depression, paranoia, A synthetic penicillin drug used to treat
wall of the laryngopharynx. and schizophrenia (see drug-induced psy- bacterial infections, such as pharyngitis,
Cancerous tumours (see nasopharynx, chosis). There is also a risk of brain tonsillitis, and dental abscesses.
cancer of; pharynx, cancer of) are relatively damage, and of death due to seizures or Possible adverse effects include rash
rare in Western countries, but more cardiac or respiratory arrest. and nausea. A few people may develop a
common in the Far East. Some forms serious allergic reaction, as can occur
of cancer have been linked with smok- phenelzine with other penicillin drugs.
ing and excessive drinking. A monoamine oxidase inhibitor anti-
depressant drug usually given when phenylbutazone
pharynx, cancer of other antidepressant drugs have been A nonsteroidal anti-inflammatory drug
A cancerous tumour of the pharynx (the found to be ineffective. Possible side (NSAID) used to relieve the symp-
part of the throat between the tonsils effects include dizziness, drowsiness, toms of the inflammatory condition
and the voicebox). Pharyngeal cancer and rash. When taken with some other ankylosing spondylitis. Phenylbutazone
usually develops in the mucous mem- drugs or certain foods, such as mature may cause nausea, fluid retention, rash,
brane lining the throat. cheese, broad beans, and yeast extract, and peptic ulcer. It may also increase
CAUSES AND INCIDENCE phenelzine can cause a dangerous rise the risk of certain blood disorders, such
In the West, almost all cases of pharyn- in blood pressure. as agranulocytosis (a deficiency in
geal cancer are related to smoking and granulocytes, a type of white blood cell).
alcohol. The disorder is more common Phenergan The drug is prescribed only under
in men, and incidence rises with age. A brand name for the antihistamine hospital supervision, and only if other
Tumours of the nasopharynx (see drug promethazine. drugs are ineffective.
nasopharynx, cancer of) have different
causes and symptoms from those that phenobarbital phenylephrine
arise lower in the pharynx. A barbiturate drug that is used mainly A decongestant drug used to relieve the
SYMPTOMS as an anticonvulsant. Phenobarbital may symptoms of seasonal allergic rhinitis
Cancerous tumours of the oropharynx be used with phenytoin in the treatment (hay fever; see rhinitis, allergic) and the
(the middle section of the pharynx) of epilepsy. Possible side effects of the common cold. As eye-drops, it is used to
usually cause difficulty in swallowing, drug include drowsiness, clumsiness, dilate the pupils for eye examinations. P
often accompanied by a sore throat and dizziness, excitement, and confusion. High doses or prolonged use of the
earache. Blood-stained sputum may be nasal preparations may cause headache
coughed up. Sometimes, there is only phenol and blurred vision; if a person stops
the feeling of a lump in the throat or a A strong antiseptic, also called carbolic taking the drug suddenly, this may
visibly enlarged lymph node in the neck. acid. Liquids or ointments that contain make nasal congestion worse. Use of
Cancer of the laryngopharynx (the phenolic compounds are used to cleanse phenylephrine for longer than a week is
lowermost part of the pharynx) initially wounds and inflamed skin, while phe- not, therefore, recommended.
produces a sensation of incomplete nol in an oil base can be injected into
swallowing; symptoms that develop in haemorrhoids in order to shrink them. phenylketonuria
the later stages include a muffled voice, Phenol is also found in chemical sub- An inherited disorder in which the
hoarseness, and also an increased diffi- stances such as disinfectants; in this enzyme that converts the amino acid
culty in swallowing. form, it is highly toxic. phenylalanine into tyrosine (another
DIAGNOSIS AND TREATMENT amino acid) is defective. Unless pheny-
Diagnosis is made by biopsy, which is phenothiazine drugs lalanine is excluded from the diet, it
often performed in conjunction with COMMON DRUGS builds up in the body and causes severe
laryngoscopy, bronchoscopy, or oesophag- • Chlorpromazine • Fluphenazine learning difficulties. All newborn babies
oscopy. The growth may be removed • Methotrimeprazine • Perphenazine are given the Guthrie test, in which a
surgically or treated with radiotherapy. • Pipotiazine • Thioridazine • Trifluoperazine blood sample is taken to screen for
Anticancer drugs may also be given. phenylketonuria.
A group of drugs that are used in the SYMPTOMS
phencyclidine treatment of psychotic illnesses (see Affected babies show few signs of
A drug of abuse, commonly known as antipsychotic drugs) some of which are abnormality, but, if phenylalanine is not
angel dust or PCP. It produces euphoria, also used to relieve severe nausea and excluded from the diet, they develop
which sometimes leads to anxiety or vomiting (see antiemetic drugs). neurological disturbances including

605
 PHENYTOIN

epilepsy. The babies tend to have blonde phlebography (for example, if a person lives in the city
hair and blue eyes, and their urine may The obtaining of X-ray images of veins that but has a fear of lifts). Treatment is more
have a musty odour. Many have the skin have been injected with a radiopaque sub- commonly sought for complex phobias. It
condition eczema. stance. An alternative name is venography. may involve cognitive–behavioural therapy
TREATMENT AND PREVENTION and sometimes antidepressant drugs.
Phenylalanine is found in most foods phlebotomy
that contain protein, and also in arti- Puncture of a vein to remove blood (see phocomelia
ficial sweeteners. A specially modified venepuncture; venesection). A limb defect in which the feet and/or
diet is generally recommended through- the hands are joined to the trunk by
out life, and sticking to this diet is espe- phlegm short stumps. The condition is extreme-
cially important during pregnancy, See sputum. ly rare, but used to occur as a side effect
because high levels of phenylalanine in of women taking the drug thalidomide
the mother can damage the fetus. phobia in early pregnancy.
A persistent, irrational fear of a certain
phenytoin object or situation. Many people have pholcodine
An anticonvulsant drug used in the treat- minor phobias, which may cause distress A cough suppressant.
ment of epilepsy. Side effects may but do not affect everyday life. A phobia is
include nausea, dizziness, tremor, and considered a psychiatric disorder when it phosphates
overgrown and tender gums. interferes with normal social functioning. Salts containing phosphorus and oxygen.
TYPES Phosphates are an essential part of the diet
pheromone Simple phobias (specific phobias) are and are present in many foods, including
A substance with a particular odour the most common. These problems may cereals, dairy products, eggs, and meat.
that, when released in minute quanti- involve fear of particular animals or sit- FUNCTION
ties by an animal, affects the behaviour uations, such as enclosed spaces (claustro- Most of the phosphorus in the body is
or development of other individuals of phobia). Animal phobias usually start in combined with calcium to form the struc-
the same species. childhood, but other types of phobia ture of bones and teeth. The remainder is
can develop at any time. present in small amounts in most of the
Philadelphia chromosome More severe, pervasive fears are called body’s tissues, and plays a part in main-
A chromosomal abnormality that is associ- complex phobias. One form is agorapho- taining the acid-base balance of the blood,
ated with one form of leukaemia (see bia, which often causes severe impair- urine, saliva, and other body fluids. ATP
leukaemia, chronic myeloid). In this abnor- ment. The disorder usually starts in the (adenosine triphosphate) is a phosphate
mality, one copy of chromosome 22 has late teens or early 20s. Another complex compound that stores the energy for
a missing section; this portion has phobia is social phobia – fear of being chemical reactions in cells.
become detached and then reattached exposed to scrutiny, such as a fear of DISORDERS
to a copy of chromosome 9. (See also eating or speaking in public. The onset In most people, the kidneys maintain a
chromosome; karyotype.) of this disorder usually occurs in late constant level of phosphates in the body
childhood or early adolescence. by regulating the amount that is excreted
P phimosis CAUSES in the urine. They can compensate for a
Tightness of the foreskin, preventing it The causes of phobias are unknown. slight deficiency of phosphates in the diet
from being drawn back over the glans Simple phobias are thought by some to by reducing the amount lost in the urine.
(head) of the penis. In uncircumcised be a form of conditioning. For example, a Hypophosphataemia (an abnormally
babies, some degree of phimosis is nor- person with a fear of dogs may have low level of phosphates in the blood)
mal, but it usually improves by age been frightened by a dog in childhood. may occur in some forms of kidney dis-
three or four. In some boys, the condi- SYMPTOMS AND COMPLICATIONS ease, hyperparathyroidism, long-term treat-
tion persists and may cause the foreskin Exposure to the feared object or situa- ment with diuretic drugs, malabsorption,
to balloon out on urination. Attempts to tion causes intense anxiety and, in some or prolonged starvation. It causes bone
retract a tight foreskin may make the cases, may lead to a panic attack. The pain, weakness, seizures, and, in severe
condition worse. person may start to avoid any situation cases, coma and death.
Phimosis may also develop in adult that might involve contact with the trig- DRUG THERAPY
men, causing painful erection and it ger for the fear, and this may adversely Phosphates may be taken by mouth in the
may lead to paraphimosis (constriction affect his or her lifestyle. Phobias may form of drug preparations or milk to treat
of the penis behind the glans). Proper also be associated with depression or hypophosphataemia.They are also used to
cleaning of the glans may not be with obsessive–compulsive behaviour. In treat hypercalcaemia (abnormally high lev-
possible, so balanitis (infection of the addition, the person may attempt to els of calcium in the blood). Diarrhoea is
glans) may develop. relieve the fear by using drugs or drink- a possible side effect of phosphate drugs.
The treatment for both adults and ing alcohol to excess.
children is circumcision. TREATMENT phospholipid
Treatment depends on the severity of the A compound formed from one or more
phlebitis condition and the wishes of the individ- lipids (fats), phosphate, and, usually,
Inflammation of a vein. A clot often ual. For simple phobias, no treatment may glycerol. They are manufactured in the
develops, in which case the condition is be necessary unless the feared object is so liver and small intestine. Examples of
termed thrombophlebitis. common that it cannot easily be avoided phospholipids include lecithins.

606
 PICA

Phospholipids are important constit- is another form of phototherapy. Photo- including invasion by a tumour (such
uents of cell membranes and nerve therapy may also be used to treat sea- as in lung cancer), results in paralysis of
tissues, particularly in the brain. In sonal affective disorder. that half of the diaphragm.
addition, those existing on the surfaces PUVA
of blood platelets play a part in blood This therapy combines the use of long- physical examination
clotting. In an autoimmune disorder called wave ultraviolet light with a psoralen drug, See examination, physical.
Hughes’ syndrome, the immune system which sensitizes the skin to light. The
may form antibodies to phospholipids procedure is used to treat psoriasis and physiological saline
and thus disrupt the clotting process, certain other skin diseases, such as vitiligo. An isotonic solution of 0.9% sodium
causing abnormal clot formation. Psoriasis may also be treated using short- chloride in water, also called normal
wave ultraviolet light, sometimes com- saline, used to replace body fluids and
phosphorus bined with the application of coal tar. rehydrate tissues. Physiological saline is
An essential mineral present in many BLUE LIGHT given by intravenous infusion.
foods, including cereals, dairy products, Visible blue light is used to treat neonatal
and meat. In the body, phosphorus is jaundice (see jaundice, neonatal), which is physiology
combined with calcium to form the due to high levels of the pigment bilirubin The study of body functions, including
bones and teeth. (See also phosphates.) in the blood.The light is thought to cause physical and chemical processes of
the conversion of bilirubin into a harm- cells, tissues, organs, and systems, and
photocoagulation less substance that can be excreted. To their various interactions.
The destructive heating of tissue by maximize exposure, the baby is undressed
intense light focused to a fine point, as and placed under the lights in an incuba- physiotherapy
in laser treatment. tor (with his or her eyes shielded). Treatment with physical methods, such
as exercise or physical agents. Physio-
photophobia phrenic nerve therapy can prevent or reduce joint
An uncomfortable sensitivity or intoler- One of the pair of main nerves that stiffness and restore muscle strength in
ance to light. It occurs with certain eye supply the diaphragm. The phrenic arthritis, or after a fracture has healed. It
disorders, such as corneal abrasion, and is nerves branch from the third, fourth, is also used to reduce pain, inflammation,
a feature of meningitis (inflammation of and fifth cervical nerves in the neck and muscle spasm, and retrain joints and
the membranes that surround the brain (see spinal nerves) and then pass down muscles, after stroke or nerve injury.
and spinal cord). through the chest to each side of the Methods include active exercises and
diaphragm. Each of the phrenic nerves passive movement, heat treatment, massage,
photorefractive keratectomy carries motor impulses to one half of ice-packs, hydrotherapy, and TENS (thera-
A surgical treatment for astigmatism (a the diaphragm and plays a part in the peutic use of electrical currents).
vision disorder resulting from uneven control of breathing. Damage that Physiotherapy is also used to main-
curvature of the front of the eye), myopia occurs to either one of the nerves, tain breathing in people with impaired
(shortsightedness), and hypermetropia lung function, and to prevent and treat
(longsightedness) in which areas of the pulmonary complications after surgery.
cornea are shaved away by laser.
LOCATION OF PHRENIC NERVES Techniques for doing this include pos- P
tural drainage, breathing exercises, and ad-
photosensitivity There are two phrenic nerves, one
on each side of the body. Each ministration of oxygen, drugs, or mois-
An abnormal reaction to light. Photo- follows a tortuous course from its ture through a nebulizer.
sensitivity usually causes a rash on skin origin in the neck, through the
exposed to sunlight or artificial ultravio- chest, to the diaphragm. phyto-
let light. This often occurs because a A prefix meaning of plant origin.
Cervical
photosensitizer (a substance such as a nerves
particular drug, dye, chemical in per- Cervical phytomenadione
vertebrae
fume or soap, or a plant such as A form of vitamin K.
mustard) has been ingested or applied
to the skin. Photosensitivity is also a phyto-oestrogens
feature of disorders such as systemic Oestrogens that occur naturally in plants.
lupus erythematosus.
People who are susceptible to photo- pia mater
sensitivity reactions should avoid being The innermost of the three membranes
exposed to sunlight and known photo- of the meninges, lying next to the brain.
sensitizers and should use sunscreens.
pica
phototherapy A craving to eat non-food substances
Treatment that uses light, including such as earth or coal. Pica is common in
sunlight, ultraviolet light, and blue light. early childhood and may occur during
Moderate exposure to sunlight is the pregnancy. It may also occur in nutri-
Diaphragm Heart Phrenic nerve
most basic form and is often helpful in tional or iron-deficiency disorders, and
treating the skin disorder psoriasis. PUVA in severe psychiatric disorders.

607
 PICKWICKIAN SYNDROME

Pickwickian syndrome There are many defects of pigmenta- pilocarpine

An uncommon disorder characterized tion, which may cause abnormally pale A drug used in the form of eye-drops to
by extreme obesity, shallow breathing, or dark skin, or may produce areas of treat glaucoma (raised pressure in the
excessive sleepiness, and obstructive discoloured skin. eyeball). Pilocarpine may initially cause
sleep apnoea. Pickwickian syndrome is of REDUCED PIGMENTATION blurred vision, headache, and eye irrita-
unknown cause. The symptoms usually Patches of pale skin occur in the skin dis- tion. In tablet form, the drug is used to
improve with weight loss; specific treat- orders psoriasis, pityriasis alba, and pity- treat dry mouth due to Sjogren’s syndrome
ment for sleep apnoea may be required. riasis versicolor; these disorders cause skin or radiotherapy to the head and neck.
scales to flake off, resulting in a loss of
PID melanin. In vitiligo, areas of skin stop pro- pilonidal sinus
The abbreviation for pelvic inflammatory ducing melanin. A pit in the skin, often containing hairs,
disease. The rare genetic disorder albinism is in the upper part of the buttock cleft.The
caused by a generalized deficiency of cause is probably hair fragments grow-
piebaldism melanin, and results in very pale skin ing inwards. Although the condition is
A rare genetic disorder in which a patchy and white hair. Another genetic condi- usually harmless, infection may occur,
absence of the dark pigment melanin tion, phenylketonuria, results in a re- causing recurrent, painful abscesses.
results in areas of skin and sometimes duced level of melanin, making suffer- If a pilonidal sinus is infected, the
hair that lack pigmentation. In many ers of the condition more pale-skinned sinus and a wide area around it will
cases, there is a white panel in the cen- and fair-haired than all the other mem- be surgically removed. The resulting
tre of the face, which may include the bers of their family. wound will usually be left open to allow
hair and eyebrows as well as the skin. INCREASED PIGMENTATION slow healing from the skin layers below.
Piebaldism shows an autosomal domi- Areas of dark skin may appear tem- Recurrence of infection is common, and
nant pattern of inheritance. porarily following disorders such as plastic surgery is sometimes required.
eczema or psoriasis, pityriasis versicolor,
piercing or chloasma (development of dark pimozide
See ear piercing. patches on the face due to hormonal An antipsychotic drug also used to treat
changes). Such areas of dark pigmenta- Gilles de la Tourette’s syndrome. Pimozide
Pierre Robin’s syndrome tion may also appear after the use of may cause sedation, dry mouth, consti-
A disorder causing abnormalities of the perfumes and cosmetics containing pation, and blurred vision.
lower jaw and throat. The condition chemicals that cause photosensitivity.
may occur by itself, or may be associat- Permanent areas of deep pigmenta- pimple
ed with other problems. It is congenital tion, such as freckles, moles, or some A small pustule or papule.
(present at birth). types of naevi (see naevus), are usually
The main structural malformations are due to an abnormality in some of the pindolol
micrognathia (an abnormally small lower melanocytes. Acanthosis nigricans, a con- A beta-blocker drug used to treat angina
jaw) and cleft palate (or an unusually dition that may be either inherited or pectoris (chest pain due to inadequate
arched palate). Functional defects include acquired, is characterized by dark patches blood supply to the heart) and hyperten-
P a tendency for the tongue to fall back- of velvetlike, thickened skin. Darkening sion (high blood pressure). Possible side
wards into the throat, causing breathing of the skin that is unrelated to sun effects are typical of other beta-blocker
difficulty and a tendency to choke. exposure may occur in certain hormon- drugs, except that pindolol is less likely
Affected babies may have difficulty in al disorders, such as Addison’s disease than some others to cause bradycardia
feeding. Micrognathia may disappear as and Cushing’s syndrome. (abnormally slow heartbeat).
the child grows, but cleft palate and air- ABNORMAL COLORATION
way obstruction may require surgery. Some forms of abnormal colouring pineal gland
result from excessive levels of certain A tiny, cone-shaped structure deep within
pigeon toes pigments or other substances in the the brain. The pineal gland is situated just
A minor abnormality in which the leg blood. An excess of the bile pigment below the back of the corpus callosum,
or foot is rotated, forcing the foot and bilirubin in jaundice turns the skin yel- the band of nerve fibres that connects the
toes to point inwards. Although the low, and an excessive blood level of iron two halves of the cerebrum (the topmost,
condition occurs commonly in tod- in haemochromatosis turns the skin and largest, area of the brain).
dlers, it has usually corrected itself by bronze. Discoloration may also be caused The sole function of the gland appears
the time the child is seven years old. by an abnormal collection of blood ves- to be the secretion of the hormone mela-
sels, as in a haemangioma, or may occur tonin in response to changes in light. The
pigmentation temporarily in a bruise, when blood amount of melatonin secreted varies over
Coloration of the skin, hair, and iris of leaks from ruptured vessels and collects a 24-hour cycle, being greatest at night.
the eyes by melanin, a brown or black under the skin. Hormone secretion is thought to be con-
pigment produced by cells called mel- trolled through nerve pathways from the
anocytes. The more melanin, the darker piles retina in the eye; a high light level seems
the coloration (the amount produced is A common name for haemorrhoids. to inhibit secretion.The exact function of
determined by heredity and exposure to melatonin is not understood, but it may
sunlight). Blood pigments can also pill, contraceptive help to synchronize circadian (24-hour)
colour skin (as in a bruise). See oral contraceptives. and other biorhythms.

608
 PITUITARY GLAND

and finally white. A penicillin drug or

LOCATION OF PINEAL GLAND tetracycline clears up the infection, but
LOCATION OF PITUITARY GLAND
the skin may be permanently disfigured.
The pineal gland is situated in This master gland is itself
the brain, below the rear part controlled by the hypothalamus,
of the corpus callosum.
pinworm infestation located immediately above it.
An alternative name for threadworm
Cerebrum
Cerebrum infestation.

pioglitazone
An oral hypoglycaemic drug (see hypogly-
caemics, oral)that is used in combination
with other oral hypoglycaemics (either
metformin or a sulphonylurea) in the
treatment of type 2 diabetes mellitus. Pio-
glitazone acts by reducing resistance to
insulin in the body tissues. Side effects
may include gastrointestinal disturbances,
Corpus
callosum
weight gain, and anaemia.
Pituitary Hypothalamus
piperazine Pituitary
An anthelmintic drug used to treat infes-
tation by roundworms and threadworms.
Pineal gland Brainstem
Possible side effects include abdominal
pain, nausea, vomiting, and diarrhoea.
pinguecula Piriton
A small, noncancerous, yellowish spot A brand name for the antihistamine effects of the drug include nausea, in-
that occurs on the conjunctiva over drug chlorphenamine. digestion, abdominal pain, swollen
the white of the eye. These spots are ankles, peptic ulcer, and liver problems.
common in elderly people and may be piroxicam
removed purely for cosmetic reasons. If A type of nonsteroidal anti-inflammatory pituitary gland
a pinguecula encroaches on the cornea, drug (NSAID) that is used to relieve the Sometimes referred to as the master
it may lead to pterygium. symptoms of types of arthritis, and to gland, the pituitary is the most important
relieve pain in bursitis, tendinitis, and of the endocrine glands (glands that release
pink-eye after minor surgery. Possible adverse hormones directly into the bloodstream).
A common name for conjunctivitis.
pinna HORMONES SECRETED BY THE PITUITARY GLAND P
The fleshy part of the outer ear, consist- Growth hormone Luteinizing and
ing of a flap of cartilage and skin. It is stimulates cell division and follicle-stimulating
also called the auricle. protein synthesis in tissues hormones (LH and FSH)
such as bone and cartilage, help control the function
pins-and-needles leading to growth. of male and female sex
organs.
A tingling or prickly feeling in an area
of skin that is usually associated with Thyroid-stimulating Melanocyte-stimulating
numbness and, sometimes, a burn- hormone (TSH) hormone (MSH)
ing feeling. The medical term for this stimulates the thyroid gland controls skin darkening by
to secrete various hormones stimulating pigment cells
phenomenon is paraesthesia. Transient vital to body metabolism. (melanocytes).
pins-and-needles is due to a temporary
disturbance in the conduction of nerve
signals from the skin to the brain. Persis- Adrenocorticotrophic Antidiuretic
tent pins-and-needles may be caused by a hormone (ACTH) hormone (ADH)
stimulates the adrenal acts on the kidneys to
nerve disorder, or neuropathy. glands to secrete hormones, decrease water loss in
with multiple effects on the urine and thus reduces
pinta metabolism. urine volume.
A bacterial skin infection, caused by TRE-
PONEMA CARATEUM , occurring in remote Prolactin Oxytocin
stimulates milk production, stimulates contraction of the
tropical America. A large spot surround- particularly in response to uterus during childbirth and
ed by smaller ones appears on the face, the infants’ sucking. milk release from the breasts.
neck, buttocks, hands, or feet. After one
to twelve months, it is followed by red
skin patches that turn blue, then brown,

609
 PITUITARY TUMOURS

DISORDERS OF THE PITUITARY GLAND

Any abnormality of the pituitary gland Tumours failure of milk production, and a wide
usually means that it produces either Pituitary tumours are usually noncancerous range of secondary effects due to the
too much or too little of one or more but may cause either overproduction of resultant underactivity of other
hormones, causing changes elsewhere pituitary hormones (hyperpituitarism) or endocrine glands. Impaired blood
in the body. Locally, serious effects may underproduction (hypopituitarism), as well supply may also occur due to vasculitis
be caused by enlargement of the gland; as headaches and loss of the visual field. or pressure on the gland from an
for example, it may press on the nearby aneurysm of a nearby artery.
optic nerves and cause visual defects. Injury
Birth injury may cause loss of pituitary Radiation
Congenital and genetic disorders function, as may head injuries at any age. Radiotherapy for a pituitary tumour may
Deficiency of growth hormone may be a cause general underactivity of the gland.
genetic disorder, or it may be due to Impaired blood supply
congenital absence or undergrowth of Rarely, the pituitary may suffer deprivation
the pituitary or to damage to the gland of its blood supply as a result of pressure INVESTIGATION
sustained during birth. Whatever the exerted on its blood vessels from a growing
tumour.This may cause a sudden loss of Techniques include analysis of pituitary
cause, deficiency of growth hormone
pituitary function, which may be fatal, or a hormones in the blood or urine, and of
leads to short stature. hormones from other endocrine glands
Congenital growth hormone more gradual loss, which produces signs of
under pituitary control; pituitary X-rays,
deficiency may also be associated with general underactivity of the gland.
CT scanning, or MRI; angiography, to
deficiency of other pituitary hormones, A similar deprivation of blood supply
show blood-vessel displacement by a
notably ACTH (adrenocorticotrophic may occur as a complication of massive pituitary tumour; and, possibly, a visual
hormone), gonadotrophin hormones, and blood loss associated with childbirth field test (see vision tests).
thyroid-stimulating hormone (TSH). (Sheehan’s syndrome). This may lead to

It regulates the activities of other endo- The posterior pituitary lobe secretes ADH cause galactorrhoea (abnormal milk pro-
crine glands and many body processes and oxytocin. These hormones are actually duction), amenorrhoea (absence of men-
(see endocrine system). produced in the hypothalamus, and pass strual periods), and infertility in women.
For information on disorders that can down nerve fibres to be stored in the pos- In men, it can cause impotence, in-
affect the pituitary gland, see the pitu- terior lobe until they are needed. fertility, feminization, and galactorrhoea.
itary gland disorders box. Tumours that affect the posterior pitu-
STRUCTURE pituitary tumours itary may disrupt the production of
The pituitary gland is a pea-sized struc- Growths in the pituitary gland. Pituitary antidiuretic hormone (ADH) and lead to
ture attached by a stalk of nerve fibres tumours are rare, and usually non- diabetes insipidus.
P to the hypothalamus, a region of the cancerous, but they can put pressure on Pressure from tumour enlargement
brain just above the gland. The hypo- the optic nerves, causing visual defects. may cause headaches, cranial nerve
thalamus controls pituitary function by CAUSES AND SYMPTOMS paralysis, and defects of vision.
nervous stimulation and by secreting sub- The causes of pituitary tumours are DIAGNOSIS AND TREATMENT
stances called hormone-releasing factors. unknown. One type, called an endocrine Diagnosis is made using blood tests to
The pituitary gland consists of three inactive tumour, causes the destruction measure hormone levels; X-rays; MRI of
lobes: the anterior, the intermediate, of some of the hormone-secreting cells the pituitary; and, often, vision tests.
and the posterior. in the pituitary gland. This leads to Treatment may consist of surgical
FUNCTIONS inadequate hormone production, caus- removal of the tumour, radiotherapy,
The three lobes of the pituitary produce ing problems such as tiredness, loss of hormone replacement, or a combina-
a range of hormones. For further infor- appetite, symptoms of hypothyroidism tion of these techniques. The drug
mation on the individual pituitary (underactivity of the thyroid gland), bromocriptine may be used; it can reduce
hormones and their effects, see the and cessation of menstrual periods or production of certain hormones and
illustrated box, overleaf. reduced sperm production. shrink some tumours.
The anterior lobe produces most of the Tumours may also cause the gland to
pituitary hormones including growth hor- produce excessive amounts of certain pityriasis alba
mone, prolactin, ACTH (adrenocortico- hormones. Tumours of the anterior lobe A common skin condition occurring in
trophic hormone),TSH (thyroid-stimulat- can cause various disorders. Overpro- childhood and adolescence, particularly
ing hormone), and the gonadotrophins duction of growth hormone causes in dark-skinned children, that is caused
FSH (follicle-stimulating hormone) and gigantism or acromegaly. Excess thyroid- by mild eczema. Irregular, fine, scaly,
LH (luteinizing hormone). The inter- stimulating hormone (TSH) can lead pale patches appear on the face; the
mediate lobe secretes melanocyte-stim- to hyperthyroidism. Excess adrenocortico- patches may be more noticeable after
ulating hormone (MSH). The secretion of trophic hormone (ACTH) can cause exposure to the sun, because they tan
these hormones is triggered by hormone- Cushing’s disease (see Cushing’s syn- poorly. The condition can usually be
releasing factors from the hypothalamus. drome). An increase in prolactin can cleared up with emollients.

610
 PLACENTAL ABRUPTION

pityriasis rosea pivot joint STRUCTURE

A common, mild skin disorder in A form of joint that allows only rotation, The placenta develops from the chorion
which a rash of flat, scaly-edged, pink such as the joint between the top of the (the outermost layer of cells that develops
spots or patches appears on the trunk spine and the skull. from the fertilized egg). It is attached to
and upper arms. It is not contagious the uterus lining and connected to the
and mainly affects children and young pizotifen baby by the umbilical cord. The placenta,
adults. Its cause is unknown, but may An antihistamine drug used to prevent and the other uterine tissues, which are
be associated with a viral infection. migraine in people with frequent, dis- all expelled at birth, are collectively
The first sign is a large, round spot, abling attacks. Adverse effects of taking known as the afterbirth.
called a herald patch, on the trunk. The the drug can include nausea, dizziness, FUNCTION
rash appears about a week later. It lasts drowsiness, dry mouth, and muscle The placenta transfers oxygen, nutri-
for four to eight weeks, may cause itch- pains. Prolonged use can in some cases ents, and protective antibodies from the
ing, and usually clears up without cause weight gain. mother’s circulation to the fetus’s circu-
treatment. Calamine lotion or antihista- lation and removes waste products from
mine drugs may relieve any itching. PKU test the fetal blood into the mother’s blood
See Guthrie test. for excretion by her lungs and kidneys.
pityriasis versicolor The organ also produces hormones
A common skin condition, also known placebo such as oestrogen, progesterone, and
as tinea versicolor, in which patches of A chemically inert substance given human chorionic gonadotrophin (HCG).
white, brown, or salmon-coloured flak- instead of a drug. Benefit may be gained These hormones enter the mother’s
ing skin appear on the trunk and neck. from a placebo because the person tak- blood to help her body adapt to the
The patches are more noticeable on ing it believes it will have a positive conditions of pregnancy; they also pre-
sun-tanned skin; they may be either effect. As the effectiveness of any drug pare the breasts for breast-feeding. High
paler or darker than the surrounding may be partly due to this “placebo levels of HCG appear in the woman’s
skin. Pityriasis versicolor mainly affects effect”, many new drugs are tested urine during early pregnancy, and
young and middle-aged adults. It is against a placebo preparation. detection of them in the urine forms
caused by PITYROSPORUM, a fungus that the basis of pregnancy tests.
exists on most people’s skin and normal- placenta
ly produces no symptoms. The condition The organ that develops inside the placental abruption
is not contagious. uterus during pregnancy and that is the Separation of all or part of the placenta
Treatment is with selenium sulphate link between the blood supplies of the from the wall of the uterus before the
shampoo, used as a lotion, or with anti- mother and the baby. baby is delivered.
fungal drugs in the form of a cream or
lotion. The whole of the affected area
must be treated thoroughly, to prevent FUNCTION OF THE PLACENTA
the infection from recurring. With care-
The mother’s and baby’s blood do not mix in the placenta, but are separated from
ful treatment, the infection will clear up
in two to three weeks, but the spots
each other by such a thin layer of cells that exchange of nutrients and oxygen (from
mother to baby) and waste products (from baby to mother) can occur between the
P
may take months to disappear. Antifun- two blood circulations.
gal tablets may be needed if the rash
does not improve or is very widespread. Pool of Maternal blood
mother’s blood vessels in wall
of uterus
pityrosporum Umbilical cord
Chorionic
A group of fungi that normally live on villi
the skin or the scalp, but which may Placenta

sometimes cause pityriasis versicolor or

may multiply excessively resulting in a
Umbilical
condition called folliculitis (inflammation cord
of the hair follicles). This overgrowth of
fungi may occur in people with lowered
resistance to infection; people taking
antibiotic drugs, corticosteroids, or oral con-
traceptives; those with diabetes mellitus;
and those under emotional stress. It may
also be associated with a predisposition
to severe dandruff or seborrhoeic dermatitis.
Treatment includes addressing any
underlying cause and using solutions or How the mother’s and baby’s
blood are brought together
creams containing antifungal drugs. The baby’s blood flows via the umbilical cord villi). These are surrounded by a pool of
to the placenta, where it enters numerous tiny maternal blood brought to the placenta by
pivmecillinam blood vessels arranged in “fingers” (chorionic a major artery.
A type of penicillin drug.

611
 PLACENTA PRAEVIA

CAUSES DIAGNOSIS AND TREATMENT

The exact cause of placental abruption is SPREAD OF PLAGUE A sample of fluid from a bubo, or a
not known, but it is more common in sputum sample, is taken to establish the
women who have long-term hypertension Stage 1 presence of plague bacteria and confirm
(high blood pressure) and in those who The bacterium that causes plague the diagnosis. Possible treatments are
have previously had the condition or who (Yersinia pestis) circulates mainly streptomycin and tetracycline drugs.
have had several pregnancies. Smoking among wild rodents; the bacterium is
and high alcohol intake may also con- spread from one rodent to another by plantar fasciitis
rodent fleas.
tribute to the risk of placental abruption. (inflammation of a layer of con-
Fasciitis
SYMPTOMS nective tissue) affecting the sole of the
Symptoms usually occur suddenly and foot, especially the heel.
depend on how much of the placenta Stage 2
has separated from the wall of the Sometimes so many wild rodents die plantar wart
that the fleas transfer to and infest new
uterus. They include vaginal bleeding, wild hosts, such as rats, or even humans See wart, plantar.
which can be severe haemorrhaging in who enter plague-affected areas.
complete separation; abdominal cramps plants, poisonous
or backache; severe, constant abdominal Several species of plant, including fox-
pain; and reduced fetal movements. glove, holly, deadly nightshade, and
Stage 3
TREATMENT The real danger is of plague spreading laburnum, are poisonous or can cause
If the bleeding does not stop, or if it starts to, and killing, large numbers of urban severe allergic reactions.
again, it may be necessary to induce rats; rat fleas might then transfer from Paradoxically, many poisonous plants
labour (see induction of labour). A small dead rats to humans en masse, causing are also sources of useful drugs. Examples
an epidemic.
placental abruption is usually treated include deadly nightshade, from which
with bed-rest in hospital. In more severe atropine is made, and foxglove, from
cases of placental abruption, an emer- which digitalis drugs are created.
gency caesarean section is often necessary CAUSES AND SYMPTOMS OF POISONING
to save the the life of the fetus. A blood plague Toxins from plants can cause poisoning
transfusion is also sometimes required. A serious infectious disease caused by either through contact with the skin, if
the bacterium YERSINIA PESTIS. It mainly a person touches or handles the plants,
placenta praevia affects rodents but can be transmitted to or internally, if a person (usually a
Implantation of the placenta in the humans by flea bites. Plague caused one child) ingests them.
lower part of the uterus, near or over the of the largest pandemics (world-wide Skin contact Nettles, hogweed, poison
cervix. The condition varies in severity epidemics) in history: the “Black Death” ivy, and primula cause skin reactions,
from marginal placenta praevia, when of the 14th century, which killed 25 including rash, itching, and blistering,
the placenta reaches the edge of the cer- million people in Europe alone. Today, on contact. In some people, these reac-
vical opening, to complete placental human plague occurs sporadically in parts tions can be extremely severe.
praevia, when the entire opening of the of the world, but not in Europe. Internal poisoning Plants that are poiso-
P cervix is covered. CAUSES, TYPES, AND SYMPTOMS nous to eat include foxglove, aconite,
SYMPTOMS There are two main types: bubonic and hemlock, laburnum seeds, and holly
Marginal placenta praevia may have no pneumonic. Bubonic plague is caused and deadly nightshade berries. Internal
adverse effect. More severe cases often by a bite from an infected flea. Pneu- poisoning most commonly affects young
cause painless vaginal bleeding in late monic plague can be a complication of children who have consumed colourful
pregnancy, as placental tissue separates bubonic plague or can be transmitted in berries. Symptoms of poisoning vary
from the wall of the uterus. infected droplets expelled in coughing. according to the plant but may include
TREATMENT Bubonic plague is characterized by abdominal pain, vomiting, flushing,
If the bleeding is slight and the preg- swollen lymph nodes (which are called breathing difficulty, delirium, and coma.
nancy still has several weeks to run, bed “buboes”). Symptoms usually start two Urgent medical attention is required.
rest in hospital may be all that is neces- to five days after infection, with fever, TREATMENT
sary. The baby will probably be delivered shivering, and severe headache. Soon, Skin reactions can be treated by wash-
by caesarean section at the 38th week. If the smooth, red, painful buboes appear, ing the area affected (and any clothes
the bleeding is heavy or if the pregnan- usually in the groin. There may be that have come into contact with the
cy is near term, an immediate delivery bleeding into the skin around the plant), and applications of alcohol or
is carried out. buboes, causing dark patches. The vic- calamine lotion. Corticosteroid drugs may
tim may have seizures. Without prompt be prescribed for severe reactions.
placenta, tumours of treatment, the person may die. Occa- Internal poisoning usually requires
See choriocarcinoma; hydatidiform mole. sionally, septicaemia (blood poisoning) gastric lavage. Fatal poisoning is rare.
may cause death before buboes appear. (See also mushroom poisoning.)
plagiocephaly Pneumonic plague affects the lungs.
Any asymmetry or distortion in the shape The symptoms are severe coughing that plaque
of the head. Plagiocephaly is usually due produces a bloody, frothy sputum and The term given to an area of athero-
to irregularity in the closure of the sutures laboured breathing. Without early treat- sclerosis (fatty deposits within arteries).
(fixed joints) between the skull bones. ment, death is almost inevitable. The plaques are symptomless until they

612
 PLATELET

plasminogen activator
DEVELOPMENT OF PLAQUE See tissue plasminogen activator.
Plaque starts with a deposit of salivary mucus on the teeth. The mucus is Plasmodium
colonized by various types of bacteria. Initially, the predominant bacteria are
spherical cocci. After a day or two, long filamentous colonies of bacteria spread
A group of protozoa (single-celled
over the surface of the teeth. organisms) including the microorgan-
isms that are responsible for malaria.
Once they are introduced into the body,
usually via a mosquito bite, plasmodia
live in liver cells, red blood cells, and in
the bloodstream.
plaster cast
See cast.
Gums Tooth Plaque
plaster of Paris
Areas of plaque build-up Mature plaque
Plaque develops predominantly at the This picture, taken with a scanning electron A white powder that is made of a cal-
margin of teeth and gums. If the gums microscope (SEM), shows a mass of cium compound that, when mixed with
are inflamed or otherwise unhealthy, filamentous bacterial colonies in plaque, water, produces a paste that can be
the plaque tends to develop more rapidly. magnified about 3,000 times. shaped before it sets. Plaster of Paris is
used for constructing casts and making
dental models (see impression, dental).
are large enough to reduce blood flow possibility of pulmonary embolism or
or until the surface of a plaque is dis- deep vein thrombosis may be ruled out plastic surgery
turbed, causing thrombosis (clotting of if plasma D-dimers are not present. Any operation carried out to repair or
blood). Plaques in coronary arteries, reconstruct skin and tissue that has been
which supply blood to the heart, cause plasmapheresis damaged or lost, is malformed, or has
coronary artery disease. A procedure for removing, or reducing changed with aging. (Any procedures that
the concentration of, unwanted sub- are performed mainly to improve the
plaque, dental stances in the blood; it is also known as appearance of a healthy person are
A rough, sticky coating on the teeth plasma exchange. described as cosmetic surgery.)
consisting of saliva, bacteria, and food Blood is withdrawn from the body Plastic surgery is often performed to
debris. It is the chief cause of tooth in the same way as for a blood donation repair damage caused by severe burns
decay (see caries, dental) and gingivitis and the plasma portion of the blood or injuries, cancer, or some operations,
(gum disease), and forms the basis of is removed by machines known as cell such as mastectomy (removal of breast tis-
a hard deposit (see calculus, dental). separators. The blood cells are mixed sue). Some congenital conditions may
Some of the microorganisms found in with a plasma substitute and re-turned also require plastic surgery; these include
plaque, particularly the bacterium STREP- to the circulation in the same way as for cleft lip and palate, hypospadias (a defect P
TOCOCCUS MUTANS , break down sugar in a blood transfusion. in the penis), and imperforate anus (see
the remains of carbohydrate food that Plasmapheresis is used to remove anus, imperforate).
sticks to the mucus, creating an acid damaging antibodies or immune complexes Techniques that are used in plastic
that can erode tooth enamel. (antibody–antigen particles) from the surgery include skin grafts, skin flaps, and
circulation in various autoimmune disor- Z-plasty; these may be combined with
plasma ders such as myasthenia gravis and implants or a bone graft.
The fluid part of blood that remains if Goodpasture’s syndrome.
the blood cells are removed. Plasma is a -plasty
solution that contains many nutrients, plasma proteins A suffix meaning “shaping by surgery”.
salts, and proteins. Proteins that are present in blood The term is usually used to describe
plasma. These proteins include albumin, various procedures in plastic surgery,
plasma D-dimers blood clotting proteins, and immuno- such as rhinoplasty (surgery on the
Substances formed in the body by the globulins (which are active in the nose) and mammoplasty (reshaping or
breakdown of blood clots (see blood immune system). In addition to their reconstruction of the breast).
clotting); for example, when the body specific roles, the plasma proteins help
clears blocked blood vessels. Tests that to maintain blood volume by prevent- platelet
can detect plasma D-dimers can be ing the loss of water from the blood The smallest type of blood cell; also
helpful in monitoring conditions such into the tissues. The proteins keep the called a thrombocyte. Platelets play a
as disseminated intravascular coagulation water in the blood by a phenomenon major role in blood clotting. When they
or in deciding whether someone may called osmotic pressure (see osmosis). If are activated, for example by contact
have had a pulmonary embolism or proteins are lost from the plasma, with damaged blood-vessel walls, they
deep vein thrombosis (see thrombosis, excessive amounts of fluid may build clump together at injury sites, releasing
deep vein). These tests are not used to up in the tissues; this fluid build-up is a chemicals that constrict the damaged
make or confirm a diagnosis, but the condition called oedema. blood vessels and trigger the process of

613
 PLATYHELMINTH

Pneumothorax (air in the pleural cavity) plication

may result in collapse of a lung; the A surgical procedure in which tucks are
condition may occur spontaneously or made in the walls of a hollow organ
may result from a penetrating injury. and then stitched in order to decrease
Cancerous tumours (see mesothelioma) the size of the organ.
may also develop in the pleura.
Plummer–Vinson syndrome
pleural effusion Difficulty in swallowing due to webs of
An accumulation of fluid between the tissue forming across the upper oesopha-
layers of the pleura (the membrane lin- gus. The syndrome often occurs along
ing the lungs and chest cavity). Pleural with severe iron-deficiency anaemia and
Scanning electron micrograph of platelets
This SEM shows activated platelets (also called
effusion may be caused by lung infec- affects middle-aged women.
thrombocytes) magnified 13,000 times. Platelets tions such as pneumonia or tuberculosis,
play an important role in blood clotting. or other lung disorders such as pul- plutonium
monary embolism, or mesothelioma (a A radioactive metallic element which
clot formation. A deficiency of platelets tumour of the pleura). It may also result occurs naturally only in uranium ores; it
(a condition called thrombocytopenia) from heart failure or cancer. Pleural effu- is produced artificially in breeder reac-
can cause certain bleeding disorders. sion may affect one or both sides of the tors. It is used as a fuel in nuclear
chest. The excess fluid puts pressure on reactors and nuclear weapons. The ele-
platyhelminth the lung beneath, gradually making ment is highly toxic if it enters the body,
A flat or ribbon-shaped parasitic worm breathing difficult. because it emits high levels of radiation
(see liver fluke; schistosomiasis; tapeworm). Diagnosis is confirmed by chest X-ray. and is absorbed into the bone marrow,
Some fluid may be removed with a nee- where it may remain for many years.
play therapy dle and syringe and examined to find
A method used in the psychoanalysis of the cause of the condition. A biopsy (tis- PMS
young children, based on the principle sue sample) of the pleura may also be The abbreviation often used for premen-
that all play has some symbolic signifi- needed. The underlying cause is treated; strual syndrome.
cance. Watching a child at play helps a fluid may also be drained off to relieve
therapist diagnose the source of the breathing problems. PMT
child’s problems; the child can then be The abbreviation for premenstrual
helped to “act out” thoughts and feel- pleurisy tension, an alternative name for premen-
ings that are causing anxiety. Inflammation of the pleura (the mem- strual syndrome.
brane lining the lungs and chest cavity).
plethora Causes include lung infections, such as pneumaturia
A florid, bright-red, flushed complexion. pneumonia, or, more rarely, pulmonary The presence of gas, including air, in the
It may be caused by dilation of blood ves- embolism, lung cancer, or rheumatoid arthri- urine. Pneumaturia usually indicates that a
sels, or, less commonly, by polycythaemia tis. Pleurisy causes a sharp chest pain, fistula (abnormal channel) has developed
P (excessive numbers of red blood cells). which is worse when breathing in; this between the bladder and the intestine.
pain is due to the inflamed layers of the
plethysmography membrane rubbing together. Treatment pneumo-
A way of estimating the blood flow in of the condition is aimed at the under- A prefix meaning related to the lungs,
vessels by measuring changes in the size lying cause, and analgesic drugs (pain- to air, or to the breath.
of a body part. Plethysmography of the killers) are also given.
penis is sometimes used to investigate pneumococcus
impotence in men by establishing whether pleurodynia A common name for the bacterium
or not a man has erections while sleeping. Pain in the chest, also known as Born- STREPTOCOCCUS PNEUMONIAE (see Streptococ-
holm disease. Pleurodynia is caused by cal infections).
pleura coxsackievirus B infection. It often occurs
A thin, two-layered membrane, one in epidemics and usually affects children. pneumoconiosis
layer covering the outside of the lungs There is sudden severe pain in the Any of a group of lung diseases that
and the other lining the inside of the lower chest or upper abdomen, with are caused by the inhalation of certain
chest cavity. Fluid in the pleural cavity fever, sore throat, headache, and malaise. mineral dusts. Dust particles of less
(the space between the two layers) pro- The disease usually settles in three to than 0.005 mm across can reach the
vides lubrication, allowing for the four days without treatment. air sacs in the lungs (see alveolus, pul-
smooth expansion and contraction of monary); they may accumulate and
the lungs during breathing. plexus cause thickening and scarring. As a
DISORDERS A network of interwoven nerves or result, the lungs may become less effi-
Pleurisy(inflammation of the pleura) is blood vessels. Examples include the solar cient at supplying oxygen to the blood.
usually due to a lung infection, such as plexus (the large network of nerves just TYPES AND CAUSES
pneumonia or tuberculosis, and may lead behind the stomach) and the brachial The main types of pneumoconiosis are
to pleural effusion (a buildup of excess plexus (a network of nerves in the neck asbestosis (see asbestos-related dis-
fluid between the layers of the pleura). and upper arm). eases), coal workers’ pneumoconiosis,

614
 PNEUMOTHORAX

and silicosis, caused by silica dust. cate the infection; lower doses are used the lungs and chest cavity), a lung
These diseases primarily affect workers in the long term to prevent infection in abscess (collection of pus), and septi-
over 50 years of age. However, the people at increased risk. caemia (blood poisoning).
incidence is falling due to better pre- DIAGNOSIS AND TREATMENT
ventive measures. pneumonectomy Diagnosis is made by physical examina-
SYMPTOMS AND COMPLICATIONS Surgery carried out to remove a lung. tion, chest X-ray, and examining sputum
The main symptom of pneumoconiosis and blood for microorganisms. Treatment
is shortness of breath. In severe cases, pneumonia depends on the cause, and usually includes
cor pulmonale (right-sided heart failure Inflammation of the lungs usually due antibiotic drugs. Aspirin or paracetamol may
due to lung damage) or emphysema to infection. There are two main types: be given to reduce fever, and, in severe
(destruction of the air sacs in the lungs) lobar pneumonia and bronchopneu- cases, oxygen therapy and artificial ventila-
may develop. The risk of tuberculosis is monia. Lobar pneumonia first affects tion may be needed.
increased in coal workers’ pneumoco- one lobe of a lung. In the condition In most cases, recovery usually occurs
niosis and silicosis; the risk of lung bronchopneumonia, inflammation ini- within two weeks.
cancer is increased in asbestosis. Smok- tially starts in the bronchi and bronchioles
ing further increases the risk. (airways), then spreads to affect patches pneumonitis
DIAGNOSIS AND TREATMENT of tissue in one or both lungs. Inflammation of the lungs that may
Pneumoconiosis is often detected by a CAUSES cause coughing, breathing difficulty,
chest X-ray before symptoms develop. Pneumonia is usually caused by various and wheezing. Causes include an aller-
Diagnosis is also based on a history of types of infection. Most cases are due gic reaction to dust containing animal
exposure to dusts, medical examina- either to viruses, such as adenovirus or or plant material (see alveolitis) and
tion, and pulmonary function tests. respiratory syncytial virus, or to bacteria, exposure to radiation (see radiation haz-
There is no treatment for the condi- such as STREPTOCOCCUS PNEUMONIAE, HAEMO- ards). Pneuomonitis may also occur as
tion apart from treating any compli- PHILUS INFLUENZAE , S TAPHYLOCOCCUS AUREUS , a side effect of drugs, such as amio-
cations. Further exposure to any dust and MYCOPLASMA PNEUMONIAE. darone and azathioprine.
must be avoided. Another form is aspiration pneumo-
nia, due to accidental inhalation of pneumothorax
pneumocystis pneumonia vomit. Aspiration pneumonia usually A condition in which air enters the
A lung infection caused by PNEUMOCYSTIS occurs in people whose cough reflex is pleural cavity (the space between the
CARINII , a type of protozoa. Pneumocystis not functioning, such as those who layers of membrane lining the lung),
pneumonia is an opportunistic infection, have drunk excessive amounts of alco- causing partial or total collapse of the
which is dangerous only to people with hol or taken certain illegal drugs, or lung. The air may enter the lungs from
impaired resistance to infection. It is par- people who have suffered a head injury. the airways or from outside the body.
ticularly common in those with AIDS. SYMPTOMS AND COMPLICATIONS CAUSES
Symptoms include fever, dry cough, and Symptoms usually include fever, chills, The most common cause is the sponta-
shortness of breath, and may last for sev- shortness of breath, a sharp chest pain, neous rupture of an enlarged alveolus
eral weeks or months. and a cough that produces yellow-green (air sac). This occurrence is much more
Diagnosis is made by examination sputum and occasionally blood. common in men than in women; it P
of sputum or a lung biopsy (tissue Potential complications include pleural usually affects tall, thin young men who
sample). High doses of antibiotic drugs effusion (fluid around the lung), pleurisy have no underlying lung disease. Other
(commonly co-trimoxazole) may eradi- (inflammation of the membrane lining possible causes include a penetrating

PNEUMONIA

Pneumonia is not a single disease,

but the name for several types of
lung inflammation usually caused Trachea
by infectious organisms. In some
cases, accidental inhalation of vomit Bronchus
or a liquid may start an infection. The
symptoms, treatment, and outcome
Upper lobe
vary greatly, depending on the
cause and on the general health Middle lobe
of the patient.

Bronchiole

Chest X-ray in lobar pneumonia

Area most
Lobar pneumonia commonly
The X-ray clearly shows lobar pneumonia in the
In this type of pneumonia, the inflammation is affected patient’s right lung (on the left in the image).
usually confined to just one lobe of one lung, by lobar The blotchy white areas within the darker areas
often a lower lobe. pneumonia Lower lobe correspond to patches of inflamed lung.

615
 POCKET, GINGIVAL

chest wound that allows air into the posure to poisonous substances in indus- ostomy (surgical creation of an opening in
pleural cavity, or a fractured rib that try, or by drug abuse. Poisoning may also the windpipe for a breathing tube), and
tears the lung beneath it. be a deliberate attempt to commit suicide. artificial ventilation are needed.
SYMPTOMS Antidotes may be available to coun- OUTLOOK
The main symptoms of pneumothorax teract the effects of the poison. Recovery from nonparalytic polio is
are chest pain or shortness of breath, complete. More than half of those with
which varies depending on the size of polio paralysis make a full recovery, fewer
the pneumothorax. If air continues to An abbreviation for poliomyelitis. than a quarter are left with severe dis-
leak, the pneumothorax may grow to ability, and fewer than 1 in 10 dies.
produce a tension pneumothorax. This poliomyelitis PREVENTION
condition may be life-threatening. It Also called polio, a highly infectious In the UK, vaccination against polio is
causes an area of high pressure that disease caused by the polio virus. It is given at approximately two, three, and
compresses the lung and heart tissues, usually mild, but in serious cases, it four months, with a booster dose given
preventing the passage of oxygen-rich attacks the brain and spinal cord, some- between the ages of three and five, and
blood from the lungs to the heart. times causing paralysis or death. again on leaving school (see immuniza-
DIAGNOSIS AND TREATMENT CAUSE AND INCIDENCE tion). Parents and carers should also
Diagnosis is confirmed by chest X-ray. A The virus is spread from the faeces of keep their immunization up-to-date.
small pneumothorax may disappear in a infected people to food. Airborne trans-
few days without treatment. A larger one, mission also occurs. In countries with pollen
or one associated with underlying lung poor hygiene and sanitation, most chil- Dustlike grains produced by the male
disease, may need hospital treatment. This dren develop immunity through being sexual organs of plants for fertilizing
involves removing the air through a tube infected early in life, when the infection the female organs. Pollens from flowers,
with a one-way valve, known as a chest rarely causes serious illness. In countries grasses, and some other plants may
drain, to allow the lung to reinflate fully. with better sanitation, this does not produce allergic reactions (see allergy)
occur and, if children are not vaccinat- in humans and cause disorders such hay
pocket, gingival ed, epidemics can occur. In the UK, fever (see rhinitis, allergic).
A feature of marginal periodontitis. however, polio is now very rare due to a
vaccination programme. pollution
podiatry SYMPTOMS Contamination of the environment by
Another name for chiropody, a paramed- Most infected children have no symp- poisons, radioactive substances, microor-
ical speciality concerned with the feet. toms at all. In others, however, there is ganisms, or other wastes.
usually an incubation period of seven to
podophyllin 14 days, after which a slight fever, sore poly-
A drug used to treat genital warts (see throat, headache, and vomiting occur. A prefix meaning “many” or “much”.
warts, genital). Podophyllin may cause Most children recover completely
irritation of the treated area and severe after a few days. In some, however, polyarteritis nodosa
toxicity on excessive application. inflammation of the meninges (mem- Also called periarteritis nodosa, an
P branes surrounding the brain and spinal uncommon form of vasculitis (inflam-
poison cord) may develop. This condition caus- mation of blood vessels), affecting
A substance that, in small amounts, dis- es fever, severe headache, stiff neck and medium-sized arteries. Areas of arterial
rupts the structure and/or function of back, and aching muscles, sometimes wall become inflamed, weakened, and
cells. (See also drug poisoning; poisoning.) with widespread twitching. In a few liable to aneurysms (ballooned-out seg-
cases, extensive paralysis, usually of the ments). The severity of the condition
poisoning legs and lower trunk, then develops depends on the arteries that are affect-
Poisons may be swallowed, inhaled, abs- within a few days. If the infection ed and how much they are weakened.
orbed through the skin, or injected under spreads to the brainstem, the affected CAUSE AND INCIDENCE
the skin (as with an insect sting). They person may find it difficult or impossible The cause seems to be an immune sys-
may also originate within the body, for to breathe and swallow. tem disturbance, sometimes triggered
example when bacteria produce endotox- DIAGNOSIS by exposure to the hepatitis B virus. It is
ins, or when metabolic disorders produce Diagnosis is made from a sample of most common in adults and affects
poisonous substances or allow them to cerebrospinal fluid (see lumbar puncture), men more than women.
accumulate. Poisoning may be acute, if a a throat swab, a faeces sample, or blood SYMPTOMS
large amount of poison enters the body in tests for antibodies to the virus. Paralysis Early symptoms of polyarteritis nodosa
a short time, or chronic, resulting from a occurring with an acute feverish illness include fever, aching muscles and
gradual accumulation of poison that is is characteristic of severe polio, and an joints, general malaise, loss of appetite
not quickly eliminated from the body. immediate diagnosis can often be made. and weight, and, sometimes, nerve
Unintentional poisoning occurs most TREATMENT pain. There may also be hypertension
commonly in young children. Adults There is no effective drug treatment for (high blood pressure), skin ulceration,
may be poisoned by mistaking the polio. Nonparalytic patients usually need and gangrene (localized tissue death). If
dosage of a prescribed drug (see drug bed rest and analgesic drugs (painkillers). the coronary arteries are affected,
poisoning), by taking very high doses of If the person is paralysed, physiotherapy myocardial infarction (heart attack) may
vitamin or mineral supplements, by ex- and, in some cases, catheterization, trache- occur. Many patients suffer abdominal

616
 POLYHYDRAMNIOS

pain, nausea, vomiting, diarrhoea, and OUTLOOK cythaemia. Treatment is by venesection

blood in the faeces. The condition may In the long term, women with polycys- (bloodletting) sometimes in combination
occasionally lead to kidney failure. tic ovary syndrome are at an increased with anticancer drugs or with radioactive
DIAGNOSIS, TREATMENT, AND OUTLOOK risk of developing diabetes mellitus dur- phosphorus. This enables most patients to
Diagnosis is made by biopsy (tissue sam- ing pregnancy and in later life. Obesity survive for 10 to 15 years.
pling) and angiography. Large doses of leads to a greater risk of atherosclerosis
corticosteroids, and in some cases immuno- and hypertension (high blood pressure). polydactyly
suppressants, may allow survival for at High levels of oestrogen may also A birth defect in which there is an exces-
least five years. Without treatment, few increase the risk of developing endo- sive number of fingers or toes. The extra
patients survive for this length of time. metrial cancer (see uterus, cancer of). digits may be fully formed or they may be
fleshy stumps. Polydactyly often runs in
polyarthritis polycythaemia otherwise normal families; however, it
Any form of arthritis (joint inflammation) A condition in which an increased pro- may also occur as part of Laurence–
that affects several joints at once. It may duction of red blood cells leads to an Biedl–Moon syndrome or some other con-
be a complication of infections such as unusually large number of them in the genital syndromes.
rubella, gastroenteritis, or sexually transmit- blood.This disorder is usually caused by
ted infections (see reactive arthritis). Other another disorder or by hypoxia (reduced
arthritic conditions that can cause poly- oxygen in the blood and body tissues),
arthritis include rheumatoid arthritis, osteo- in which cases it is called secondary
arthritis, and juvenile chronic arthritis. polycythaemia. If the increase in red
blood cells occurs for no apparent rea-
polycystic kidney son, it is called polycythaemia vera or
See kidney, polycystic. primary polycythaemia.
SECONDARY POLYCYTHAEMIA
polycystic ovary syndrome Secondary polycythaemia occurs natu-
A condition, previously known as rally at high altitudes due to the
Stein–Leventhal syndrome, that is charac- reduced oxygen level. It can also result
terized by multiple ovarian cysts together from a disorder that impairs the oxygen Polydactyly
with oligomenorrhoea (scanty periods) supply to the blood, such as chronic Polydactylic digits are sometimes fully formed but
or amenorrhoea (absence of periods), bronchitis (see pulmonary disease, chron- are most often rudimentary (undersized). They are
usually removed surgically during childhood.
reduced fertility, hirsutism (excessive hair- ic obstructive). In these cases, the low
iness), and obesity. Most women with level of oxygen in the blood stimulates
the syndrome begin menstruation at a the kidneys to produce a hormone polydipsia
normal age, but between the ages of 15 called erythropoietin, which in turn Persistent excessive thirst (see thirst, ex-
and 30 periods become irregular and stimulates the bone marrow to produce cessive). Examples of conditions that
then cease. Hirsutism and obesity occur more red cells and thus compensate for can cause polydipsia include diabetes
in about half of all cases. the lack of oxygen. Secondary poly- mellitus and diabetes insipidus.
CAUSES cythaemia may also be secondary to P
The condition is now thought to result liver cancer, some kidney disorders, or polyhydramnios
from insulin resistance, which leads to heavy smoking. Excess amniotic fluid surrounding the
the overproduction of insulin. This situ- Descending to sea level, or effective fetus during pregnancy.
ation is associated with increased levels treatment of an underlying disorder, CAUSES
of androgen hormones, giving rise to returns the blood to normal. The condition often has no known
symptoms. Polycystic ovary syndrome POLYCYTHAEMIA VERA cause. It sometimes occurs if the fetus
may also have a genetic element. Polycythaemia vera is a rare disorder has a malformation that makes normal
DIAGNOSIS AND TREATMENT that mainly affects people over the age swallowing impossible, or if the preg-
A diagnosis of polycystic ovary syn- of 40. The large number of red blood nant woman has diabetes mellitus.
drome is based on the patient’s history, cells causes increased volume and thick- SYMPTOMS
measurement of hormone levels, and ening of the blood, which may lead to The excess amniotic fluid usually accu-
ultrasound scanning of the ovaries. Treat- headaches, blurred vision, and hyperten- mulates during the second half of
ment depends on which aspect of the sion (high blood pressure). There may pregnancy, producing symptoms from
condition most concerns the patient. also be flushed skin, dizziness, night about week 32. The main symptom is
Weight reduction often brings about an sweats, and widespread itching. The abdominal discomfort. Other possible
improvement in all other symptoms spleen is often enlarged. symptoms are breathlessness and swell-
and the return of regular periods. Met- Possible complications include a ten- ing of the legs (see oedema). The uterus
formin, an oral hypoglycaemic drug, may dency to bleed easily or for the blood to is larger than expected.
be used to reduce insulin resistance and clot; stroke; and disorders affecting the Occasionally, acute polyhydramnios
as an aid to weight loss; hirsutism may bone marrow, such as myelofibrosis or occurs. Fluid collects rapidly, causing
respond to treatment with an anti- acute leukaemia (see leukaemia, acute). abdominal pain, breathlessness, nausea,
androgen drug, such as cyproterone; Diagnosis is made from a physical vomiting, and leg swelling. The abdo-
fertility treatment with the anti-oestro- examination and blood tests and by ruling men becomes tense, and the skin is
gen drug clomifene is often successful. out other possible causes of poly- shiny. Premature labour may occur.

617
 POLYMERASE CHAIN REACTION (PCR)

DIAGNOSIS AND TREATMENT polyp polyunsaturated fats

The condition is usually evident from a A growth that projects, usually at the Fats (see fats and oils) with relatively few
physical examination, but ultrasound end of a stalk, from the lining of the hydrogen atoms in their chemical struc-
scanning may be needed. In mild cases, nose, the cervix, the intestine, the lar- ture. Polyunsaturated fats tend to protect
only rest is needed. In more severe ynx, or from any other mucous mem- against cardiovascular disease.
cases, amniotic fluid may be withdrawn brane. Some types of polyp are liable to
using a needle. In late pregnancy, induc- develop into cancer, and these types are polyuria
tion of labour may be performed. surgically removed. See urination, excessive.
polymerase chain reaction polypeptide PoM
(PCR) A compound made up of many peptides. The abbreviation for prescription-only
A method of rapidly copying DNA se- medicine.
quences so that they can be analysed. polypharmacy
The practice of prescribing several drugs pompholyx
polymorphic light eruption to one person at the same time. Combina- An acute form of eczema in which itchy
(PLE) tions of drugs may be more effective than blisters form on the palms and/or soles.
A common skin condition that occurs single drugs and may reduce the risk of The condition, also called dyshydrotic
in people who are sensitive to light (see drug resistance. However, polypharmacy eczema, is sometimes due to an allergic
photosensitivity) and results from expo- increases the risk of drug interactions response. Rarely, it is associated with
sure to ultraviolet light rays in sunlight. and, as a result, the risk of adverse effects. fungal infections of the skin. Treatment is
PLE is thought to be a form of delayed with an emollient and topical application
allergy, but the cause is unknown. polyposis, familial of a corticosteroid drug.
Light causes an itchy rash of papules adenomatous
(raised bumps) to develop on exposed A rare, inherited disorder, also known pons
areas of skin. The rash may last for sev- as polyposis coli, in which many polyps The middle part of the brainstem.
eral days. Sunblock should be used as a are present throughout the large intes-
preventative measure. A mild case of PLE tine, but mainly in the colon. If familial Ponstan
may be treated by applying a topical adenomatous polyposis (FAP) is not A brand name for the nonsteroidal anti-
steroid. In severe cases, a short course of treated, cancer of the colon (see colon, inflammatory drug mefenamic acid.
oral steroids can be used to prevent or cancer of) is almost certain to develop.
treat an attack. Controlled exposure to The polyps may appear from the age POP
ultraviolet light (see phototherapy) may of ten. They may cause bleeding and An abbreviation for “progestogen-only
reduce the symptoms in resistant cases. diarrhoea; however, there are often no pill” (see oral contraceptives) and for
symptoms until cancer has developed. “plaster of Paris” cast.
polymyalgia rheumatica The polyps are detected by colonoscopy
An uncommon disease that occurs in (examining the interior of the colon popliteal cyst
elderly people, which is marked by pain with a viewing instrument). A fluid-filled sac that develops at the
P and stiffness in the muscles of the hips, There is a 50 per cent chance that a back of the knee. The cysts may occur
thighs, shoulders, and neck. Symptoms child of an affected person will inherit in both adults and children, but for dif-
are worse in the mornings. The cause is the disease, so medical surveillance is ferent reasons.
unknown, but the condition may be necessary from about the age of 12. In children, the condition may be
associated with temporal arteritis. It is Individual polyps may be heat-treated due to a swollen bursa (fluid-filled
unusual before the age of 50. (see cauterization). Since there is a high pad) behind the knee; the cause is un-
The diagnosis is often difficult to con- risk of developing cancer; a colectomy known, but not related to any knee
firm; it is based on the patient’s history, and ileostomy are often performed. problem. These cysts usually cause no
a physical examination, and blood tests symptoms and disappear spontaneously.
(including an ESR). If temporal arteritis polysaccharide In adults, the cysts usually result from
is suspected, a biopsy (removal of a A carbohydrate that is formed from many conditions that cause chronic swelling
tissue sample for analysis) may be per- monosaccharides (simple sugar mole- or an accumulation of fluid in the knee
formed on an artery at the side of the cules) joined together. Examples of joint. One possible cause is osteo-
scalp. Corticosteroid drugs usually im- polysaccharides include glycogen (the arthritis; others include injuries to the
prove the condition within a few days. main form in which carbohydrates are meniscus (cartilage inside the knee) or
stored in the body); starch, a form of to the ligaments, which allow synovial
polymyositis carbohydrate obtained from fruits, veg- fluid (which lubricates joints) to escape
A rare disease in which the muscles are etables, and cereals; and cellulose, an from the joint capsule.
inflamed and weak. indigestible material found in plant-based Most popliteal cysts disappear with-
foods (see fibre, dietary). out treatment, although some may
polymyxins rupture, resembling a deep vein thrombo-
A group of antibiotic drugs derived from Polytar sis (DVT). A diagnosis of DVT must be
the bacterium BACILLUS POLYMYXA. Poly- A brand name for liquid preparations excluded before treatment with rest and
myxins, which include the drug colistin, containing coal tar, used in treatments analgesic drugs. In some cases, the cyst
are given to treat eye and skin infections. for dandruff, eczema, and psoriasis. may need to be removed surgically.

618
 PORTAL HYPERTENSION

pore Avoiding sunlight and/or precipitating lymph nodes, or to inflammation result-

A tiny opening, usually in the skin. drugs is the most important measure. ing from an infection). In tropical areas,
Acute intermittent porphyria, hereditary a common cause is disease that causes
porphyria coproporphyria and variegate porphyria the spleen to enlarge and results in an
Any of a group of rare, often inherited may be helped by the administration of increased blood flow from the spleen
disorders caused by the accumulation of glucose or hemin (a substance that is through the portal vein.
substances called porphyrins. chemically related to haem). Cases of A rare cause of portal hypertension is
CAUSES porphyria cutanea tarda may sometimes an abnormal connection that occurs
Porphyrins are chemicals formed in the be helped by venesection (withdrawing between the portal vein and an artery
body during the manufacture of haem blood from a vein). (see arteriovenous fistula); this type is
(a component of haemoglobin, the oxy- usually the result of injury.
gen-carrying pigment in red blood portal hypertension SYMPTOMS
cells). A block in this process causes a Increased blood pressure in the portal Symptoms may only appear once com-
buildup of porphyrins, which can act as vein, which carries blood from the plications have developed. Ruptured
a poison. Such blocks may result from stomach, intestines, and spleen to the oesophageal varices lead to massive,
various genetic enzyme deficiencies. Por- liver. The pressure causes oesophageal recurrent vomiting of blood and pro-
phyria may also be due to poisoning. varices (widened veins in the oesopha- duce black faeces (melaena). Ascites
TYPES AND SYMPTOMS gus), which may rupture and cause results in abdominal swelling and dis-
There are six types of porphyria, each of internal bleeding. In addition, fluid is comfort, and sometimes difficulty in
which has different symptoms. Sufferers forced out of the overloaded portal breathing. In addition, the veins that are
often have a rash or blistering brought on vein, resulting in ascites (accumulation situated just under the skin of the abdo-
by sunlight, and may have abdominal of fluid in the abdomen). men may be visibly swollen.
pain and nervous system disturbances due CAUSES DIAGNOSIS
to the effects of certain drugs or alcohol. The most common cause of portal Diagnosis is usually made from the
Acute intermittent porphyria This form hypertension is cirrhosis of the liver, in symptoms and signs. Doppler ultrasound
usually appears in early adulthood, which areas of scar tissue in the liver scanning may be used to assess the pres-
causing abdominal pain, and often limb obstruct the portal vein. Another possi- sure in the portal vein.
cramps, muscle weakness, and psychi- ble cause is thrombosis (abnormal blood TREATMENT
atric disturbances. The patient’s urine clotting) due to narrowing of the portal Various treatments may be used to reduce
turns red when left to stand. Barbiturate vein. The narrowing may be congenital blood pressure and to stop bleeding or
drugs, phenytoin, oral contraceptives, and (present from birth), appear shortly prevent further bleeding. For example,
certain other drugs precipitate attacks. after birth, or develop later in life (due ruptured blood vessels may be treated by
Variegate porphyria This condition has to compression of the vein by enlarged sclerotherapy, in which a chemical is
similar effects to acute intermittent por-
phyria, and may be caused by the same
drugs. An additional symptom is blister- PORTAL HYPERTENSION
ing on skin that is exposed to sunlight.
Hereditary coproporphyria This form also
The most common cause of portal hypertension is cirrhosis of the liver or some
other obstruction to the blood flow through the liver. The portal vein becomes
P
has similar effects to acute intermittent congested with blood, with the result that back pressure develops through the
porphyria, and may cause additional system of veins that join the portal vein.
skin symptoms.
Protoporphyria In this form of porphyria, Oesophageal varices
mild skin symptoms appear after expo- The back pressure may
sure to sunlight. cause oesophageal veins
to widen and rupture.
Porphyria cutanea tarda This condition
causes blistering of skin that is exposed Liver Enlarged
to the sun, but with no disturbances of spleen
the digestive or nervous systems.
Wounds are slow to heal, and urine is
sometimes pink or brown. Many cases Normal action Portal vein
are precipitated by liver disease. of portal vein
Congenital erythropoietic porphyria This The vein carries nutrient-
rich blood from the
is the rarest and most serious form of abdominal organs to the
porphyria. It causes red discoloration of liver for processing.
urine and teeth, excessive hair growth,
severe skin blistering and ulceration, Portal vein Back pressure
and haemolytic anaemia. Death may Features of portal hypertension
occur in childhood. The portal vein becomes congested, the
DIAGNOSIS AND TREATMENT pressure in it rises, fluid is forced out into From stomach
Diagnosis is made from abnormal levels the abdomen, and veins that supply the
portal vein are widened and may rupture. From intestines
of porphyrins in the urine and faeces.
Treatment of porphyria is difficult.

619
 PORT-WINE STAIN

injected into the veins to block them. A common, and least serious, is irritation (infection of the genital tract after child-
shunt is sometimes carried out to prevent of the genital tissues (see vulvovaginitis). birth), including inspection of the lochia
further bleeding. Ascites is controlled by Other causes include cervical erosion; (vaginal discharge after childbirth). If
restriction of salt and with diuretic drugs. cervical cancer (see cervix, cancer of); the woman has had an episiotomy or if
growths in the uterus (see uterus, cancer she has torn tissue around the vagina, the
port-wine stain of; polyp); or, rarely, cancer of the vulva wounds are checked daily.
A purple-red birthmark that is a perma- or the vagina. All postmenopausal The woman is encouraged to walk as
nent, non-raised type of haemangioma. bleeding must be investigated in order soon as possible after the delivery to
Port-wine stains are a feature of to exclude the possibility of cancer. reduce the risk of thrombosis (abnormal
Sturge–Weber syndrome. blood clotting). If necessary, help is
postmenopausal osteoporosis given with feeding techniques (see bot-
positron emission tomography Osteoporosis (loss of bone density) in tle-feeding; breast-feeding). There may also
See PET scanning. women who have gone through the be instruction on various abdominal
menopause (the time when ovulation exercises and pelvic floor exercises, which
posseting and menstruation cease). In postmeno- can help to restore muscle tone.
A term for the regurgitation of small pausal women, thinning of the bones is A final postnatal check-up usually
quantities of milk by infants after they due to the sharp decrease in levels of takes place about six weeks after deliv-
have been fed. Posseting is common oestrogen hormones, which normally ery. The obstetrician or GP may check
and harmless. help to maintain bone mass. the woman’s blood pressure, weight,
breasts, haemoglobin levels, and emo-
postcoital contraception postmenopause tional state; may examine the uterus
See contraception, emergency. The period of a woman’s life following and bladder to make sure they are in the
the menopause (the time when ovulation correct positions; may check for urinary
posterior and menstruation cease). incontinence (see incontinence, urinary);
Relating to the back of the body, or may take a smear; and ensures that any
referring to the rear part. postmortem examination wounds are healing properly. Advice on
An alternative term for an autopsy. contraception may also be given.
postherpetic neuralgia
Burning pain due to nerve irritation (see postmyocardial infarction postnatal depression
neuralgia) occurring at the site of a pre- syndrome Depression in a woman after childbirth.
vious attack of herpes zoster (shingles). Another name for Dressler’s syndrome. The cause is probably a combination of
sudden hormonal changes and psycho-
postmaturity postnasal drip logical and environmental factors. The
A condition in which a pregnancy per- A watery or sticky discharge from the depression ranges from an extremely
sists for longer than 42 weeks; the back of the nose into the nasopharynx common and mild, shortlived episode
average length of a normal pregnancy is (the uppermost part of the throat, (“baby blues”) to a rare, severe depres-
40 weeks (see gestation). Postmaturity behind the nose), particularly at night sive illness: puerperal psychosis.
P may be associated with a family tenden- when a person is lying down. The fluid MILD DEPRESSION
cy to prolonged pregnancy. may cause a cough, hoarseness, or the Most mothers first get the “blues” four
Postmaturity is associated with a pro- feeling of a foreign body. The usual to five days after childbirth and may feel
longed labour and an increased risk of a causes are allergic rhinitis (inflammation miserable, irritable, and tearful.The feel-
difficult delivery; this is because a post- of the mucous membrane in the nose) ing is caused by hormonal changes,
mature fetus is larger than average, and and the common cold. Another cause, perhaps coupled with a sense of anticli-
the skull bones are harder and mould less in young children, is enlarged adenoids. max after the birth or an overwhelming
readily to fit through the birth canal. The sense of responsibility for the baby. With
risk of fetal death increases after 42 postnatal care reassurance and support, the depression
weeks because the placenta becomes less Care of the mother after childbirth until usually passes in two to three days.
efficient, causing the fetus to be starved about six weeks later. MORE SEVERE DEPRESSION
of oxygen and nutrients. Postmature After delivery, the mother’s tempera- In some women, postnatal depression
infants tend to have dry skin and may be ture, pulse, and blood pressure are lasts for several weeks and causes a con-
more susceptible to infection. monitored, especially after a caesarean stant feeling of tiredness, difficulty in
Many obstetricians attempt to prevent section or if there have been complica- sleeping, loss of appetite, and restless-
postmaturity by induction of labour as the tions, such as pre-eclampsia or bleeding. ness. The condition usually clears up of
pregnancy nears 42 weeks. The length of the stay in hospital its own accord or is treated with antide-
depends on whether or not there have pressant drugs and emotional support.
postmenopausal bleeding been any complications. Women used to PUERPERAL PSYCHOSIS
Abnormal vaginal bleeding in women remain in hospital for up to a week This condition causes severe mental
who have already gone through the after delivery, but nowadays the length confusion, feelings of worthlessness,
menopause (the time when ovulation of stay after a straightforward delivery threats of suicide or harm to the baby,
and menstruation cease). The bleeding may be only 48 hours or even less. Dur- and sometimes delusions. Admission to
may be a symptom of various disorders ing the hospital stay, a daily check is hospital, ideally with the baby, and anti-
of the reproductive organs. The most made for any signs of puerperal sepsis depressant drugs are often needed.

620
 POTENCY

postpartum depression include flashbacks (recurring memories results from loss of fluids through diar-
See postnatal depression. or dreams of the event), a sense of pers- rhoea and/or vomiting, and causes
onal isolation, and disturbed sleep and fatigue, drowsiness, dizziness, and mus-
postpartum haemorrhage concentration. There may be a deaden- cle weakness. Children are particularly
Excessive blood loss after childbirth. It is ing of feelings, or irritability and feelings susceptible to this form of potassium
more common after a long labour or of guilt, sometimes building up to loss. In more severe cases of hypo-
after a multiple birth. depression. The symptoms may be wors- kalaemia, there may be abnormal heart
CAUSES AND SYMPTOMS ened by any reminder of the trauma. rhythms and muscle paralysis.
Most cases of postpartum haemorrhage Most people recover, in time, with Other potential causes of hypokal-
occur immediately after delivery (pri- emotional support and counselling. aemia include any prolonged treatment
mary postpartum haemorrhage) and are However, prolonged physical and emo- that involves taking diuretic drugs or cor-
due to excessive bleeding from the site tional trauma (such as that experienced ticosteroid drugs; overuse of laxative drugs;
where the placenta was attached to the in a concentration camp) may scar a diabetes mellitus; Cushing’s syndrome (over-
uterus. Normally, once the placenta is person psychologically for life, altering production of corticosteroid hormones
delivered, contractions of the uterus his or her personality. by the adrenal glands); aldosteronism
constrict the blood vessels at the site, (overproduction of the hormone aldo-
and stop the bleeding. Excessive bleed- postural drainage sterone by the adrenal glands); certain
ing may be caused by failure of the A technique that enables sputum kidney diseases; excessively high intake
uterus to contract efficiently after deliv- (phlegm) or other secretions to drain of coffee or alcohol; and extremely pro-
ery. It may also be due to the retention from a person’s lungs in order to clear fuse sweating.
of placental tissue within the uterus. the lungs and so ease breathing. POTASSIUM EXCESS
Haemorrhaging immediately after Postural drainage is used in the treat- Excess potassium in the blood is known
delivery may also be caused by tears ment of cystic fibrosis and bronchiectasis, as hyperkalaemia and is much less com-
anywhere along the birth canal. Tearing a lung disorder. The person lies on his mon than hypokalaemia. It may be due
is more likely to occur during a forceps or her front or side, with the head to excessive intake of potassium supple-
delivery or a breech delivery. In some lower than the chest. This position ments, severe kidney failure, Addison’s
cases, however, postpartum haemor- allows the secretions to drain by gravity, disease, or prolonged treatment with
rhage occurs because the mother has a into the trachea (windpipe), from potassium-sparing diuretics. The effects
bleeding disorder. where they can be coughed up. Tapping of high potassium levels in the blood
Occasionally, haemorrhage occurs the person’s chest with cupped hands can include numbness and tingling, dis-
with pain and fever between five and can help to loosen sticky secretions. turbances of the heart rhythm, and
10 days after delivery (secondary post- muscle paralysis. In severe cases, there
partum haemorrhage). In these cases of postural hypotension may be heart failure.
haemorrhage, the cause is usually infec- See hypotension.
tion of a retained fragment of placenta. potassium channel activators
TREATMENT posture A class of drugs that are used in the pre-
A blood transfusion may be given to The relative positions of different parts vention and long-term treatment of
replace lost blood, and emergency treat- of the body when a person is at rest or angina (chest pain due to inadequate P
ment may be needed for shock (a severe during movement. Good posture con- blood supply to the heart). Nicorandil
drop in blood pressure, which may be sists of balancing the body weight is a potassium channel activator that
due to heavy blood loss). Other treat- around the body’s centre of gravity, acts in a similar way to nitrates, and
ment depends on the cause of the which is in the lower spine and pelvis. widens both arteries and veins. Possible
haemorrhage. Any retained placental Maintaining good posture helps pre- side effects of taking potassium channel
tissue may need to be removed; an in- vent neck pain and back pain. activators include flushing, nausea,
jection of a drug such as ergometrine vomiting, and dizziness.
may be given to stimulate uterine con- post-viral fatigue syndrome
tractions; and any lacerations that have See chronic fatigue syndrome. potassium citrate
been made in the vagina or on the A substance used to relieve discomfort
cervix are sutured (stitched). Antibiotic potassium in mild urinary tract infections by making
drugs are used to treat infection and iron A metallic mineral needed to help main- the urine less acid.
supplements may be needed to counter- tain normal heart rhythm, regulate the
act iron deficiency due to blood loss. body’s water balance, conduct nerve potassium permanganate
impulses, and contract muscles. A drug that has an antiseptic and astrin-
post-traumatic stress disorder Many foods contain potassium; par- gent effect and is used to treat dermatitis.
A form of anxiety that develops after a ticularly rich dietary sources include Potassium permanganate can occasion-
stressful or frightening event. Common lean meat, whole grains, green leafy ally cause irritation and can also stain
causes include natural disasters, vio- vegetables, beans, and various fruits, skin and clothing.
lence, rape, torture, serious physical such as apricots, dates, and peaches.
injury, and military combat. POTASSIUM DEFICIENCY potency
Symptoms may develop immediately When there is a low level of potassium The ability of a man to perform sexual
after the event or may not appear for in the blood, the condition is known as intercourse; or the ability of a drug to
many months or years afterwards. They hypokalaemia. This condition usually cause desired effects.

621
 POTT’S FRACTURE

Pott’s fracture Underdevelopment of sexual organs, can cause the production of sex hor-
A combined fracture and dislocation of especially in boys, may be corrected by mones at an abnormally early age. Some
the ankle caused by excessive or violent treatment with sex hormones. Growth hor- possible underlying causes include a
twisting. The fibula (the outer of the mone may be given for short stature. brain tumour or other brain abnormali-
two bones of the lower leg) breaks just Learning difficulties are treated with ties; abnormality of the adrenal glands
above the ankle; in addition, the tibia appropriate education or therapy. (for example, congenital adrenal hyper-
(shin) breaks or the ligaments tear, plasia); ovarian cysts, and tumours, or a
resulting in dislocation. pravastatin tumour in the testes. In some cases, no
A lipid-lowering drug. underlying cause can be identified.
poultice SYMPTOMS
A warm pack consisting of a soft, moist praziquantel The hormones may cause a premature
substance (such as kaolin) that is spread An anthelmintic drug used to treat tape- growth spurt followed by early fusion of
between layers of soft fabric. Poultices worm infestation and schistosomiasis. Side the bones. As a result, affected children
are applied to the skin. They were once effects may include dizziness, drowsi- may initially be tall but, if untreated,
widely used for the reduction of local- ness, and abdominal pain. final height is often greatly reduced.
ized pain or inflammation, bringing INVESTIGATION AND TREATMENT
boils to a head, and improving circula- prazosin The child’s pattern of pubertal develop-
tion in a specific area. A vasodilator drug used to treat hyperten- ment is assessed by a doctor. Blood tests
sion (high blood pressure), heart failure, are performed in order to measure hor-
pox Raynaud’s disease, and urinary symptoms mone levels. Ultrasound scanning of the
Any of various infectious diseases char- resulting from an enlarged prostate gland ovaries and testes, and CT scanning of the
acterized by blistery skin eruptions (for (see prostate, enlarged). Side effects adrenal glands or brain, may also be
example chickenpox). Pox is sometimes include dizziness and fainting, nausea, carried out, depending on the underly-
used as a slang word for syphilis. headache, and dry mouth. ing cause that is suspected.
Treatment is of the underlying cause,
Prader–Willi syndrome precancerous and hormone drugs may be given to
A rare genetic disorder that is believed to A term applied to any condition in delay puberty and increase final height.
result from a chromosomal abnormality which there is a tendency for cancer to
affecting chromosome 15. The condi- develop. Such conditions are character- predisposing factors
tion is congenital (present at birth). ized by abnormal changes in cells; the Factors that lead to increased suscepti-
The physical features of this con- affected areas may need to be removed bility to a disease.
dition include short stature; hypogonadism in order to prevent cancer.
(underdeveloped testes or ovaries); a Examples of precancerous conditions prednisolone
small penis, in males; very small hands are cervical intraepithelial neoplasia, the A corticosteroid drug used in the treat-
and feet; almond-shaped eyes; and squint. pre-invasive stage of cervical cancer (see ment of a wide variety of disorders.
Mental characteristics include specific cervix, cancer of); leukoplakia of the
learning difficulties. mouth, vulva, or penis, which can pre-eclampsia
P Affected babies have hypotonia (flop- develop into squamous cell carcinoma; A serious condition that can arise from
py muscles), feeding difficulties, and and familial adenomatous polyposis 20 weeks of pregnancy. Features of pre-
are abnormally sleepy; these problems (growth of multiple polyps within the eclampsia include hypertension (high
lessen after about six months. Young intestine; see polyposis, familial adenoma- blood pressure), oedema (accumulation
children may be slow learning to walk tous), which may also become cancerous. of fluid in tissues), and proteinuria (pro-
and talk (see developmental delay). Certain other disorders carry a risk of tein in the urine). If severe, symptoms
Affected children develop an uncon- cancerous changes, but such changes may include headache, nausea and vomit-
trollable hunger and an obsession with are less inevitable than with precancer- ing, abdominal pain, and visual disturb-
eating. If their food intake is not con- ous conditions. These disorders may ances.The cause is not fully understood.
trolled, they will eat continually. This require monitoring, but do not always The condition, which is sometimes
can lead to obesity, which may in turn need treatment. Examples are ulcerative called pre-eclamptic toxaemia or PET, is
cause other disorders, such as diabetes colitis (chronic inflammation and ulcer- more common in first pregnancies and
mellitus and heart failure. The desire for ation of the lining of the colon and if the mother suffers from diabetes melli-
food may cause behavioural problems if rectum), carrying an increased risk of tus, hypertension, or kidney disease.
a child is prevented from eating; in tumours in the colon and rectum, and Pre-eclampsia may cause liver, kidney, or
addition, he or she may suffer from atrophic gastritis (inflammation of the blood clotting problems. Untreated pre-
anxiety and show harmful behaviour, stomach lining). eclampsia may lead to eclampsia, which
such as picking at the skin. In most can cause seizures in the mother and even
other aspects, children with Prader– precocious puberty death of the mother and/or fetus.
Willi syndrome are generally good- The development of secondary sexual For some cases, treatment is with
natured, although their problems may characteristics that occurs before age bedrest and antihypertensive drugs. The
cause them to be socially isolated. eight in girls and nine in boys. health of the fetus and functioning of
Treatment is for the symptoms. Par- CAUSES the placenta must be carefully moni-
ents, teachers, and carers must ensure Precocious puberty is uncommon. It tored. In late pregnancy, or if severe,
that the child does not eat too much. may be due to various disorders that induction of labour or caesarean section

622
 PREGNANCY

may be necessary. The condition can be STAGES AND FEATURES OF PREGNANCY stage. During the second trimester, the
prevented by frequent blood pressure Pregnancy is traditionally dated from mother’s nipples enlarge and darken and
checks and urinalysis (to look for protein the first day of a woman’s last menstrual weight rises rapidly. The baby is usually
in the urine) as part of antenatal care. period (LMP), although conception felt moving by 16–22 weeks. During the
would not have taken place until two third trimester, stretch marks and colo-
pregnancy weeks after this. A normal pregnancy is strum (nipple secretions) may appear, and
The period from conception to birth. Preg- considered to last between 37 and 42 Braxton Hicks’ contractions may be felt. The
nancy begins with fertilization of an ovum weeks; it is divided into three stages baby’s head engages at about 36 weeks.
(egg) and its implantation. The egg (trimesters) of three months each. For For details on the physical features
develops into the embryo, which becomes the first eight weeks of pregnancy, the and changes of pregnancy, see the illus-
the fetus, and the placenta, the organ that developing baby is called an embryo; trated box below. For information on
nourishes the embryo and then the fetus. thereafter it is called a fetus. the hormones involved in sustaining
Most eggs implant into the uterus. In the first trimester the breasts start pregnancy, see the box overleaf.
Very occasionally, an egg implants into to swell and may become tender. Morn- PROBLEMS IN PREGNANCY
an abnormal site, such as a fallopian ing sickness is common. The baby’s major In addition to the expected features of
tube, resulting in an ectopic pregnancy. organs have developed by the end of this pregnancy, such as experiencing nausea

STAGES AND FEATURES OF PREGNANCY

Pregnancy typically lasts 40 weeks, counted from the first the developing baby is referred to as an embryo; thereafter,
day of the pregnant woman’s last menstrual period, and is it is known as a fetus. It is during the early part of pregnancy
conventionally divided into three trimesters, each lasting (first trimester), while the growing baby is still an embryo, that
three months. For the first eight weeks following conception, it is at its most vulnerable to damage.

During this first The fetus, now The fetal

stage, all the with features that organs mature
major organ are recognizably in preparation
structures are human, grows for birth and
developing. rapidly in size. life outside the
uterus

First trimester (0 to 12 weeks) Second trimester (13 to 28 weeks) Third trimester (29 to 40 weeks)
The first sign of pregnancy is usually the From 16 weeks, the enlarging uterus is easily felt In some women, stretch marks develop on the
absence of a menstrual period, although from the outside and the woman begins to look abdomen, breasts, and thighs. Also, a dark line
some women have breakthrough bleeding. The noticeably pregnant. The nipples enlarge and may appear that runs from the umbilicus to the
breasts start to swell and may become tender darken, and skin pigmentation may deepen. Some pubic hair. Colostrum (secretions from the
as the mammary glands develop to prepare women may feel warm and flushed. Appetite tends nipples) can be expressed from the nipples.
for breast-feeding. The nipples start to enlarge to increase and weight rises rapidly. The woman’s Minor problems are common. Many women
and the veins over the surface of the breasts facial features tend to become heavier. By 22 become hot and sweat easily because body
become more prominent. A supportive bra weeks (and usually between the 16th and 20th temperature rises slightly. More rest may be
should be worn. weeks), most pregnant women have felt the baby needed at this stage, although for many
Nausea and vomiting are common, and moving around (a sensation that is sometimes women it is difficult to find a comfortable
are often worse in the morning; these problems known as “quickening”). position. Braxton Hicks’ contractions may
usually persist for six to eight weeks (see During the second trimester, nausea, vomiting, start to get stronger.
Vomiting in pregnancy). There is a need to and frequency of urination diminish, and the The baby’s head engages (drops down low
pass urine more frequently and there is often a woman may feel generally better and more into the pelvis) around the 36th week in a first
creamy white discharge from the vagina. Many energetic than she did during the early weeks. The pregnancy, but not until a few weeks later in
women feel unusually tired during the early heart-rate increases, as does the volume of blood subsequent pregnancies. This so-called
weeks of pregnancy. Some notice a metallic pumped by the heart; these changes allow the “lightening” may relieve pressure on the upper
taste in the mouth or a craving for certain foods fetus to develop properly. However, they put abdomen and on breathing, but it increases
or non-edible products. Weight begins to an extra strain on the heart of women who have pressure on the bladder and may result in a
increase towards the end of this stage. pre-existing heart disease. more copious vaginal discharge.

623
 PREGNANCY, DRUGS IN

and tiredness, some women experience pregnancy, the growing fetus puts pres- maturity; and Rhesus incompatibility. (See
certain common, minor health prob- sure on the internal organs; this pressure also childbirth; fetal heart monitoring; preg-
lems. Although these conditions may be may result in haemorrhoids, heartburn nancy, multiple.)
uncomfortable or troublesome, they (due to acid reflux), swollen ankles, and
usually disappear after delivery. varicose veins. Other common disorders pregnancy, drugs in
During pregnancy, food passes during pregnancy include urinary tract Certain drugs taken during pregnancy,
through the intestine more slowly than infections, stress incontinence (see incon- such as thalidomide and isotretinoin, may
normal. This enables more nutrients to tinence, urinary), and vaginal candidiasis. pass from the mother to the fetus
be absorbed for the baby, but also tends Complications of pregnancy and dis- through the placenta. They may inter-
to cause constipation. Pica (craving to orders that affect it include antepartum fere with fetal development, leading to
eat substances other than foods) is haemorrhage; diabetic pregnancy; miscar- birth defects. Relatively few drugs have
another common condition. In late riage; polyhydramnios; pre-eclampsia; pre- been proved to cause harm to a devel-
oping baby, but no drug should be
considered completely safe, especially
EFFECTS OF HORMONES DURING PREGNANCY in early pregnancy. Pregnant women
should seek medical advice before tak-
A pregnant woman undergoes many changes that enable her to maintain the
pregnancy, nourish the baby, and prepare for breast-feeding. These adaptations
ing any drug, including over-the-
are brought about by increased levels of the female sex hormones oestrogen and counter preparations. However, if the
progesterone, and by the action of two other hormones, human chorionic gonado- benefits of a drug to the mother out-
trophin (HCG) and human placental lactogen (HPL), produced only by the placenta. weigh the risks to the fetus, the drug
may be recommended.
Hormone Effect Problems may also be caused in a
developing baby if a pregnant woman
Progesterone Decreases the excitability of smooth muscle, thereby helping to prevent drinks alcohol, smokes tobacco (see
uterine contractions and premature labour. smoking), or takes drugs of abuse. The
babies of women who use heroin during
Causes constipation and oesophageal acid reflux as a result of its effects
on smooth muscle. pregnancy tend to have a low birth-
weight and a higher death rate than
Increases body temperature. normally expected during the first few
Affects mood. weeks of life. Babies of women who
abuse drugs intravenously are at high
Increases breathing rate. risk of HIV infection.
Human placental Increases energy production necessary for fetal development. pregnancy, false
lactogen (HPL)
Causes enlargement of breasts and development of milk glands. An uncommon psychological disorder,
which is also known as pseudocyesis. In
Induces temporary diabetes mellitus (gestational diabetes) in susceptible
false pregnancy, a woman has many of
P women as a result of its effects on metabolism.
the physical signs of pregnancy, including
morning sickness, amenorrhoea (absence of
Human chorionic Increases energy production necessary for fetal development.
gonadotrophin periods), enlarged breasts, and abdo-
(HCG) Induces gestational diabetes in susceptible women. minal swelling, but is not pregnant. The
woman is convinced that she is preg-
Oestrogens Are important for the development of the reproductive system and breasts. nant. Treatment for false pregnancy may
Stimulate growth of the uterine muscle to enable the powerful contractions
involve counselling or psychotherapy. (See
of labour. also conversion disorder.)
Increase vaginal secretions. pregnancy, multiple
Increase the size of the nipples and help the development of milk glands More than one fetus in the uterus. Mul-
in the breasts. tiple pregnancy can occur if two or
Increase the production of protein, which is essential for healthy growth of more ova (eggs; see ovum) are fertil-
the woman and fetus. ized at the same time or if a single egg
divides early in development.
Alter collagen and other substances to allow body tissues to soften and
CAUSES AND INCIDENCE
stretch in preparation for labour.
Twins are the most common type of
Relax ligaments and joints. multiple pregnancy and occur in about
May cause sciatica and backache, and may also contribute to the 1 in 80 pregnancies; triplets occur in
formation of varicose veins as a result of their effects on body tissue. about 1 in 8,000, and quadruplets in
about 1 in 500,000. Multiple preg-
Melanocyte- Stimulates pigmentation (in combination with oestrogens), particularly of nancies are more common in women
stimulating the nipples. May also produce chloasma (darkening of the facial skin). who are treated with fertility drugs, or if
hormone a number of fertilized ova are implanted
in the uterus during in vitro fertilization.

624
 PREMATURE MENOPAUSE

SYMPTOMS AND COMPLICATIONS pregnancy tests which the ovaries are destroyed or
The common problems that are associ- Tests on urine or blood performed to removed or ovarian functions are per-
ated with normal pregnancy may be determine whether a woman is pregnant. manently disrupted (radiotherapy of the
more severe in a multiple pregnancy. Pregnancy testing kits are available over pelvic region, for example). Hormone
There is also an increased risk of severe the counter from pharmacies. replacement therapy can relieve symp-
morning sickness, anaemia, and ante- All kits are designed to test for the toms and reduce the risk of osteoporosis
partum haemorrhage. Hypertension (high presence of human chorionic gonado- (loss of bone tissue). For women who
blood pressure), polyhydramnios (an trophin (HCG) in a sample of urine. This want to conceive, in vitro fertilization
excess of amniotic fluid), postpartum hormone is normally produced only by (IVF) is possible, using donor eggs.
haemorrhage, and malpresentation (abnor- a developing placenta; the tests are ex-
mal positioning of a fetus just before tremely accurate (about 97 per cent
birth) all occur more frequently in a accurate for a positive result and 80 per PREGNANCY TEST KIT
multiple pregnancy. Prematurity is a com- cent accurate for a negative result) and
mon complication, and the weight of can be reliably used from the first day of The pregnancy test shown here is
each baby is usually less than the weight a missed period. The test can, however, one of a variety that are available
over the counter at chemist’s shops,
of a single baby. Caesarean section is misdiagnose pregnancy in cases of hyda- allowing pregnancy testing to be
required more frequently than for sin- tidiform mole, due to very high HCG levels. carried out at home. All of the kits
gle pregnancies. Different brands of test vary, but all test for the presence of the hormone
DIAGNOSIS AND TREATMENT involve introducing a sample of urine human chorionic gonadotropin
During the woman’s antenatal exam- to a test stick that has been treated with (HCG) in a sample of urine. HCG is
ination, the doctor or midwife may be a chemical that reacts with HCG. Blood normally produced only by a
able to feel more than one fetus, and tests for detecting pregnancy can be developing placenta, which
may find that the abdomen is larger used from 9 to 12 days after conception makes the tests very accurate,
than expected for the stage of gestation. (even before a period is missed). even if they are carried out
The doctor or midwife may also be able early in a pregnancy.
to hear more than one fetal heartbeat premature aging syndrome
when listening through a stethoscope. See progeria. Result window

Ultrasound scanning may be used to

confirm the diagnosis. premature ejaculation Urine
The woman is advised to take more See ejaculation, disorders of.
rest during pregnancy and to increase
her intake of protein. Supplements of premature menopause
iron and folic acid are also recommended Menopause (cessation of ovulation and Chemically
treated part
in order to prevent iron-deficiency menstruation) that occurs before the of test stick
anaemia in the mother and neural tube age of 40. Premature menopause can be
defects in the fetuses, respectively. caused by any disorder or treatment in
he indicator stick is dipped into a
1T container of urine (as shown here). P
MULTIPLE PREGNANCY Alternatively, the user can place it directly into
the urine flow while passing urine normally.
About one pregnancy in 80 is multiple (e.g. twins or triplets). The rate is highest
among women in their 30s. Problems arise more often in multiple pregnancies
than in single pregnancies. For example, twins are much more likely than single Test function
indicator
babies to be born prematurely.

Result window

Amniotic sacs

Fetal heads Test function

indicator

HCG indicator

Ultrasound scan
revealing twins
Ultrasound scanning of the
The first line that becomes visible in the
woman’s uterus can reveal the
presence of twins within the first
several weeks of pregnancy.
2working.
result window shows that the test is
If HCG is present, this line is quickly
Here, two fetal heads and a limb followed by a second, different coloured line,
that belongs to the fetus on the which signifies pregnancy. A result can be
right can be seen. obtained within a few minutes.

625
 PREMATURE SEXUAL MATURATION

premature sexual maturation

See precocious puberty. PREMATURITY

prematurity A premature baby may need to be

The birth of a baby that occurs before nursed in an incubator where the
temperature and humidity are
37 weeks’ gestation. The premature
carefully controlled and the baby
infant may not be sufficiently devel- can be closely observed. If breathing
oped to cope with independent life difficulties develop, they may be
and needs special care. treated by artificial ventilation. Very
CAUSES small babies cannot suck so they
Nearly 50 per cent of premature deliv- must be fed intravenously or via a
eries occur for no known reason. The tube passed into the stomach. If
remainder are due to conditions such as jaundice develops, they may be
pre-eclampsia, hypertension, diabetes mel- treated by phototherapy (light
litus, long-standing kidney disease, and therapy), which breaks up the
heart disease. Other causes are antepar- bilirubin that causes the yellow
Premature infant
tum haemorrhage, intrauterine infection, discoloration of the skin. This baby was born several weeks prematurely and
or premature rupture of the mem- is being fed via a flexible tube that passes through
the nose and oesophagus into the stomach.
branes. A common cause of premature
birth is multiple pregnancy (see preg-
nancy, multiple). FEATURES AND COMPLICATIONS OF PREMATURITY
FEATURES AND COMPLICATIONS
Physical features
A premature infant is smaller than a
full-term baby. He or she lacks subcuta-
neous fat, is covered with downy hair
• Low birthweight (often less than 2.5kg) • Downy (lanugo) hair

(lanugo), and has very thin skin. • Small size • Reduced vernix (greasy substance that
covers the newborn)
The baby’s internal organs are also • Relatively large head and hands
immature. The major complication is • Protuberant abdomen
respiratory distress syndrome, which may
• Thin, smooth, shiny skin
• Enlarged clitoris (girls)
occur because the lungs are insufficiently • Veins visible under the skin
developed. There are also increased risks • Small scrotum (boys)
• Little fat under the skin
of brain haemorrhage, jaundice, and • Feeble, whining cry
hypoglycaemia (low blood sugar). The
• Wizened, wrinkled features
• Irregular breathing
baby has a limited ability to suck and to • Soft, flexible ear cartilage
maintain a normal body temperature, • Poor sucking and swallowing ability
• Short toenails (but normal length
and he or she is also prone to infection fingernails) • Tendency to regurgitate
due to a poorly developed immune
P system. The earlier a baby is born, the Complications
more likely it is that he or she will have
such problems. • Increased risk of birth injury • Hypoglycaemia (low blood sugar level)
and other disturbances of body
TREATMENT AND OUTLOOK • Respiratory distress syndrome chemicals
Premature infants are usually nursed in
a special baby unit that provides inten- • Recurrent episodes of breathing • Rickets
stoppage
sive care. The baby is placed in an • Increased bleeding tendency
incubator. He or she may have artificial • Jaundice
ventilation to assist breathing, artificial • Brain haemorrhage
• Infection
feeding through a stomach tube or into • Necrotizing enterocolitis (severe
a vein, and treatment with antibiotic • Poor temperature control intestinal inflammation that may lead
• Anaemia to death of intestinal tissue)
drugs and iron and vitamin supplements.
The baby is usually kept in hospital
until he or she has reached a weight of
at least 2.25 kg, is growing sufficiently,
and is feeding well. premedication premenstrual syndrome
With the modern techniques that are The term applied to drugs that are The combination of physical and emo-
now generally available, some infants given, usually by injection, one to two tional symptoms that occurs in many
survive even if they are born as early as hours before an operation in order to women in the week or so running up
24 weeks’ gestation. Most babies that are prepare a person for surgery. The pre- to menstruation. Premenstrual syndrome
born after 28 weeks, and given specialist medication injection usually contains an (commonly known as PMS) begins at
care, survive. The majority of premature opioid analgesic drug (painkiller), and or after ovulation (the mid-point of the
babies catch up with full-term babies, in often an anticholinergic drug (which menstrual cycle, when an egg is
terms of their development, before the reduces the secretions in the airways released from an ovary) and continues
end of their first year. and protects the heart). up until the onset of menstruation. In

626
 PRESSURE SORE

some women, the condition may be so SYMPTOMS AND CAUSES subsequently reclassified to over-the-
severe that work and social relationships The symptoms of presbyacusis develop counter (OTC) drugs once their efficacy
are seriously disrupted. gradually. People with the condition and safety have been established.
CAUSES often find it difficult to understand
Theories for the cause of PMS include speech and cannot hear well when there presenile dementia
hormonal changes and vitamin or min- is background noise. The severity and A type of dementia (a deterioration in
eral deficiencies, but none of these has progression of the disorder vary consid- brain function) that occurs in a person
been confirmed. erably from person to person. under 65. (Most dementia affects those
SYMPTOMS Presbyacusis may be exacerbated by over 65.) Possible causes of presenile
The most common emotional symp- exposure to high noise levels, dimin- dementia include damage to brain tis-
toms are fatigue, irritability, tension, ished blood supply to the inner ear due sue resulting from AIDS or alcohol
aggression, tearfulness, and depression. to atherosclerosis (the buildup of fatty dependence; severe vitamin deficiencies,
Physical symptoms include breast tender- deposits on artery walls), and damage as in Wernicke–Korsakoff syndrome or per-
ness, fluid retention, headache, backache, to the inner ear from drugs such as nicious anaemia; a serious head injury; or
and lower abdominal pain. aminoglycoside drugs. Alzheimer’s disease.
TREATMENT DIAGNOSIS AND TREATMENT The underlying cause of presenile
No single treatment has proved com- Diagnosis is by physical examination dementia is treated, if possible. Dam-
pletely successful. Remedies for specific using an otoscope, and by various hear- age to brain tissue is irreversible,
symptoms include dietary changes, ing tests to determine the type and however, but drug treatment may help
relaxation techniques, and regular phys- degree of hearing loss. Hearing-aids help to relieve any associated symptoms
ical exercise. Pyridoxine (vitamin B6) most affected people. such as depression.
may help to relieve some symptoms in
some women. Oral contraceptives can presbyopia presentation
relieve symptoms by suppressing the The progressive loss of the power of A term describing the position of
normal menstrual cycle. Progesterone adjusting the eye (see accommodation) the fetus before childbirth . The pre-
supplements may sometimes be used for near vision. The focusing power of sentation is classified by the part of the
but are not always effective. The antide- the eyes weakens with age. Presbyopia is fetus that is closest to the cervix and
pressant drug fluoxetine is now licensed usually noticed around the age of 45 will emerge first. The cephalic (head)
to treat PMS. when the eyes cannot accommodate to presentation is normal. Forms such as
read small print at a normal distance. the breech presentation (in which the
premenstrual tension Reading glasses with convex lenses are buttocks lie over the cervix) and the
See premenstrual syndrome. used to correct presbyopia. shoulder presentation may cause prob-
lems during delivery (see also breech
premolar prescribed diseases delivery). The term presentation is also
One of eight permanent grinding teeth, A group of industrial diseases that give used to describe how an illness or con-
two in the upper and two in the lower sufferers legal entitlement to financial dition manifests itself.
jaw on each side of the mouth, located benefit. To be eligible, a claimant has to
between the canines and molars. (See have worked in an occupation that is preservative P
also permanent teeth; eruption of teeth.) recognized to increase the risk of devel- A substance that inhibits the growth of
oping a particular disease. bacteria, yeasts, and moulds and there-
Prempak-C Examples include conditions due to fore protects foods from putrefying and
A brand-name drug used in hormone physical agents (such as occupational fermenting. Examples include sulphur
replacement therapy to relieve symptoms deafness), biological agents (for exam- dioxide, benzoic acid, salt, sugar, and
of the menopause and to prevent osteo- ple, anthrax), or chemical agents (such nitrites. (See also food additives.)
porosis. Prempak-C contains conjugated as lead poisoning); pneumoconiosis; and
oestrogens (see oestrogen drugs) and byssinosis. (See also notifiable diseases; pressure points
norgestrel (a progestogen drug). occupational disease and injury.) Places on the body where pressure can
be applied by hand to limit severe arter-
prenatal prescription ial bleeding (in which bright red blood
A term referring to the period of preg- An instruction written by a doctor that is pumped out in regular spurts with
nancy; often a synonym for antenatal. directs a pharmacist to dispense a par- the heartbeat). At these points, arteries
ticular drug in a specific dose. A lie near the surface of the body and can
prepuce prescription details how often the drug easily be compressed against a bone to
See foreskin. must be taken, how much is to be dis- stop the blood flow.
pensed, and other relevant facts. Major pressure points of the body
presbyacusis include the brachial pressure point in
The progressive loss of hearing that prescription-only medicine (PoM) the middle part of the upper arm and
occurs with age. Presbyacusis is a form Drugs and medicines that are not avail- the carotid pressure point at the side of
of sensorineural deafness (degeneration able over the counter and can only be the neck, below the jaw.
of the hair cells and nerve fibres in the obtained by prescription. PoMs are those
inner ear), which makes sounds less whose safe use is hard to ensure with- pressure sore
clear and tones less audible. out medical supervision. Some are See bedsore.

627
 PREVALENCE

prevalence red, itchy spots cover the affected areas permanent teeth from about the age of
The total number of cases of a disease of skin and are accompanied by prick- six years. There are 20 primary teeth in
in existence at any one time in a ling sensations. The irritation tends to total, ten of which are in the upper jaw
defined population. Prevalence is often affect areas where sweat collects, such and ten in the lower jaw. (See also teeth;
expressed as the number of cases per as the armpits. eruption of teeth; teething.)
100,000 people. (See also incidence.) The cause is not fully known, but
unevaporated sweat is an important con- primidone
preventive dentistry tributory factor; the ducts from sweat An anticonvulsant drug that is used to
An aspect of dentistry concerned with glands become blocked with debris and treat epilepsy and, occasionally, tremor. It
the prevention of tooth decay and gum leak sweat into the skin. Frequent cool is usually prescribed with another anti-
disease. It consists of the encourage- showers and sponging of the affected convulsant. Adverse effects of the drug
ment of good oral hygiene, fluoride areas relieve the itching. may include drowsiness, clumsiness,
treatment, and scaling. and dizziness.
primaquine
preventive medicine A drug used to treat vivax and ovale primitive reflex
The branch of medicine that deals with malaria. It is given after treatment with See reflex, primitive.
disease prevention. It involves public chloroquine. Side effects include nausea,
health measures, such as the provision vomiting, and abdominal pain. In peo- Prinzmetal’s angina
of pure water supplies and sanitation; ple with G6PD deficiency, primaquine See variant angina.
health education and promotion; spe- may cause haemolytic anaemia (see
cific preventive measures, such as anaemia, haemolytic). prion
immunization against infectious diseases; A tiny, protein-based infectious particle.
and screening programmes to detect dis- primary Prions transmit diseases that cause
eases before they cause symptoms. A term that is used to describe a disease degeneration of the central nervous
In affluent countries, the main objec- that has originated within the affected system, including Creutzfeldt–Jakob dis-
tive of preventive medicine is to educate organ or tissue and is not derived from ease in humans and bovine spongiform
the adult population to adopt a healthi- any other cause or source; an example encephalopathy (BSE) in cattle.
er lifestyle. In the UK, many of the is primary cancer. The term “primary” Prions do not contain nucleic acids,
deaths that occur in adults before the is also applied to the first of several unlike viruses, and are difficult to des-
age of 65 are preventable, being due to diseases that may affect a tissue or troy because they are highly resistant to
accidents and/or linked to such factors organ. The preventive measures that are heat and disinfectants. There is currently
as smoking, an unhealthy diet, excessive taken before an illness has manifested no treatment available for prion dis-
alcohol consumption, and insufficient itself are known as primary prevention; eases. (See also slow virus diseases;
exercise. Adoption of a healthier lifestyle, secondary prevention is used to prevent spongiform encephalopathy.)
the wider use of screening for various a recurrence of the disease.
cancers, and measures to reduce acci- Pripsen
dents could all lead to substantial primary biliary cirrhosis A brand name for the anthelmintic
P improvements in health. See biliary cirrhosis. (worm-killing) drug piperazine.
priapism primary care PRK
Persistent, painful erection of the penis Health care that is provided by a general The abbreviation for photorefractive kera-
that occurs without sexual arousal. This practitioner (GP) or other healthcare tectomy.
is a dangerous condition that requires professional who is the first point of
emergency treatment. contact for a patient who is seeking probenecid
Priapism occurs when the penis has medical treatment. A drug that was formerly used in
become erect but blood cannot drain the long-term treatment of gout. Pro-
from the spongy tissue, and as a result primary central nervous system benecid is used to prevent kidney
the erection cannot subside. Possible lymphoma (PCNSL) damage in AIDS patients who are taking
causes include a blockage in the penile A form of non-Hodgkin’s lymphoma the drug cidofovir for the treatment of
blood vessels due to a blood disorder (see lymphoma, non-Hodgkin’s) affecting cytomegalovirus retinitis. Probenecid
such as sickle cell anaemia; damage to the brain or spinal cord. The cancer may cause nausea and vomiting. Other
nerves supplying the penis; or, rarely, occurs most commonly in immunocom- possible side effects of probenecid
the effects of treatment for impotence. promised people (those with lowered include flushing and dizziness.
Urgent treatment is needed to avoid resistance to infection), such as people
permanent damage to the tissues of the with AIDS and those who are taking probiotic bacteria
penis. Blood may be withdrawn from immunosuppressant drugs. Species of microorganisms that inhabit
the penis with a needle. the digestive tract, guarding it against
primary teeth harmful microorganisms such as bacte-
prickly heat The first teeth to erupt (also known as ria, yeasts, and viruses. Some drinks are
An irritating skin rash that is associated milk teeth), which usually start to manufactured using probiotic bacteria;
with profuse sweating. The medical appear around the age of six months. they are thought to protect the health of
name is miliaria rubra. Multiple tiny, The primary teeth are replaced by the the digestive system.

628
 PROGESTOGEN DRUGS

procainamide proctoscopy body, one of which is enlargement of

An antiarrhythmic drug that is used to Examination of the anus and rectum the breasts. A fall in the mother’s prog-
treat certain types of tachycardia (abnor- using a proctoscope (a rigid viewing esterone level in late pregnancy helps to
mally rapid heartbeat). Procainamide instrument). initiate labour (see childbirth).
may cause nausea, vomiting, loss of Other effects of progesterone in
appetite, and, rarely, confusion. Pro- procyclidine women include increased fat deposition
longed treatment with this drug may An anticholinergic drug that is used to and increased sebum production by
induce lupus erythematosus. treat Parkinson’s disease. It is also used glands in the skin.
to minimize the side effects of some
procaine antipsychotic drugs. The possible adverse progestogen drugs
A local anaesthetic (see anaesthesia, effects of procyclidine include a dry COMMON DRUGS
local). mouth and blurred vision. • Desogestrel • Dydrogesterone
• Levonorgestrel • Medroxyprogesterone
procarbazine prodrome • Norethisterone • Norgestimate • Norgestrel
An anticancer drug used most often in An early warning symptom of illness. • Progesterone
Hodgkin’s disease. Side effects are typical One example of a prodrome is an aura,
of anticancer drugs. which is a particular set of physical A group of drugs that are similar to
and mental symptoms that may occur progesterone hormone. They include both
prochlorperazine immediately before an attack of natural progesterone and synthetic pro-
A phenothiazine-type antipsychotic drug migraine or epilepsy. gesterone derivatives.
used to relieve symptoms of certain Progestogen drugs are used in oral
psychiatric disorders, such as schizo- progeria contraceptives. They may be used on
phrenia and mania. Prochlorperazine is Premature aging. There are two forms of their own in, for example, the progesto-
also used in small doses as an antiemetic progeria, and both are very rare. gen-only pill, as contraceptive implants,
drug. It may in some cases cause invol- In Hutchinson-Gilford syndrome, or as contraceptive injections (see con-
untary movements of the face and premature aging starts at about four traceptives, injectable), or in combination
limbs, lethargy, dry mouth, blurred years old, and many features of old age, with oestrogen drugs in the combined
vision, and dizziness. including grey hair, balding, sagging pill. Progestogens work by making the
skin, and atherosclerosis (buildup of cervical mucus impenetrable to sperm;
procidentia fatty deposits on artery walls), have reducing the production of gonadotro-
A medical term for severe prolapse, usu- developed by the age of ten to twelve. phin hormones, which may prevent eggs
ally of the uterus. Death usually occurs at puberty. Wern- from ripening in the ovaries; and alter-
er’s syndrome (adult progeria) starts in ing the lining of the uterus in order to
proctalgia fugax adolescence or early adulthood and fol- prevent the implantation of fertilized
A severe cramping pain in the rectum lows the same course. eggs. They also reduce the movement of
unconnected with any disease. It may The cause of Hutchinson-Gilford an egg along the fallopian tube, which
be due to muscle spasm. The pain is syndrome is a gene mutation. The cause may lead to an increased risk of an
usually of short duration and subsides of progeria is unknown. ectopic pregnancy. P
without any treatment. Another use for progestogens is in
progesterone hormone hormone replacement therapy (HRT). A
proctitis A female sex hormone essential for the progestogen drug is used in combina-
Inflammation of the rectum, causing functioning of the female reproductive tion with an oestrogen drug to reduce
soreness and bleeding, sometimes with system. Progesterone is made in the the risk of uterine cancer (see uterus,
a mucus and pus discharge. Proctitis ovaries during the second half of the cancer of), which may occur if oestro-
commonly occurs as a feature of cer- menstrual cycle (see menstruation), and gens alone are taken over a long period
tain diseases including ulcerative colitis, by the placenta during pregnancy. Small of time. The progestogens induce a
Crohn’s disease, or dysentery. In cases amounts are also produced by the adre- monthly shedding of the uterine lining,
where inflammation is confined to the nal glands and, in men, by the testes. if taken cyclically (for the last 10–13
rectum, the cause is often unknown. During the menstrual cycle, increas- days of the cycle).
Proctitis is sometimes due to gonorrhoea ing progesterone levels after ovulation Progestogen drugs are also pre-
or another sexually transmitted infec- (the release of an egg from an ovary) scribed as a treatment for various men-
tion, especially in male homosexuals. cause the endometrium (uterine lining) strual problems (see menstruation, disor-
Rare causes of proctitis include tubercu- to thicken in preparation for receiving a ders of). In addition, they are used to
losis, amoebiasis, and schistosomiasis. fertilized egg. If fertilization does not treat premenstrual syndrome, endomet-
Diagnosis is made by proctoscopy occur, the production of progesterone riosis (a condition in which fragments
(examination of the rectum with a and oestrogen hormones falls to a level of uterine lining are found elsewhere
viewing instrument). A biopsy (collec- that results in a menstrual period, during in the pelvic cavity), and are some-
tion of a tissue sample) is sometimes which the uterine lining is expelled times used as anticancer drugs.
carried out at the same time. Treatment from the body. Adverse effects of taking progestogen
of the underlying condition usually If pregnancy occurs, progesterone is drugs are weight gain, oedema (accu-
clears the problem. Corticosteroid drugs produced by the placenta. It causes a mulation of fluid in body tissues),
may relieve symptoms. number of changes in the mother’s headache, dizziness, rash, irregular

629
 PROGESTOGEN-ONLY PILL

periods, breast tenderness, and, less prolapse contraction of the disease, as well as to
commonly, ovarian cysts. (See also con- The displacement of part or all of an prevent infection following a bite (see
traception, hormonal methods of.) organ or tissue from its normal position bites, animal; bites, human).
in the body (see disc prolapse; mitral
progestogen-only pill valve prolapse; rectal prolapse; uterovagi- Pro Plus
See oral contraceptives. nal prolapse; uterus, prolapse of). A brand name for caffeine in the form of
over-the-counter tablets.
prognathism promazine
Abnormal protrusion of the lower jaw A phenothiazine-type antipsychotic drug propranolol
or both jaws. that is used as a sedative drug. Possible A beta-blocker drug used to treat hyper-
adverse effects include abnormal move- tension (high blood pressure), angina
prognosis ments of the face and limbs, drowsi- pectoris (chest pain due to inadequate
An assessment of the probable course ness, lethargy, constipation, dry mouth, blood supply to the heart), and cardiac
and outcome of a disease. and blurred vision. Long-term treat- arrhythmias (irregular heartbeats). It may
ment may cause parkinsonism. also be used to reduce the risk of further
progressive heart damage after myocardial infarction
A term that is used to describe a condi- promethazine (heart attack). In addition, it relieves
tion that becomes more severe and/or An antihistamine drug used to relieve symptoms of hyperthyroidism (overactiv-
extensive over time. itching in a variety of skin conditions, ity of the thyroid gland) and anxiety, and
such as eczema. It is also used as an can prevent migraine attacks.
progressive muscular atrophy antiemetic drug, and sometimes as a pre- Possible adverse effects of propra-
A type of motor neuron disease in which medication. Possible adverse effects of nolol are typical of most beta-blocker
the muscles of the hands, arms, and promethazine include a dry mouth, drugs; they include fatigue, nausea, and
legs become weak and wasted and blurred vision, and drowsiness. cold hands and feet.
twitch involuntarily. As the muscular
atrophy advances, it eventually spreads pronation proprietary
to other muscles. The act of turning the body to a prone A term for a drug patented for produc-
(face-down) position, or the hand to a tion by one company.
proguanil palm-backwards position.
An antimalarial drug that is used in the proprioception
prevention of malaria. Side effects of the propantheline The body’s internal system for collect-
drug are rare. Indigestion, nausea, or An antispasmodic drug used to treat irrita- ing information about its position and
vomiting may occur but usually disap- ble bowel syndrome and forms of urinary the state of contraction of its muscles.
pear as treatment continues. incontinence. Possible adverse effects of Information originating from proprio-
propantheline include a dry mouth, ceptors (sensory nerve endings in the
prolactin blurred vision, and retention of urine. muscles, tendons, joints, and inner ear)
A hormone produced by the pituitary passes to the brain and spinal cord. The
P gland. Prolactin helps to stimulate the Propecia information is used to make adjust-
development of the mammary glands A brand name for finasteride, an anti- ments to maintain posture and balance.
(see breast), and to initiate and main- androgen drug (one that blocks the During movement, there is a constant
tain milk production for breast-feeding. effects of male sex hormones). This feedback of information from the pro-
(See also prolactinoma.) preparation is used to treat male-pattern prioceptors and the eyes to the brain.
baldness (see alopecia). This helps the brain to ensure that
prolactinoma actions are smooth and coordinated.
A noncancerous tumour of the pituitary prophylactic
gland that causes overproduction of the A drug, procedure, or piece of equip- proptosis
hormone prolactin. In women, this may ment that is used to prevent disease. The A term meaning protrusion, especially
result in galactorrhoea (breast secretion term is also used to describe a condom. of the eyeballs (see exophthalmus).
at any time other than during breast-feed-
ing), amenorrhoea (absence of menstrual prophylactic antibiotics propylthiouracil
periods), or infertility. In men, it may lead Antibiotic drugsthat are used to prevent A drug used to treat hyperthyroidism
to impotence and gynaecomastia (devel- the development of bacterial infections. (overactivity of the thyroid gland) or to
opment of breasts). In either sex, it may They are used, for example, in people control its symptoms before a thyroid-
cause headaches, diabetes insipidus, and, who are undergoing surgery or in those ectomy (surgical removal of thyroid
if the tumour presses on the optic with recent, serious injuries. They are tissue). Possible side effects are itching,
nerves, loss of the outer visual field. given, for example, to prevent endo- headache, rash, joint pain, and de-
Diagnosis of the condition is made carditis in patients who have replace- creased production of white blood cells.
from blood tests and CT scanning or ment heart valves or heart-valve lesions
from MRI of the brain. Treatment of who are undergoing dental procedures. prostaglandin
prolactinoma may involve removal of They may also be given to people who One of a group of fatty acids that is
the tumour, radiotherapy, or prescribing are in close contact with a source of made naturally in the body and acts in a
the drug bromocriptine. meningococcal meningitis to prevent similar way to hormones. Prostaglandins

630
 PROSTATE, ENLARGED

were first discovered in semen but are inflammation by reducing prostaglandin Transrectal ultrasound (a procedure in
now known to occur in many different production in the tissues. If taken for a which an ultrasound probe is inserted
body tissues, including the uterus, brain, long period, however, NSAIDs and into the rectum) and a biopsy (removal
and kidneys. Prostaglandins are divided aspirin may increase the risk of a peptic of a tissue sample for analysis) are used
into broad groups according to their ulcer, in part by reducing the produc- to confirm a diagnosis. Blood tests and a
chemical structure. tion of the prostaglandins that protect bone scan (see radionuclide scanning)
Prostaglandins produce a wide range the stomach lining. may also be carried out.
of effects on the body. These actions TREATMENT
include causing pain and inflammation prostaglandin drugs Medical opinions vary regarding the
in damaged tissue; protecting the lining Synthetically produced prostaglandins. appropriate treatment for localized pro-
of the stomach and duodenum against Dinoprostone is used with synthetic state cancer. If the man is elderly and
ulceration; lowering blood pressure; oxytocin for induction of labour. Mifepris- has a small prostate cancer that has not
and stimulating contractions in labour. tone may be taken orally to induce an spread, no treatment may be recom-
(These effects may also be achieved abortion; this is followed by insertion of mended; the man’s condition will be
by the use of prostaglandin drugs.) For a gemeprost suppository, which softens monitored. For younger men, prostat-
further information describing the and helps to dilate the cervix. Alpro- ectomy (removal of the prostate gland)
effects of various prostaglandins, see stadil is used to treat newborn infants or radiotherapy may be performed.
the box below. who are awaiting surgery for certain In many cases, widespread disease is
Certain drugs counteract the effects congenital heart diseases. controllable for some years with the use
of prostaglandin in the body. Examples of drugs or with orchidectomy (removal
of these drugs are aspirin, nonsteroidal prostate, cancer of of part or all of the testes).
anti-inflammatory drugs (NSAIDs), and A cancerous growth in the prostate gland
corticosteroids, which relieve pain and that is one of the most common types prostatectomy
of cancer in men. The cause of the can- The surgical removal of part or all of
EFFECTS OF SOME cer is unknown, but the male sex hor- the prostate gland. Prostatectomy is per-
PROSTAGLADINS mone testosterone has been found to formed to treat enlargement of the
influence the growth rate and spread prostate (see prostate, enlarged), in cases
Type Effect of the tumour. Men who have a family where the enlarged prostate is ob-
history of prostate cancer are at an structing the flow of urine, and cancer
PGA1
increased risk of developing cancer of (see prostate, cancer of).
• Lowers blood pressure.
the prostate and the condition most The most common method is trans-
• May protect against peptic ulcer. commonly affects elderly men. urethral prostatectomy, in which the
SYMPTOMS prostate is accessed via the urethra (the
PGD2 • Causes inflammation. An enlarged prostate (see prostate, en- channel in the penis through which
larged) may cause symptoms that in- urine is excreted), thereby avoiding
• Involved in asthma.
clude difficulty in starting to pass urine, open surgery. If the prostate gland is
poor urine flow, and increased frequen- very enlarged, retropubic prostatectomy
PGE1 • Stimulates contractions of the
uterus. cy of urination. If a tumour blocks the may be performed: an incision is made P
urethra (the passage from the bladder to expose the prostate and the tissue is
• Lowers blood pressure. to the outside of the body) or the can- removed. These techniques are shown
• Reduces stickiness of platelets cer spreads to the ureters (the tubes in the illustrated box overleaf.
in blood. linking each kidney to the bladder), Prostatectomy may affect potency or
urine flow may eventually cease alto- sexual sensation, though this is not
PGE2 • Causes inflammation. gether (see urinary retention). common. The operation usually causes
In some cases, there are no urinary sterility due to a condition called retro-
• Widens airways.
symptoms and the first signs may only grade ejaculation, in which semen is
• Increases stickiness of platelets appear once secondary cancers have expelled backwards into the bladder
in blood. arisen. Such signs may include pain in rather than out of the penis. This condi-
• Stimulates contractions of the the bones, enlarged lymph nodes, short- tion, though abnormal, is not harmful.
uterus. ness of breath (due to tumours in the
lungs), and weight loss. prostate, enlarged
• Protects against peptic ulcer.
SCREENING AND DIAGNOSIS Increased size of the inner zone of the
PGF2 • Stimulates contractions of the Some older men and men suspected of prostate gland, caused by benign pro-
alpha uterus. having prostate cancer may be screened static hypertrophy (see prostatic hypertro-
for the disorder. This procedure involves phy, benign), prostate cancer, or prostatitis
• Narrows airways.
tests to detect blood levels of a protein (inflammation of the prostate gland).
called prostate-specific antigen (PSA), as Enlargement of the prostate can cause
PGG2 • Causes inflammation. well as a rectal examination. If blood levels obstruction to the flow of urine from the
of PSA are above a certain level, this may bladder to the urethra, leading to prosta-
PGI2 • Reduces stickiness of platelets
be an early sign of prostate cancer; rectal tism and urinary retention (the inability to
in blood.
examination allows a doctor to assess pass urine). The size of the gland can be
the size and hardness of the gland. assessed by a rectal examination.

631
 PROSTATE GLAND

PROSTATECTOMY: REMOVAL OF THE PROSTATE GLAND

Two of the possible methods of removal are shown. The usually permits a shorter stay in hospital. The retropubic
transurethral method (TURP) is the most commonly used. method may be necessary if the prostate is very enlarged
It avoids the disadvantages of an abdominal incision and or if surgery is a treatment for prostate cancer.

TRANSURETHRAL PROSTATECTOMY Bladder RETROPUBIC PROSTATECTOMY

Resectoscope Viewing light

Site of
incision
Prostate gland

Under general or spinal anaesthesia,

1viewing
a special type of cystoscope (bladder
tube) called a resectoscope is
Under general anaesthesia, an incision
1bladder
is made in the abdomen to expose the
and prostate. The surgeon cuts
passed up the urethra so that the prostate open the capsule containing the gland.
can be seen.
Capsule Enlarged prostate gland
Capsule

Tissue
Prostate gland washed out

Electrode
cauterizes
Bladder bleeding
vessels

Cutting edge

2andAedge,
heated wire loop, or sometimes a cutting
is inserted through the resectoscope
used to cut away as much of the prostatic
3 The pieces of tissue are washed out
through the resectoscope and any
bleeding vessels are cauterized by means
The surgeon then removes the prostatic
2vessels
tissue. Once it is removed, bleeding
tissue as possible. of an electrode passed up the tube. are cauterized and a catheter is then
passed up the urethra in order to drain urine
from the bladder.

P
4andThe resectoscope
is then withdrawn
a catheter passed
Catheter Blood and urine Bladder
Drainage tube

via the urethra into the

bladder. The catheter
drains urine from the
bladder and allows
blood to be washed
out. It can usually Remains of Stitching
be removed within prostate
24 hours.
3mayAcapsule
tube is inserted beside the empty
to drain any fluid and blood that
collect; the abdomen is sewn up. The tube
and catheter are left in for a few days.

prostate gland the seminal vesicles through the static hypertrophy, benign), cancer (see
A solid, chestnut-shaped organ that prostate gland to enter the urethra; the prostate, cancer of), and prostatitis (in-
surrounds the first part of the male ure- ducts carry fluid and nutrients from flammation of the prostate gland).
thra. The prostate gland is situated just the vesicles to be added to the semen.
underneath the bladder. It produces The prostate gland weighs only a few prostate-specific antigen (PSA)
secretions that form part of the seminal grams at birth. At puberty, androgen An enzyme that is normally produced by
fluid during ejaculation. hormones cause the gland to enlarge, the prostate gland. If the enzyme is pro-
The prostate gland consists of two and it reaches adult size at around age duced in excess, it may indicate the
distinct zones: an inner zone, which 20. In most men, the prostate begins presence of prostate cancer; tests to
produces secretions that keep the lin- to enlarge further after the age of 50. detect blood levels of PSA are therefore
ing of the urethra moist, and an outer There are a number of disorders that used as a screening test for prostate can-
zone, which produces seminal secre- affect the prostate gland. These include cer. However, PSA levels may also be
tions. Two ejaculatory ducts pass from benign prostatic hypertrophy (see pro- raised in other conditions such as

632
 PROTEIN SYNTHESIS

Mild cases do not require treatment, but proteins

LOCATION OF severe abdominal pain due to blockage Large molecules consisting of hundreds
PROSTATE GLAND
of the urine flow needs immediate or thousands of amino acids linked into
Located under the bladder and in
treatment. Men with a severely enlarged long chains. Proteins may be combined
front of the rectum, the prostate prostate usually require prostatectomy with sugars (glycoproteins) and lipids
gland secretes substances into (surgical removal of the prostate gland). (lipoproteins).
the semen as the fluid passes Alternatively, alpha-blocker drugs may be There are two main types of proteins.
through ducts leading from the given to improve the flow of urine or The first type, fibrous proteins, are
seminal vesicles into the urethra. antiandrogen drugs may be used to coun- insoluble and form the structural basis
Bladder Prostate Rectum
teract the effects of testosterone. of many body tissues. The second type,
lobular proteins, are soluble and in-
prostatism clude all enzymes, many hormones, and
Symptoms that arise from the enlarge- some blood proteins, such as haemoglo-
ment of the prostate gland (see prostate, bin. In addition, the chromosomes in cell
enlarged) due to its compression and dis- nuclei are formed from proteins linked
tortion of the urethra, which impedes with nucleic acids, and cell walls are
the flow of urine from the bladder formed in part from proteins linked
(outflow obstruction). Symptoms of with lipids (see cell).
Seminal prostatism often include frequent uri- Dietary proteins are needed mainly in
vesicle
nation (see urination, frequent), getting order to supply the body with amino
up at night to urinate, delay before the acids. Ingested proteins are broken
Urethra
urine stream starts, dribbling at the end down in the digestive system to form
Bladder of the stream, and incontinence (see amino acids, which are then absorbed
Prostate incontinence, urinary). and rebuilt into new body proteins (see
Prostatic protein synthesis).
urethra prostatitis
Inflammation of the prostate gland, usu- protein synthesis
Seminal (ejaculatory) duct ally affecting men aged between 30 and The formation of protein molecules
50. It is often caused by a bacterial through the joining of amino acids. Pro-
infection that has spread from the ure- teins provide many of the structural
benign prostatic hypertrophy (see pro- thra. The presence of a urinary catheter components and the enzymes that pro-
static hypertrophy, benign)
and prostatitis increases the risk of prostatitis. mote biochemical reactions in the body,
(inflammation of the prostate). The main symptoms of prostatitis are so their manufacture is essential for
fever, flulike symptoms, and pain in the development and growth.
prostatic hypertrophy, benign lower back. There may also be pain Different cells manufacture various
An increase in size of the prostate gland, around the rectum, which is particular- ranges of proteins. The instructions for
which is most common in men over ly troublesome on passing faeces. Diag- these processes are held by the DNA
the age of 50. The cause is unknown. nosis is made by rectal examination and (deoxyribonucleic acid) in the nucleus P
SYMPTOMS tests on urine samples. Treatment is of the cell. Protein synthesis starts when
The enlarging prostate compresses and with antibiotic drugs. The condition may a gene (a particular length of DNA) acts
distorts the urethra, impeding the flow be slow to clear up and tends to recur. as a template to form a strand of a sub-
of urine from the bladder (known as stance called messenger RNA. Like DNA,
outflow obstruction). This causes symp- prosthesis RNA consists of a string of build-
toms of prostatism, such as frequent An artificial replacement for a missing ing blocks, which are called nucleotide
urination and dribbling at the end of or diseased part of the body; for exam- bases; the sequence of bases provides
the urine stream. There may also be ple, artificial limbs (see limb, artificial), the genetic code for making whichever
incontinence (see incontinence, urinary). heart valves (see heart-valve surgery), or protein is required.
Eventually the bladder is unable to expel glass eyes (see eye, artificial). The strand of messenger RNA
all the urine (see urinary retention) and passes out of the cell nucleus, where it
becomes distended, causing swelling, prosthetics, dental is then decoded (see the illustrated box
which may be painful. The bladder’s The branch of dentistry concerned with overleaf) to form a polypeptide chain (a
inability to empty completely each time the replacement of missing teeth and string of amino acids). Several poly-
urine is passed may lead to urinary tract their supporting structures. It includes peptide chains may be combined to
infections. Kidney failure may occur as a dentures, overdentures (semipermanent form one protein molecule.
complication of outflow obstruction. fittings over existing teeth), crowns The rate of protein synthesis is regu-
DIAGNOSIS AND TREATMENT (see crown, dental), and bridges (see lated by adjustments in the amount of
Prostate enlargement is detected by a rec- bridge, dental). messenger RNA formed in the nucleus
tal examination. Tests may include blood of the cell. Highly complex mechanisms
tests, ultrasound scanning, and recording protease inhibitors operate in order to ensure that the cell
the strength of urine flow. Tests to A type of antiretroviral drug that is used manufactures the correct type of pro-
exclude prostate cancer as a cause of to delay the progression of HIV infec- teins, in the required quantities, and at
enlargement may be needed. tion. (See also AIDS.) exactly the right time.

633
 PROTEINURIA

proteinuria
STEPS IN PROTEIN SYNTHESIS The presence of protein in the urine. It
may result from kidney disorders, such
Proteins consist of one or more subunits, which are called polypeptides. These
as glomerulonephritis and urinary tract
are formed, within cells, from building blocks called amino acids, which are
infection. Proteinuria may also occur
provided to each cell as raw materials. The instructions for making polypeptides
are encoded in the DNA that is present within the cell nucleus. because of a generalized disorder that
causes increased protein in the blood. It
is diagnosed by urinalysis.
Cell
1twoTopolypeptide,
make a specific protein or
DNA separates into
strands and acts as a template to
Prothiaden
Nucleus
make a strand of a substance called A brand name for the antidepressant
messenger RNA. Like DNA, this consists drug dosulepin.
of a string of substances called DNA
nucleotide bases.
Cytoplasm prothrombin time
A form of blood-clotting test. The conver-
DNA sion of prothrombin to thrombin is one
of the chemical reactions that takes place
Nucleus
The messenger RNA during the process of blood clotting. This
Messenger RNA
2nucleus
passes out of the cell
into the cytoplasm,
reaction depends on the presence of clot-
ting factors together with calcium and a
where it is latched on to by
several decoding particles
substance called thromboplastin. If calci-
called ribosomes. Starting um and thromboplastin are added to
Ribosome Nucleotide bases at one end, the ribosomes a sample of blood, it should clot within a
Amino acids travel along the RNA strand. certain time. A clotting time that is
abnormally slow indicates a deficiency of
clotting factors, as occurs in some liver
diseases and in vitamin K deficiency.Tests
to measure prothrombin time are used
to monitor people undergoing treatment
with warfarin (an anticoagulant drug). (See
also International Normalized Ratio.)
proton pump inhibitors
A type of ulcer-healing drug, for example
omeprazole, that is used in the treat-
ment of peptic ulcers.
P As it moves along the RNA, each ribosome
3special
connects a chain of amino acids, using protoplasm
chemical “keys” (called transfer RNAs) A term for the entire contents of a cell.
within the cell. The correct order of the amino
acids is coded by the sequence of bases in the
messenger RNA.
protozoa
The simplest, most primitive type of
animal, consisting of a single cell. Pro-
tozoa are bigger than bacteria but still
microscopic. About 30 types are human
parasites, including those responsible
for malaria, amoebiasis, giardiasis, sleep-
ing sickness, trichomoniasis, toxoplasmosis,
and leishmaniasis.
Finished
polypeptide
proximal
A term describing a part of the body
nearer to a central point of reference,
such as the trunk. (See also distal.)
Prozac
Ribosome A brand name for the antidepressant
drug fluoxetine.
4foldsAtribosome
the end of the messenger RNA strand, the
parts from the amino acid chain, which
up to form the finished polypeptide or protein.
prurigo
Thickening and itching of the skin due
to repeated scratching.

634
 PSORIASIS

pruritus cause is unknown; in rare cases, it is a psoralen drugs

The medical term for itching. complication of diabetes mellitus, hyper- Drugs containing chemicals called pso-
parathyroidism, and haemochromatosis. ralens, which occur in some plants and
pruritus ani Symptoms are similar to gout. Diagnosis are present in some perfumes. When
Itching of the anus. Causes of pruritus is from a sample of joint fluid. Treat- absorbed into the skin, psoralens react
ani may include an anal fissure, haemor- ment is with nonsteroidal anti-inflamm- with ultraviolet light to cause skin dark-
rhoids, or threadworm infestation. atory drugs (NSAIDs). ening or inflammation. Psoralen drugs
may be used in conjunction with ultra-
PSA pseudohermaphroditism violet light (a combination called PUVA)
The abbreviation for prostate specific A congenital abnormality in which the to treat psoriasis and vitiligo.
antigen. external genitalia resemble those of the Overexposure to ultraviolet light dur-
opposite sex, but ovarian or testicular ing treatment, or to too high a dose of a
pseud-/pseudo- tissue is present as normal. A female psoralen drug, may cause redness and
Prefixes meaning false. with pseudohermaphroditism may have blistering of the skin. Psoralens in per-
an enlarged clitoris that resembles a fumes may cause photosensitivity.
pseudarthrosis penis and enlarged labia resembling a
A term meaning “false joint”, which is scrotum. A male may have a very small psoriasis
used to describe an operation in which penis that may resemble a clitoris and a A common skin disease characterized
the ends of the two opposing bones in a divided scrotum resembling labia. (See by thickened patches of red, inflamed
joint are removed and a piece of tissue also hermaphroditism, sex determination.) skin, often covered by silvery scales. The
is fixed in the gap as a cushion. The disease usually appears between the
term also describes a rare childhood pseudomonas ages of 10 and 30, tends to run in fami-
condition in which congenital abnor- Species of rodlike bacteria that are lies, and affects both men and women.
mality of the lower half of the tibia inhabitants of soil and some decompos- The exact cause of the disease is un-
leads to spontaneous fracture. ing matter. PSEUDOMONA AERUGINOSA is known, although one form (guttate
capable of causing disease in humans psoriasis) may be caused by a streptococ-
pseudoacanthosis nigricans and is present in pus from wounds. cal infection, such as tonsillitis.
The most common form of acanthosis SYMPTOMS AND TYPES
nigricans, a condition in which dark psilocybin In psoriasis, new skin cells are made
patches of thickened skin appear in the An alkaloid that is present in certain about ten times faster than normal. The
body’s various skin folds. types of mushrooms. It is a hallucino- excess cells accumulate, forming thick-
genic drug possessing properties that ened patches covered with dead, flaking
pseudocyesis are similar to those of LSD. skin. Sometimes, there is also a painful
See pregnancy, false. swelling and stiffness of the joints (see
psittacosis arthritis). Psoriasis tends to recur in
pseudodementia A rare illness resembling influenza that
Severe depression in elderly people that is caused by the microorganism CHLAMY-
mimics dementia. Symptoms of pseudo- DIA PSITTACI. The disease is contracted by
LOCATION OF PSOAS MUSCLE P
dementia include intellectual impair- inhaling dust containing the droppings
The muscle has two parts – major
ment and loss of memory. of infected birds, such as pigeons or and minor. The psoas major acts to
poultry. Most cases occur among poul- flex the hip (bend it up towards the
pseudoephedrine try farmers, pigeon owners, and people trunk) and rotates the thigh inwards.
A decongestant drug used to relieve nasal working in pet shops. Common symp- The psoas minor acts to bend the
congestion. High doses may cause anxiety, toms are severe headache, fever, and spine down towards the pelvis.
nausea, and dizziness. Occasionally, hyper- cough, developing a week or more after
tension, headache, and palpitations occur. infection. Other symptoms may include
Pseudoephedrine nasal drops should not muscle pains, sore throat, nosebleed, Psoas minor
be taken for longer than a week because lethargy, depression. In some cases,
this may cause a sudden increase in con- breathing difficulty may also occur.
gestion on stopping the drug. A diagnosis of psittacosis is made by Spinal
confirmation of the presence of anti- column
pseudoepidemic bodies against CHLAMYDIA PSITTACI in the
Psoas major
An outbreak of an illness in a com- blood. Treatment of the disease is with
munity or in an institution that is tetracycline antibiotic drugs. If no treat-
thought to be due to a form of hysteria. ment is given, death may result. Ileum
Typical symptoms are headache and a
general feeling of sickness. psoas muscle
A muscle that bends the hip upwards
pseudogout towards the chest. There are two parts:
A form of arthritis that results from psoas major and psoas minor. The psoas Femur
the deposition of calcium pyrophos- major acts to flex the hip.The psoas minor
phate crystals in a joint. The underlying bends the spine down to the pelvis.

635
 PSYCH-

psyche psychogenic
A term meaning mind. (See also psycho- A term used to describe a symptom or
analytic theory.) disorder that is caused by psychological
or emotional problems.
psychiatry
The branch of medicine concerned psychology
with the study, prevention, and treat- The scientific study of mental processes.
ment of mental illness and emotional Psychology deals with all internal aspects
and behavioural problems. Psychiatrists of the mind, such as memory, feelings,
conduct examinations of physical and thought, and perception, as well as exter-
mental state and trace the patient’s per- nal manifestations, such as speech and
sonal and family history. Treatment may behaviour. In addition, psychology is
include medication, counselling, psy- concerned with intelligence, learning,
chotherapy, psychoanalysis, cognitive– and personality development.
Front view Rear view behavioural therapy, or ECT.
psychometry
psychoanalysis The measurement of psychological func-
A treatment that is based on psychoana- tions with the use of intelligence tests,
lytic theory that is used to help people personality tests, and tests for specific
who have neuroses and personality disor- aptitudes, such as memory, logic, concen-
ders. A modified approach may also be tration, and speed of response.
used in the treatment of psychosis. Psy-
choanalysis aims to help the patient to psychoneurosis
understand his or her emotional devel- A term that can be used interchangeably
opment and to make adjustments in with neurosis.
particular situations. Interpretation of the
patient’s dreams is another aspect of the psychopathology
treatment (see dream analysis). The study of abnormal mental process-
es. There are two main approaches: the
psychoanalytic theory descriptive, which aims to record symp-
Psoriasis on the knees A system of ideas developed by Sig- toms that make up a diagnosis of mental
Distribution and appearance of psoriasis mund Freud that explains personality illness; and the psychoanalytic, which is
The knees, elbows, scalp, trunk, and back are
common sites for psoriasis. The usual appearance
and behaviour in terms of unconscious concerned with a person’s unconscious
is of patches of thickened skin covered by dry, wishes and conflicts. The main empha- feelings and motives.
silvery, adherent scales. sis was on sexuality. Freud believed that
a child passes through three stages in psychopathy
attacks, which may be triggered by fac- the first few years of life: oral, anal, and An outdated term for an antisocial
P tors such as emotional stress, skin genital. After this, the child develops a personality disorder.
damage, and physical illness. sexual attraction to the parent of the
There are different forms of the dis- opposite sex and wants to eliminate the psychopharmacology
ease, and the most common of which is other parent (Oedipus complex). Sexual The study of drugs that affect mental
discoid, or plaque, psoriasis, in which feelings become latent around the age states, such as antipsychotic drugs, anti-
patches appear on the trunk, limbs, and of five but re-emerge at puberty. Psy- depressant drugs, and anti-anxiety drugs.
scalp. Another type, guttate psoriasis, chological problems may develop if
occurs most often in children, and con- fixation occurs at a primitive stage. psychosexual disorders
sists of many small patches that develop MODERN DEVELOPMENTS A range of disorders related to sexual
over a wide area of skin. Pustular psori- Modern psychoanalysis has progressed function. Psychosexual disorders in-
asis is characterized by small pustules from these early ideas and is generally clude transsexualism, psychosexual dys-
over part or all of the body. based on the observation that the major- function, and sexual deviation.
TREATMENT ity of emotional problems are caused by
In most cases of psoriasis, the condition childhood experiences. The aim of psy- psychosexual dysfunction
can be improved with topical treat- choanalysis is to free the individual A disorder in which there is inter-
ments, such as those containing cortico- from the past, thereby helping him or ference with the sexual response for no
steroid drugs, coal tar, calcipotriol and other her to adjust to the present. physical cause. (See also sex therapy.)
vitamin D analogues. Other treatments
include dithranol ointment, PUVA, and psychodrama psychosis
drugs such as methotrexate. Psoriasis is An aid to treatment with psychotherapy A severe mental disorder in which the
usually a long-term condition. in which the patient acts out certain individual loses contact with reality and
roles or incidents. Psychodrama is often develops a distorted view of life. Unlike
psych- carried out with a partner or in a group; neurotic people, who know they have a
A prefix meaning mental processes or music, dance, and mime are often used problem, those with psychoses may be
activities, as in psychology. as part of psychodrama. unaware they are ill. The cause is most

636
 PUBERTY

likely to be a disorder of brain function.

Drug abuse may also precipitate psy-
chosis, which can be acute or chronic.
Psychosis is divided into three main
categories, namely schizophrenia, manic–
depressive illness, and organic brain syn-
drome (see brain syndrome, organic).
Paranoia may be considered to consti-
tute a fourth category. Symptoms of
Appearance of pterygium Congenital ptosis in a child
psychosis include delusions, hallucina- The conjunctiva has extended beyond the white of This condition, which is present from birth, should
tions, and change in affect (mood), the eye to encroach on the cornea (the transparent be corrected surgically in order to prevent any
including mania and depression. front part of the eye). disturbance of visual development.
Episodes of acute psychosis may
improve with or without drug treat- ptosis ptyalism
ment. Antipsychotic drugs are usually Drooping of the upper eyelid. It may be See salivation, excessive.
effective in controlling the symptoms. congenital, occur spontaneously, or be
Long-term treatment, rehabilitation, and due to injury or disease, such as myas- puberty
support are often needed. (See also thenia gravis. It may be due to weakness The period during which adult body
puerperal psychosis.) of the levator muscle of the eyelid or features (see sexual characteristics, sec-
interference with nerve supply. Severe ondary) develop and sexual organs
psychosomatic congenital ptosis is corrected surgically. mature, making reproduction possible.
A term that describes physical disorders
that seem to be caused, or made worse,
CHANGES OF PUBERTY
by psychological factors. Common
examples of conditions that may be There is considerable variation in the age of onset of puberty, but girls, on average,
psychosomatic are headache, breathless- undergo puberty at an earlier age than boys. The entire process takes about three
ness, nausea, asthma, irritable bowel to four years to reach completion. In addition to the changes specific to each sex,
syndrome, dyspepsia, and some types of height and weight of both girls and boys increase rapidly.
eczema. (See also somatization disorder.)

psychosurgery
Any operation on the brain that is car-
ried out as a treatment for serious mental
illness. It is performed only as a last
resort when other treatments have failed.
Prefrontal lobotomy has now been largely
replaced by types of stereotaxic surgery.
P
psychotherapy
Treatment of mental and emotional
problems by the use of psychological
methods. Patients talk to a therapist
about their symptoms and problems,
with the aim of learning about them-
selves, developing insights into their
relationships, and, ultimately, changing
their behaviour patterns.
psychotropic drugs
Drugs that have an effect on the mind,
including hallucinogenic drugs, sedative
drugs, sleeping drugs, tranquillizer drugs,
and antipsychotic drugs.
pterygium 10 to 12 15 to 16 12 to 14 15 to 18
A wing-shaped thickening of the con-
Girls Boys
junctiva that extends from either side of Puberty most often starts between the ages The main changes are enlargement of the
the eye towards the centre. Pterygium is of 10 and 12 in girls. Major changes include sex organs, widening of the shoulders,
attributed to prolonged exposure to growth of breasts and pubic hair, widening deepening of the voice, and the growth of
bright sunlight and is common in trop- of the hips, enlargement of the uterus, and facial and pubic hair. The onset is usually
the onset of menstruation. between the ages of 12 and 14.
ical areas. It is surgically removed if it
threatens vision or causes discomfort.

637
 PUBIC BONE

Puberty usually occurs between the ages pubic bone There may be very severe depression,
of 10 and 15. It is initiated by the pitu- The front part of each of the two hip including thoughts of suicide and/or of
itary gland producing gonadotrophin bones (see pelvis). The two pubic bones harming the baby. Many women who
hormones, which in girls stimulate the meet at the pubic symphysis, which is suffer from puerperal psychosis have a
ovaries to increase secretion of oestro- situated at the front of the pelvis. family history of psychotic illness or
gen hormones and in boys the testes to have had such an illness themselves.
increase secretion of testosterone. pubic lice Puerperal psychosis requires urgent
Puberty is accompanied by a signi- Small, wingless insects (PHTHIRUS PUBIS), psychiatric assessment and hospitaliza-
ficant growth spurt. Body weight may also called crab lice or crabs, that live in tion, ideally in a mother and baby
double during this period, primarily the pubic hair and feed on blood. A psychiatric unit.Treatment of the condi-
due to muscle growth in boys and louse has a flattened body, up to 2 mm tion is with antipsychotic drugs and
increased fat in girls. The growth spurt across. Female lice lay eggs (nits) on the antidepressant drugs.
occurs later in boys. hair, where they hatch about eight days
PUBERTY IN GIRLS later. On men, the lice may also be puerperal sepsis
The first sign of puberty in girls is found in hair around the anus, on the An infection that originates in the geni-
usually breast budding, which occurs legs, on the trunk, and on the face. The tal tract within the first ten days after
around the age of 11; in about one bites sometimes cause itching. childbirth, miscarriage, or abortion. For-
third of girls, pubic hair appears first. The lice are usually spread from per- merly a common cause of death,
The breasts may grow at unequal rates, son to person by sexual contact. puerperal sepsis is now easily treated
but any difference usually disappears by Children can become infested by trans- with antibiotic drugs.
the time full maturity is reached. Other mission from parents, and the lice may
secondary sexual characteristics, such as live on the eyelids. An insecticide puerperium
the wider pelvis, the female distribution lotion will kill the lice and eggs. In The period of time after childbirth dur-
of fat, and the growth of pubic and addition, anyone in contact with the ing which the uterus and genitals return
underarm hair, develop progressively infested person should be treated, and to their pre-pregnancy state.
during this period. clothes and bedding should be washed
The first menstrual period (see men- in water hotter than 60°C before use. pulmonary
struation) usually occurs a year or Relating to the lungs.
more after the start of puberty. The public health
process of puberty is considered com- The branch of medicine that is con- pulmonary disease, chronic
plete when periods occur at regular, cerned with prevention of disease obstructive
predictable intervals. The age at which through measures such as health educa- A combination of the two lung
menstruation starts has decreased dur- tion, provision of clean water supplies, conditions chronic bronchitis and emphy-
ing the past century, probably because sewage disposal, safer working condi- sema. Chronic obstructive pulmonary
of an improvement generally in nutri- tions, methods of infection control, disease (COPD) severely restricts air
tion and living standards, but is now immunizations, and care of pregnant flow into or out of the lungs. Bronchitis
stable. Strenuous sports or other hard women and young children. Public causes inflammation and narrowing of
P physical activity (such as ballet), and health functions are covered by many the airways, while emphysema results
debilitating disease, can also delay the people and agencies, such as Environ- in damage to the alveoli (tiny air sacs)
onset of menstrual periods. mental Health Officers, Medical Officers in the lungs, making them much less
PUBERTY IN BOYS of Environmental Health, and the Public effective at transferring oxygen from
In boys, puberty is heralded by a sud- Health Laboratory Service. the lungs to the bloodstream.
den increase in the growth of the testes The major cause of COPD is smoking.
and scrotum, followed by the appear- pudenda Atmospheric pollution is a contributory
ance of pubic and facial hair. The penis The external genitalia. factor, and occupational exposure to
begins to grow around the age of 13 dusts and certain other irritants can
and reaches its adult size about two pudendal block worsen pre-existing COPD.
years later; however, there is a wide A type of nerve block used to provide SYMPTOMS
variation, so that, at the age of 14, some pain relief for a forceps delivery. A local Some affected people (so-called “pink
boys may be fully grown while others anaesthetic (see anaesthesia, local) is puffers”) maintain adequate oxygen in
still have immature genitals. injected into either side of the vagina their bloodstream through an increase
Secretion of the male sex hormone near the pudendal nerve. in their breathing rate; however, they
testosterone increases; this stimulates suffer from almost constant shortness of
sperm production and causes the puerperal psychosis breath. Others (“blue bloaters”) have
prostate gland and seminal vesicles to A severe mental illness that follows cyanosis (a bluish discoloration of the
mature. It leads to the development of childbirth. Symptoms of psychosis usually skin and mucous membranes), and
the typical male distribution of hair on develop within two weeks of delivery of sometimes oedema (accumulation of
the face, chest, and abdomen. The lar- the baby and include confusion and fluid in tissues), mainly due to heart fail-
ynx enlarges and the vocal cords mood swings, together with disordered ure resulting from the lung damage.
become longer and thicker, causing the thinking and behaviour, for example DIAGNOSIS AND TREATMENT
pitch of the voice to drop. (See also believing that the baby is abnormal. Hal- COPD may be diagnosed from the
delayed puberty; precocious puberty.) lucinations and delusions also occur. symptoms and a physical examination.

638
 PULMONARY HYPERTENSION

The diagnosis of COPD is confirmed by and immobility, including long-haul pulmonary fibrosis
procedures such as pulmonary function flights. It may also be linked to throm- Scarring and thickening of lung tissue,
tests, chest X-rays and CT scans. bophilia (a genetic tendency for blood to usually as a result of previous lung
Lung damage that is pre-existing clot too readily). A massive embolus can inflammation. It may be confined to an
is irreversible, but the affected person cause sudden death. Smaller emboli area of the lung affected by a condition
must stop smoking immediately in may cause severe shortness of breath, such as pneumonia or tuberculosis, or it
order to prevent further damage. Also, rapid pulse, dizziness, chest pain that is may be widespread through the lungs
exposure to smoke, pollution, dust, made worse by breathing, and cough- (see fibrosing alveolitis). Shortness of
damp, and cold should be minimized. ing up of blood. Tiny emboli may not breath is a common symptom.
Drug treatment for COPD may in- produce any symptoms, but, if recur- Diagnosis is confirmed by chest X-ray.
clude bronchodilator drugs to widen the rent, they may eventually lead to Treatment depends on the cause, but in
airways, diuretic drugs to remove excess pulmonary hypertension (high blood pres- most cases the fibrosis is irreversible
fluid, and antibiotic drugs for chest sure in the arteries that supply the and treatment aims to prevent the con-
infections. Some people may need oxy- lungs). After having a first embolism, dition from progressing.
gen therapy for the relief of severe the risk of developing further emboli is
shortness of breath. significantly increased. pulmonary function tests
DIAGNOSIS A group of procedures that are used to
pulmonary embolism A diagnosis may be made using proce- evaluate lung function, to confirm the
Obstruction that affects the pulmonary dures including chest X-rays, radionuclide presence of lung disorders, or to ensure
artery or one of its branches in the scanning, and pulmonary angiography. that surgery on the lungs will not
lung by an embolus, usually a blood An ECG and analysis of arterial blood disable the patient. Pulmonary function
clot that has formed as a result of deep gases may also be performed. tests include an assessment of the
vein thrombosis (see thrombosis, deep TREATMENT degree of bronchospasm (narrowing of
vein). In cases in which the embolus is Treatment depends on the size and the airways due to muscle contraction)
large enough to block the main pul- severity of the embolus. A small clot with a peak-flow meter, spirometry, mea-
monary artery or if there are many gradually dissolves; thrombolytic drugs surement of lung volume, a test of blood
clots, it may lead to cardiac arrest and may be given to speed up this process. gases, and measurement of the ex-
require emergency resuscitation (see Surgery may be needed to remove larg- change of gases across the alveoli (the
cardiopulmonary resuscitation). er clots. Anticoagulant drugs reduce the tiny air sacs in the lungs).
CAUSES AND SYMPTOMS chance of developing further clots. If
Pulmonary embolism is more likely the condition recurs, however, tests are pulmonary hypertension
after recent surgery, pregnancy, oestro- needed to investigate the possibility of A disorder in which the blood pressure
gen treatment – for example with the blood clotting disorders. Affected fe- in the arteries supplying the lungs is
combined pill (see contraceptives, oral) males should stop using combined oral abnormally high, which develops in
or hormone replacement therapy (HRT) – contraceptives and HRT. response to increased resistance to
blood flow through the lungs. In order
to maintain an adequate blood flow, the
PULMONARY EMBOLISM right-hand side of the heart needs to P
contract more vigorously than previ-
This condition results when one or more emboli (fragments of material) break off ously. As a consequence of this extra
from a blood clot, usually in a vein, and are carried, via the heart, to the lungs. The
effects mainly depend on the size and numbers of emboli but also on the general
work for the heart, right-sided heart fail-
health of the person’s lungs and heart. ure may later develop.
CAUSES
Right lung
Trachea
Causes of pulmonary hypertension may
Unaffected include chronic obstructive pulmonary
Pulmonary artery
disease (COPD) (see pulmonary disease,
artery
chronic obstructive), a pulmonary embo-
Unaffected
lung tissue lism, pulmonary fibrosis, and some con-
genital heart diseases (see heart disease,
Embolus congenital), but it can also develop with-
out an obvious cause.
Lung tissue SYMPTOMS
deprived of
blood
Symptoms, which include enlarged veins
in the neck, enlargement of the liver, and
generalized oedema, only develop when
heart failure occurs.
Site of obstruction
Emboli are carried into the lungs by the TREATMENT
pulmonary artery. They may lodge within one Treatment is aimed at the underlying
of the larger or medium-sized arteries and disorder (if this is known) and the
Heart
partially deprive a section of lung tissue of relief of the heart failure. Diuretic drugs
a blood supply.
or other drugs may be given, and oxy-
gen therapy may also be necessary.

639
 PULMONARY INCOMPETENCE

PULMONARY HYPERTENSION Enamel

In this condition, there is increased resistance to blood flow through the lungs
(blue arrows), usually due to lung disease. The result is a rise in pressure in the Dentine
pulmonary artery, the right side of the heart (black lines and arrows), and in the
Pulp
veins that bring blood to the heart.

Superior vena Pulmonary Left lung Gum

cava artery
Jawbone

Cementum

Nerve and
blood supply

Causes Location of the dental pulp

The most common cause of The pulp is the soft core at the centre of a tooth.
increased resistance to blood If tooth decay reaches as far as the pulp, the latter
flow through the lungs is degenerates rapidly and must be removed in order
constriction of the small to save the tooth.
arteries in the lungs and
Heart thickening of their muscular pulpectomy
walls. This thickening usually The removal of the tooth pulp. Pulpec-
results from a lung disease
Back pressure such as chronic bronchitis or
tomy is part of the procedure called
The increased pressure is emphysema. root-canal treatment.
Inferior Right transmitted back to veins
vena cava ventricle throughout the body. pulpitis
Inflammation of the dental pulp, which
most commonly occurs as a result of
pulmonary incompetence pulmonary stenosis dental caries. Pulpitis can lead to peri-
A rare defect of the pulmonary valve at A heart condition in which the outflow apical periodontitis and a periapical abscess
the exit of the heart’s right ventricle of blood from the right ventricle (lower (see abscess, dental).
(lower chamber).The valve fails to close heart chamber) is obstructed, causing
properly, allowing blood to leak back the heart to work harder in order to pulpotomy
into the heart. The usual causes of pul- pump blood to the lungs. Removal of the coronal part of the pulp
monary incompetence are rheumatic CAUSES of a tooth after it has become inflamed,
fever, endocarditis (inflammation of the The obstruction may be caused by nar- usually by infection. Infection of the
inner lining of the heart), or severe pul- rowing of the pulmonary valve at the pulp is most often caused by extensive
P monary hypertension. exit of the ventricle; by narrowing of tooth decay (see caries, dental) or to
the pulmonary artery, which carries dental fractures (see fracture, dental).
pulmonary oedema blood to the lungs; or by narrowing of Now, pulpotomy is performed only on
Accumulation of fluid in the lungs, the upper part of the ventricle. primary teeth. The technique prevents
which is usually due to left-sided heart SYMPTOMS further degeneration of the pulp.
failure.The build-up of fluid may also be Pulmonary stenosis is usually congenital,
due to a chest infection, to inhalation of and it may occur on its own or with a pulse
irritant gases, or to any of the problems set of heart defects that collectively are The rhythmic expansion and contrac-
that cause generalized oedema (fluid called the tetralogy of Fallot. In rare cases, tion of an artery as blood is forced
accumulation in tissues). the stenosis develops later in life, after through it, pumped by the heart. The
The main symptom of pulmonary rheumatic fever, and it may cause symp- pulse can be felt at various points on
oedema is breathlessness, which is usu- toms of heart failure. the exterior of the body where arteries
ally worse when the person is lying flat DIAGNOSIS AND TREATMENT lie just below the skin’s surface. Exam-
and may disturb sleep (see paroxysmal Diagnosis of pulmonary stenosis is ples of such pulse points are the inside
nocturnal dyspnoea). There may also be a made by a chest X-ray, ECG, echocardiogra- of the wrist, the side of the neck, and
cough that produces frothy sputum, phy, and Doppler ultrasound scanning. the top of the thigh.
which is sometimes pink coloured. In A balloon catheter may relieve the nar-
some cases breathing may sound bubbly rowing. In more serious cases, heart- pump, infusion
or possibly wheezy. valve surgery or other types of open heart A machine that is used in order to
A diagnosis of pulmonary oedema is surgery are often very successful. administer a continuous and controlled
made by a physical examination and by a amount of a drug or sometimes of
chest X-ray. Treatment of the condition pulp, dental another fluid (such as insulin or opioid
may include morphine, diuretic drugs, The soft tissue containing blood vessels analgesic drugs). The fluid is delivered
aminophylline, and oxygen therapy; artifi- and nerves that is situated in the middle through a needle that is inserted into a
cial ventilation may also be given. of each tooth (see teeth). vein or under the skin.

640
 PYLORIC STENOSIS

pump, insulin component of adenine and guanine, pustule

A type of infusion pump (see pump, two nucleotide bases found in the nucleic A small skin blister that contains pus.
infusion) used to administer a contin- acids DNA and RNA.
uous dose of insulin to some patients PUVA
with diabetes mellitus. The rate of flow is purpura A type of phototherapy that is used to
adjusted so that the level of blood glu- Any of a group of disorders that are treat a variety of skin conditions, in par-
cose (sugar) is constant. characterized by purple to red-brown ticular psoriasis. PUVA is a combination
areas (or spots) on the skin, caused by of a psoralen drug and a controlled dose
punch-drunk bleeding within the skin or mucous of long-wavelength ultraviolet light.
A condition that is characterized by membranes. The term purpura also
slurred speech, impaired concentration, refers to the discoloured areas them- pyelitis
and slowed thought processes. It is selves, which do not blanch (go pale) See pyelonephritis.
caused by brain damage from several when pressure is applied to the skin
episodes of brief loss of consciousness (see glass test). pyelography
due to head injury. There are many different types and Another term for urography (see intra-
causes of purpura. Common purpura, venous urography).
PUO which is also known as senile purpura,
See pyrexia of unknown origin. mostly affects women who are middle- pyelolithotomy
aged or elderly. Large discoloured areas, An operation that is performed in order
pupil which are caused by thinning of the tis- to remove a kidney stone (see calculus,
The circular opening in the centre of sues supporting blood vessels under the urinary tract). Pyelolithotomy has been
the iris. In bright conditions, the pupil skin, appear on the thighs or the back largely replaced by other procedures
constricts; in dim light, it dilates. of the hands and forearms. One type, that are less invasive. One example is
Henoch–Schönlein purpura, is caused by lithotripsy, which uses ultrasonic waves
inflammation of the blood vessels that to break up the stones.
LOCATION OF THE PUPIL
lie just beneath the skin. Purpura can
also occur as a result of thrombocytopenia pyelonephritis
The pupil is the circular opening
in the centre of the iris. It can be (a bleeding disorder). Additionally, pur- Inflammation of the kidney, which is
widened or narrowed by muscles pura can be associated with septicaemia usually the result of a bacterial infec-
in the iris to adjust the amount of (blood poisoning) and it can be seen tion. Pyelonephritis is more common
light entering the eye. with meningitis (inflammation of the in women and is most likely to occur
membranes that cover the brain and during pregnancy. Symptoms include a
Light Iris the spinal cord). high fever, chills, and back pain. Septi-
caemia (blood poisoning) may be a
complication. Treatment is with antibiot-
Cornea ic drugs. Recurrent pyelonephritis can
lead to kidney failure. (See also vesi-
coureteric reflux.) P
pyeloplasty
A surgical procedure that is used to
relieve hydronephrosis (a buildup of
fluid in the kidney) that results from
Appearance of Henoch–Schönlein purpura structural defects in the renal pelvis (the
This condition can occur following an infection, or part of the kidney involved in collecting
it may be caused by an allergic reaction. Here, a urine) or in the ureter (the tube carry-
raised rash has appeared on the arm. ing urine from the kidney to the
Retina Lens Pupil
bladder). The operation involves reshap-
purulent ing the affected areas.
A term that means containing, produc-
purgative ing, or consisting of pus. pyloric sphincter
A term for a laxative drug. The valve situated at the base of the
pus stomach; its function is to control move-
purine A pale yellow or green, creamy fluid ment of food into the duodenum.
Any of a group of nitrogen-containing that is found at the site of a bacterial
compounds synthesized in the body or infection. The creamy fluid is composed pyloric stenosis
produced by the digestion of certain of many millions of dead white blood A condition that is characterized by nar-
proteins. Increased levels of purine can cells, as well as partly digested tissue, rowing of the pylorus (the lower outlet
cause hyperuricaemia, which may lead to dead and living bacteria, and some from the stomach). Pyloric stenosis
gout. Foods that have a high purine con- other substances. When a collection of causes an obstruction to the passage of
tent include sardines, liver, kidneys, pus occurs within a solid area of tissue, food into the duodenum (the first part of
pulses, and poultry. Purine is also a this is called an abscess. the small intestine).

641
 PYLOROPLASTY

CAUSES pyloroplasty pyrimethamine

Pyloric stenosis occurs in babies as a An operation in which the pylorus (the A drug that is used in combination with
result of thickening of the pyloric mus- outlet leading from the stomach) is other drugs to treat resistant malaria.
cle. When it occurs in adults, however, widened in order to allow free passage
the condition is due to scarring from a of food into the intestine. Pyloroplasty pyrogen
peptic ulcer or stomach cancer. may be performed as part of the surgery A substance that produces fever. The
SYMPTOMS for a peptic ulcer, or may be performed term is usually applied to proteins
Babies start projectile vomiting (profuse in order to prevent tightening of the released by white blood cells in response
vomiting in which the stomach con- pyloric muscles after vagotomy (cutting to infections. The word is also some-
tents may be ejected several feet) two to of the vagus nerve to reduce stomach times used to refer to chemicals
five weeks after birth. Adults with the acid production). released by microorganisms.
disorder vomit undigested food several
hours after a meal. pyo- pyromania
DIAGNOSIS A prefix that is used to denote a rela- A persistent impulse to start fires. It is
In infants, ultrasound scanning is the pro- tionship to pus. The prefix py- is also more often seen in males, and may be
cedure used for confirmation of the used in the same way. associated with a low IQ, alcohol abuse,
diagnosis. In adults, however, diagnosis and a psychosexual disorder.
is likely to be made by means of a bari- pyoderma gangrenosum
um X-ray examination and a gastroscopy A rare condition that is characterized by pyruvate kinase deficiency
(examination of the stomach using a ulcers, usually on the legs, that turn A disorder in which there are abnor-
viewing instrument). into hard, painful areas surrounded by mally low levels of an enzyme called
TREATMENT discoloured skin. Pyoderma gangreno- pyruvate kinase, which is carried in red
In infants, surgical treatment involves sum occurs as a rare complication in blood cells. Normally, pyruvate kinase
making an incision along the thickened ulcerative colitis. aids the breakdown of glucose to create
muscle. In adults, surgery is carried out energy in anaerobic (low-oxygen) con-
to correct the underlying cause. pyogenic granuloma ditions. If there is a deficiency of the
A common, noncancerous skin tumour enzyme, the red cells cannot generate
that develops on exposed areas after enough energy for themselves; they also
PYLORIC STENOSIS minor injury. The tumour can be develop chemical imbalances that cause
IN INFANTS removed surgically, by electrocautery, or them to be destroyed prematurely by
by cryosurgery. the spleen, thereby causing anaemia
In infantile pyloric stenosis, the (see anaemia, haemolytic) and enlarge-
muscle surrounding the outlet pyrazinamide ment of the spleen. The disorder is
from the stomach is abnormally
thickened, as shown in the enlarged
A drug sometimes used to treat tubercu- usually the result of an autosomal reces-
drawing (below). The condition losis. Possible adverse effects are nausea, sive gene defect (see genetic disorders).
occurs more often in male than joint pains, gout, and liver damage. The severity of the disease varies.
Most people require no treatment. Blood
P female babies and tends to run in
families – infants of a woman who pyrexia transfusions may be needed in some
was affected with pyloric stenosis A medical term for fever. cases, particularly when the person is
as a baby may develop it. under physiological stress (such as
pyrexia of unknown origin acute illness or pregnancy), at which
Stomach
Persistent fever, lasting ten days or times the disease tends to be worse.
more, with no apparent cause. It is usu- Splenectomy (removal of the spleen) may
Duodenum ally due to an illness that is difficult to be recommended in severe cases.
Pylorus
diagnose or a common disease that
appears in an unusual way. Such illness- pyuria
es include viral infections; tuberculosis; The presence of white blood cells in the
cancer, particularly lymphoma; and colla- urine, which is often an indication of an
Colon gen diseases, such as systemic lupus infection of a kidney or urinary tract infec-
erythematosus and temporal arteritis. An- tion and inflammation.
other possible cause of pyrexia of
Normal unknown origin is a reaction to a drug.
thickness
of muscle
pyridoxine
Vitamin B6 (see vitamin B complex).
Dietary deficiency of this vitamin is
very rare but can be induced by some
Enlarged
muscle drugs. Supplements of pyridoxine (50
wall to 100 mg per day) are sometimes used
to treat premenstrual syndrome. There is a
possible risk of toxicity if high doses of
the supplement are taken long term.

642
 QUINSY

Quarantine procedures are now rarely

Q
LOCATION OF THE used due to the reduced incidence of
QUADRICEPS MUSCLE
serious infectious diseases and the avail-
ability of vaccinations for many of them.
One upper end attaches to the
pelvis; the other two ends attach The principal remaining quarantine reg-
to the femur. The lower ends merge ulations apply to animals imported into
into a tendon that surrounds the countries that are free from rabies.
patella and attaches to the tibia.
quickening
The first fetal movements felt by a preg-
Pelvis
nant woman, which usually occur after
QALY about 18 weeks’ gestation.
A quality-adjusted life year. QALY is
used by health economists to compare Femur quinapril
the relative costs and outcomes of treat- An ACE-inhibitor drug used in the treat-
Quadriceps
ment for various diseases. Each year of muscle
ment of hypertension and heart failure.
life saved or prolonged is adjusted by a
factor, Q, which takes account of how quinine
close to normal the individual’s lifestyle Quadriceps
The oldest drug treatment for malaria.
is before and after treatment. muscle Quinine is mainly used in large doses to
treat strains that are resistant to other
Q fever Patella antimalarials. There is a high risk of side
An uncommon illness causing symptoms Tibia effects such as headache, nausea, ringing
that are similar to those of influenza. Q in the ears, hearing loss, and visual dis-
fever occurs throughout the world. turbance. It is also prescribed in low
CAUSES doses to help prevent leg cramps at
Q fever is caused by the rickettsia (a type DISORDERS night; side effects in this case are rare.
of small bacterium) COXIELLI BURNETTI and The most common quadriceps disorder
may be contracted by inhaling dust con- is a haematoma (collection of blood), due quinolone drugs
taminated with faeces, urine, or birth to a direct blow. Bruising may follow COMMON DRUGS
products from infected farm animals. after a few days. Rarely, bone forms in • Ciprofloxacin • Levofloxacin • Nalidixic acid
Rarely, it is spread by tick bites. the haematoma, restricting movement. • Norfloxacin • Ofloxacin
SYMPTOMS Sudden stretching of the leg may tear
Symptoms develop suddenly about 20 the muscle, especially in middle-aged or A group of antibiotic drugs used to treat
days after infection. They include high elderly people. Rupture of the quadriceps bacterial infections. Quinolones are de-
fever (lasting up to two weeks), severe tendon can be caused by a direct blow to rived from chemicals, rather than from
headache, muscle and chest pains, and a the leg or stumbling. Knee disorders that living organisms. They are used to treat
cough. A form of pneumonia subse- cause pain or swelling, limiting full exten- a range of conditions, including prostati-
quently occurs. Most people recover, sion of the leg, cause the muscle to begin tis (inflammation of the prostate), urinary
but the disease is sometimes prolonged: to waste away within 48 hours, making tract infections, acute diarrhoeal diseases Q
occasionally, hepatitis (liver inflamma- the knee feel as if it is giving way when (such as those caused by salmonella
tion) or endocarditis (inflammation of the weight is placed on the affected leg. Exer- infections), and enteric fever. Ciproflox-
inner lining of the heart) may develop. cises to strengthen the quadriceps are acin may also be used as an initial
DIAGNOSIS AND TREATMENT used to treat certain knee disorders. treatment for anthrax. The absorption of
After diagnosis is confirmed by a blood quinolones is reduced by antacid drugs.
test,treatment is with antibiotic drugs. A quadriparesis POSSIBLE ADVERSE EFFECTS
vaccine is available for people at risk. Muscle weakness in all four limbs and Side effects include nausea, diarrhoea,
the trunk. (See also quadriplegia.) headache, sleep disorders, rash, and
quackery blood disorders. Rarely, there is tendon
A false claim by someone to have the quadriplegia damage (especially in the elderly and
ability to diagnose and treat disease. Paralysis of all four limbs and the trunk, those taking corticosteroid drugs).
also known as tetraplegia. Quadriplegia WARNING
quadrantectomy may be caused by damage to the spinal Quinolones should be used with cau-
A surgical procedure that involves the cord in the neck region. The condition tion by people with epilepsy, during
removal of tissue in one quadrant of a results in loss of feeling and power in pregnancy and breast-feeding, and by
breast in order to treat breast cancer. the affected parts. (See also paraplegia.) children and adolescents. Swelling and
(See also lumpectomy; mastectomy.) pain in the tendons should be reported.
quarantine
quadriceps muscle The isolation of a person or animal re- quinsy
A large muscle with four distinct parts, cently exposed to a serious infectious Another name for a peritonsillar abscess
located at the front of the thigh. The disease in order to prevent the spread of (an abscess in the soft tissue around the
quadriceps muscle straightens the knee. the disease by symptomless individuals. tonsils), a complication of tonsillitis.

643
 RABIES

rad

R
any of these types of radiation consti-
A unit of absorbed dose of ionizing tute a health hazard. However, alpha
radiation (see radiation unit), which has particles cannot penetrate the skin, and
been superseded by the gray (Gy). therefore sources of alpha radiation are
“Rad” stands for radiation absorbed dose. only dangerous if they are ingested or
inhaled. Gamma radiation can travel
radial keratotomy large distances through many sub-
See keratotomy, radial. stances; even distant gamma sources can
pose a risk to humans.
radial nerve Most sources of radiation are natural.
A branch of the brachial plexus. The radi- Natural sources of ionizing radiation
rabies al nerve, one of the main nerves of the include cosmic rays from space and
An acute viral infection of the nervous arm, runs from the shoulder to the hand. radioactive minerals. In some areas, the
system, once known as hydrophobia, The radial nerve controls the muscles gas radon, which is found in soil, rocks,
that affects mammals, including bats. that straighten the wrist. It conveys sen- or building materials, is a major source
The virus travels along nerve pathways sation from the back of the forearm; the of ionizing radiation. Sources of ionizing
to the brain; once symptoms develop, thumb, second, and third fingers; and radiation that are artificial include X-ray
rabies is usually fatal. the base of the thumb. machines, radioactive isotopes used in
CAUSES AND INCIDENCE The radial nerve may be damaged by diagnosis and treatment (see radionuclide
Rabies can be transmitted from a rabid a fracture of the humerus (upper-arm scanning), and nuclear reactors.
animal to a human by a bite or a lick over bone) or by persistent pressure on the NONIONIZING RADIATION
broken skin; most human cases result armpit, such as from the use of a Less energetic types of radiation, such as
from being bitten by a rabid dog. Rabies crutch. Such damage may result in wrist- ultraviolet light, may cause biological
is an extremely rare disease in the UK. drop (an inability to straighten the damage by mechanisms other than ion-
SYMPTOMS wrist) and numbness in the areas of ization. Ultraviolet radiation from the sun
The average incubation period (the time skin supplied by the radial nerve. does not penetrate the body deeply, but
between exposure to the infection and can damage genetic material in cells and
the appearance of symptoms) is one to radiation may lead to skin cancer.
two months, depending on the site of The emission of energy (as electromag- Other types of nonionizing radiation
the bite. The first symptoms of rabies netic waves) or matter (as particles) from to which people are subjected are ultra-
are slight fever and headache. These are unstable atoms, which turns them into a sound, used in medicine for diagnosis
followed by restlessness, hyperactivity, more stable form. Some types of radia- and treatment, and radio waves that are
and, in some cases, strange behaviour, tion are harmful to life; other types are generated during MRI (magnetic reso-
hallucinations, and paralysis. The victim essential, such as light and heat energy nance imaging). These techniques are
develops seizures, arrhythmias (see arrhy- radiated from the sun. Even harmful not thought to have any adverse side
thmia, cardiac), and paralysis of the respir- radiation may be used for beneficial effects. (See also radiation hazards; radia-
atory muscles.There is often intense thirst purposes. In treatment by radiotherapy, tion sickness; radiation unit).
but drinking induces painful spasms of for example, the biologically damaging
the throat. Death usually occurs ten to 14 effects of radiation are used to destroy radiation dermatitis
days after the onset of symptoms. cancerous cells. A type of dermatitis (inflammation of
TREATMENT AND PREVENTION IONIZING RADIATION the skin) that may be caused by single
R Following an animal bite, immunization
with human rabies immunoglobulin and
Four significant types of harmful radia-
tion are gamma radiation, X-rays, alpha
exposure to a high dose of radiation.

a course of rabies vaccine is necessary; particles, and beta particles. Gamma radiation enteritis
this may prevent the onset of rabies. If radiation and X-rays are types of elec- A potentially long-standing form of
symptoms appear, they are treated with tromagnetic waves and are similar to enteritis (inflammation of the small
sedative drugs and analgesics (painkillers). more energetic forms of light. The intestine) that is caused by exposure of
Emphasis is placed on preventing the principal difference between the two is the intestine to radiation, including the
disease through quarantine regulations that gamma rays are produced by the use of radiotherapy. The symptoms of
and human and animal immunization. spontaneous decay of radioactive mate- radiation enteritis include nausea, vom-
Prophylactic immunization is recom- rials whereas X-rays are produced by a iting, and diarrhoea.
mended for certain people, for example machine. Particle radiation may be pro-
wild animal handlers and travellers to duced either during the decay of radiation fibrosis
countries where rabies is endemic. (See radioactive atoms or by machine. Scarring and thickening of the tissues
also bites, animal.) All four types of harmful radiation around an area of the body that has
cause damage by ionization: the waves been treated with radiotherapy.
rachitic or particles knock out electrons from
A term that is used to describe abnor- atoms in the matter that they pass radiation hazards
malities associated with rickets (a bone through, turning them into highly reac- Hazards brought about by radiation (the
disease caused by a deficiency of vitamin tive ions. In the case of living tissue, the emission of energy in the form of
D) or to refer to people or populations ions formed can cause biological dam- waves or particles) that may arise either
particularly afflicted by rickets. age. Radioactive substances that emit from external sources of radiation, such

644
 RADIOISOTOPE SCANNING

as X-rays or gamma rays, or from (pinpoint spots of bleeding under the breast cancer,which involves removing
radioactive materials taken into the body. skin). Some people are successfully the entire affected breast along with
The effects of radiation depend on the treated with a bone marrow transplant or chest muscles, underarm lymph nodes,
dose, the duration of exposure, and the by isolation in a sterile environment until and other tissue; radical neck dissection
organs exposed. the bone marrow recovers. (see neck dissection, radical), in which
With some forms of radiation, dam- With a dose of 10 to 30 Gy there is the lymph nodes in the neck are
age occurs only when the radiation also an early onset of nausea and vomit- removed; and amputation, which is usu-
dose exceeds a certain limit – this is ing, but these symptoms tend to ally performed to prevent the spread of
usually 1 sievert (Sv) (see radiation disappear a few hours later. However, gangrene (tissue death).
unit). Examples of such damage are damage to the gastrointestinal tract,
radiation dermatitis, cataract, organ fail- which causes severe and frequently radiculopathy
ure (which may occur many years bloody diarrhoea (known as the gastro- Damage to the nerve roots that enter or
later), or radiation sickness (an early intestinal syndrome), and overwhelming leave the spinal cord. Radiculopathy may
reaction to massive irradiation). infection due to damage to the immune be caused by disc prolapse, spinal arthri-
For other types of radiation damage, system are likely to result in death tis, diabetes mellitus, or ingestion of
the risk that damage will occur increas- between four and 14 days after exposure. heavy metals, such as lead. Symptoms
es with repeated doses of radiation. Acute exposures of 30 to 100 Gy of radiculopathy are severe pain and,
Cancer that is caused by radiation- cause the rapid onset of nausea, vomit- occasionally, loss of feeling in the area
induced mutation (a change in the ing, anxiety, and disorientation. Within supplied by the affected nerves. There
genetic material of living cells) is a hours, the victim usually loses conscious- may also be weakness, paralysis, and
major example of this type of damage. ness and dies due to damage to the wasting of the muscles that are supplied
Radioactive leaks from nuclear reactors nervous system and oedema (accumula- by the nerves.
can cause a rise in mutation rates, tion of fluid) of the brain; these Where possible, the underlying cause
which may lead to an increase in the combined effects are known as the cen- is treated; otherwise, symptoms may be
incidence of cancers, such as leukaemias; tral nervous system syndrome. relieved by analgesic drugs (painkillers),
birth defects in succeeding generations; physiotherapy, or, in some cases, surgery.
and hereditary diseases. Cancer usually radiation unit
develops years after exposure. Several different internationally agreed radioactivity
Damage can be controlled by limiting units (called SI units) are used to mea- The emission of alpha particles, beta
exposure to radiation. People exposed sure ionizing radiation. For example, the particles, and/or gamma radiation that
to radiation at work should have their becquerel (symbol Bq) is the SI unit of occurs during the spontaneous disinte-
exposure closely monitored to ensure spontaneous activity of a radioactive gration of the nuclei (see nucleus) of
that it does not exceed safe limits. Peo- source such as uranium. In medicine, the unstable atoms.
ple of reproductive age or younger most commonly used units are the gray Many radioactive substances, such
should have their reproductive organs (symbol Gy) and sievert (symbol Sv). as uranium ores, are naturally occur-
shielded when having X-rays or under- The gray is the SI unit of radiation ring. However, the majority of ele-
going radiotherapy. that is actually absorbed by any tissue or ments can be made radioactive by
There is no evidence of radiation haz- substance as a result of exposure to rad- bombarding them with high-energy
ards arising from visual display units iation. One Gy is the absorption of one particles, such as neutrons.
(VDUs) or the irradiation of food. joule of energy (from gamma radiation
or X-rays) per kilogram of irradiated radioallergosorbent test
radiation sickness
The term applied to the acute effects of
matter. The gray supersedes an older
unit called the rad (1 Gy = 100 rads).
See RAST.
R
ionizing radiation on the whole, or a Because some types of radiation radiography
major part, of the body when the dose affect biological organisms more than The use of radiation to obtain images
exceeds 1 gray (Gy) of X-rays or gamma others, the sievert is used as a measure of parts of the body. Radiographers pre-
rays or 1 sievert (Sv) of other types of of the impact of an absorbed dose. It pare patients for X-ray examinations, take
radiation (see radiation unit). uses additional factors, such as the and develop X-ray pictures, and assist
The effects of radiation depend on kind of radiation and its energy, to with other imaging techniques, such
the dose and the duration of exposure. quantify the effects on the body of as radionuclide scanning, ultrasound scan-
Total-body doses of less than 2 Gy are equivalent amounts of different types of ning, and MRI (magnetic resonance
unlikely to be fatal to a healthy adult. At absorbed energy. (See also Radiation units imaging). (See also radiology).
doses of 1 to 10 Gy, transient nausea box, overleaf.)
and occasional vomiting may occur, but radioimmunoassay
these usually disappear rapidly and are radical surgery A sensitive laboratory technique that
often followed by a two- to three-week Extensive surgery that is aimed at uses radioactive isotopes to measure the
period of relative wellbeing. By the end eliminating a major disease, usually can- concentration of specific proteins, such
of this period, the effects of radiation cer, by removing all the affected tissue as hormones or antibodies, in a person’s
damage to the bone marrow and immune and any surrounding tissue that might blood. (See also immunoassay).
system begin to appear, with repeated also be diseased.
infections (which may be fatal unless Some examples of radical surgery are radioisotope scanning
treated with antibiotic drugs) and petechiae radical mastectomy performed to treat See radionuclide scanning.

645
 RADIOLOGY

be studied. For example, iodine is taken

RADIATION UNITS
up mainly by the thyroid gland, so by
In the SI system (the internationally agreed system of units), three main units are “tagging” a sample of iodine with a
used to measure radiation levels – the becquerel, the gray, and the sievert. These radioactive marker (radionuclide), the
three units are defined below, along with two other radiation units (the rad and thyroid gland’s uptake of iodine can be
rem) that have now been largely superseded but are still occasionally used for monitored to investigate the function-
some purposes. ing of the gland.
HOW IT WORKS
Becquerel The radionuclide is swallowed or alter-
The SI unit of radioactivity. One becquerel (symbol Bq) is defined as one disintegration (or other natively injected into the bloodstream
nuclear transformation) per second. Although the number of becquerels is a measure of how
strongly radioactive a particular source is, it takes no account of the different effects of different and then accumulates in the target
types of radiation on tissue; for medical purposes, the sievert is generally more useful. organ. The organ emits radiation in the
form of gamma radiation, which is
Gray detected by a gamma camera and then
The SI unit of absorbed dose of ionizing radiation, the gray (symbol Gy) has superseded the rad. an image is produced.
One gray is defined as an energy absorption of 1 joule per kilogram of irradiated material. One Cross-sectional images (“slices”) can
gray is equivalent to 100 rads. be obtained by using a computer-con-
trolled gamma camera that rotates
Rad around the patient. This specialized
An acronym for radiation absorbed dose, the rad is a unit of absorbed dose of ionizing radiation.
One rad is equal to an energy absorption of 100 ergs (an erg is a unit of work or energy) per gram
form of radionuclide scanning is known
of irradiated material. The rad has been superseded by the gray (the corresponding SI unit); as SPECT (single photon emission com-
1 rad is equivalent to 0.01 grays. puted tomography). Moving images can
also be taken with the use of a comput-
Rem er; a series of images is recorded im-
An acronym for roentgen equivalent man, the rem is the absorbed dose of ionizing radiation that mediately following the administration
produces the same biological effect as 1 rad of X-rays or gamma rays. The rem was introduced as a of the radionuclide.
result of the observation that some types of ionizing radiation, such as neutrons, produce a
WHY IT IS DONE
greater biological effect for an equivalent amount of absorbed energy than X-rays or gamma rays.
In short, the rem is a measure of the biological effectiveness of irradiation. For X-rays and gamma Radionuclide scanning is capable of
rays, the rem is equal to the rad. For other types of radiation, the number or rems equals the detecting some disorders at an earlier
number of rads multiplied by a special factor (called the quality factor or relative biological stage than other types of imaging tech-
effectiveness) that depends on the type of radiation involved. The rem has been superseded by niques because changes in the func-
the sievert in the SI system of units; 1 rem is equivalent to 0.01 sieverts.
tioning of an organ often occur before
the structure of the organ is affected.
Sievert The technique is also used to detect dis-
The SI unit of equivalent absorbed dose of ionizing radiation, the sievert (symbol Sv) has
superseded the rem. One sievert is the absorbed dose of radiation that produces the same orders that affect only the function of
biological effect as 1 gray of X-rays or gamma rays. One sievert is equivalent to 100 rems. an organ. Moving images can provide
information about blood flow, the
movement of the heart walls, the flow
of urine through the kidneys, and bile
radiology radionuclide scanning flow through the liver.
The medical speciality that uses X-rays, A diagnostic technique that is based on RISKS
R ultrasound scanning, MRI (magnetic reson-
ance imaging), and radionuclide scanning
the detection of radiation emitted by
radioactive substances introduced into
Radionuclide scanning is a safe proc-
edure, requiring only minute doses of
to investigate, diagnose, and treat disease. the body. Different substances are taken radiation that are excreted within hours.
Radiological methods provide images up in different concentrations by differ- The radionuclides carry virtually no risk
of the body in a noninvasive way so that ent tissues, allowing specific organs to of toxicity or hypersensitivity.
exploratory surgery is not required.
The techniques also enable instruments radiopaque
(such as needles and catheters) to be A term describing anything that is able
accurately guided into different parts of to block radiation, especially X-rays and
the body both for diagnosis and for gamma rays. As many body tissues are
treatment, a subspeciality known as radiolucent (almost transparent to X-
interventional radiology. rays), some X-ray imaging procedures
require the introduction of radiopaque
radiolucent substances into the body in order to
A term referring to anything that is almost make the organs stand out clearly. (See
transparent to radiation, especially to X-rays also radiotransparent.)
and gamma rays. Some X-ray imaging pro-
cedures require the introduction of radio- radiotherapy
Radionuclide bone scan
paque substances into the body to make Here, the radionuclide has been absorbed by bone.
Treatment of cancer and, occasionally,
radiotransparent and radiolucent organs Abnormalities (such as metastases) absorb it in some noncancerous tumours, by the
and/or body tissues stand out more clearly. greater amounts and appear as ‘hot spots’. use of X-rays or other radiation. Radio-

646
 RADIOTHERAPY

active sources produce ionizing radia- a cancerous tumour is often followed example, part of an overactive thyroid
tion, which destroys or slows down the by radiotherapy to destroy any remain- gland (see thyrotoxicosis) may be
development of abnormal cells. Normal ing tumour cells, such as in the destroyed using radioactive iodine.
cells should suffer little or no damage in treatment of breast cancer. HOW IT IS DONE
the long term, but short-term damage is Radiotherapy may also be used to Radiotherapy is usually performed on
a side effect of radiotherapy. relieve the symptoms of a cancer that an outpatient basis. X-rays (or some-
WHY IS IT DONE is too advanced to be cured. An exam- times electrons), which are produced
Radiotherapy may be used on its own in ple of such palliative treatment is by a machine called a linear accelerator,
an attempt to destroy all the abnormal radiotherapy to reduce the size of a are aimed at the tumour from many
cells in various types of cancer, such as brain tumour in order to relieve head- directions. Alternatively, a source of
squamous cell carcinoma (a type of skin aches and paralysis. radiation, in the form of tiny pellets,
cancer) and Hodgkin’s disease (a cancer If the benefits of destroying diseased is inserted into the tumour through
of lymphoid tissue). It may also be used tissue outweigh the risks of damage to a hollow needle (see interstitial radio-
in conjunction with other cancer treat- healthy tissue, radiotherapy may be used therapy) or into a body cavity (see
ments. For example, surgical excision of to treat noncancerous diseases; for intracavitary therapy). These techniques

USE OF RADIOTHERAPY

Radiotherapy destroys cancer cells using

radiation. A linear accelerator is used for
external radiation (right). The position and Radiation source
dose of radiation are carefully calculated to
minimize exposure of normal cells to the
radiation, allowing them to recover with
little or no long-term damage.
Beam of
Internal radiation (below) involves radiation
placing radioactive materials in the body,
directly into or around a cancer.

External radiation
The patient lies still on a table under the machine.
A radiographer operates the machine, which
sends X-rays, in the predetermined directions
and amounts, through the diseased areas of the
patient’s body. The machine can be tilted to
irradiate the cancer from different angles (see
below, centre). The procedure causes no
discomfort, and usually lasts a few minutes, but
setting up the equipment may take 30 minutes.
Adjustable table

INTERNAL RADIATION

Lymphoid tissue R
Energy Before
beam treatment
There is a
proliferation of
Bladder
lymphoid tissue
Tumour in this lung
X-ray of a
Uterus patient with
Hodgkin’s
disease.

After
treatment
Radioactive Prostate The invading
pellets gland lymphoid
tissue has
Use of radioactive pellets Rays from different directions diminished
Tiny radioactive pellets are inserted, via a hollow By aiming relatively low-energy rays coming following
needle, directly into the organ or tissue to be from many directions at a tumour, a large radiotherapy.
treated (here, the prostate gland). enough dose of radiation is achieved in
the locality of the tumour to destroy it
completely (see above).

647
 RADIOTRANSPARENT

are both types of brachytherapy. Radio- Fracture of the radius just above the ramipril
active iodine used to treat thyrotoxi- wrist (see Colles’ fracture) is the most An ACE inhibitor drug used in the treat-
cosis is given by mouth. common of all fractures in people over ment of hypertension (high blood
COMPLICATIONS AND RESULTS 40. It is usually caused by falling on the pressure) and heart failure (reduced
There may be some unpleasant side palm of a hand, resulting in backward pumping efficiency). Ramipril is also
effects of radiotherapy, such as fatigue, displacement of the wrist and hand. used to prevent or delay kidney damage
nausea and vomiting (for which anti- Fracture of the disc-shaped head of in patients with diabetes mellitus. Side
emetic drugs may be prescribed), and the radius, just below the elbow, is one effects may include a persistent dry
loss of hair from irradiated areas. Rarely, of the most common fractures in young cough, a disturbance in taste, hypoten-
there may be reddening and blistering adults. Treatment depends on the type sion (low blood pressure), and other
of the skin, which can be alleviated by and severity of the fracture. A minor effects common to all ACE inhibitors.
corticosteroid drugs. fracture may heal if placed in a soft,
Radiotherapy can be used success- supportive bandage; others may require Ramsay–Hunt syndrome
fully to treat most types of cancer; the surgical correction. If the head of the A type of herpes zoster (shingles) that
chances of success increase the earlier bone is crushed or splintered, it may affects the facial nerve. Symptoms of
the treatment is started. need to be removed. Ramsay–Hunt syndrome include facial
Fracture of the shaft of the radius paralysis, intense ear pain, hearing loss,
radiotransparent may result in displacement of the bro- loss of taste, a painful rash on the affect-
A term referring to anything that is ken ends of the bone. An operation may ed part of the face, and pain in other
entirely transparent to radiation, espe- be required in order to reposition the parts of the body supplied by the facial
cially to X-rays and gamma rays. Some bone ends and fix them together before nerve. Treatment of the condition is
X-ray imaging procedures require the the limb is immobilized. with antiviral drugs and, sometimes, anti-
introduction of radiopaque substances Fractures of the radius usually take inflammatory drugs.
into the body to make radiotransparent approximately six weeks to heal.
and radiolucent organs and/or body tis- randomized controlled trial
sues stand out more clearly. radon A type of controlled trial used to evaluate
A colourless, odourless, tasteless, radio- the effectiveness of a drug or treatment
radium active gaseous element produced by the in which subjects are randomly allocat-
A rare, radioactive, metallic element that radioactive decay of radium. ed to one of the study groups. This
occurs naturally only as compounds in random allocation means an individual
uranium ores. Radium has four naturally raloxifene is equally likely to be selected to receive
occurring isotopes (varieties of the ele- A drug that is prescribed to prevent the treatment being investigated as to be
ment that are chemically identical but and treat postmenopausal osteoporosis. part of the control group of the trial,
differ in some physical properties): radi- Raloxifene has no beneficial effect on which may be given a placebo (a chem-
um 226, radium 228, radium 224, and other menopausal problems, such as ically inert substance). A comparison is
radium 223. Radium 226 was used to hot flushes. The drug may carry an made between various results of the
treat tumours but it has been superseded increased risk of developing a deep vein two groups to assess the benefit of the
by other radioisotopes, such as cobalt 60. thrombosis (see thrombosis, deep vein). treatment in question.
radius ranitidine
The shorter of the two long bones of LOCATION OF THE RADIUS An ulcer-healing drug belonging to the
R the forearm; the other is the ulna. The
radius is the bone on the thumb side of The radius bone is on the outside of
H2-receptor antagonist group. Ranitidine
is used to prevent and treat peptic ulcers
the forearm (here, the right), with the
the arm, which articulates with the palm facing forwards, or on the inside and to treat oesophagitis (inflammation
humerus (the upper arm bone) at the with the palm facing backwards. of the oesophagus). Side effects may
elbow and the carpal bones (upper include headache, skin rash, nausea,
wrist bones) at the wrist. constipation, and lethargy.
Humerus
The radius takes most of the strain
when weight is placed on the wrist, ranula
and it is a common site of fractures A cyst in the floor of the mouth, which
(see Colles’ fracture; radius, fracture of). A Radius produces a translucent bluish swelling.
fall or a blow may sometimes cause Ranulas probably arise from damage to
dislocation of the radius from the a salivary gland. Treatment of the ranula
elbow joint, along with fracture of is by surgical removal.
Thumb
the ulna, a condition that is known as
Monteggia’s fracture. Ulna
rape
Sexual intercourse with an unwilling
radius, fracture of partner, achieved by the use or the threat
A common type of fracture that may of force or violence. Rape is rarely sexual-
affect the lower end, upper end, or shaft ly motivated; it is a crime of dominance,
of the radius (the shorter of the two anger, and hostility, not a crime of pas-
long bones in the forearm). sion. Rape is a criminal offence.

648
 REACTIVE ARTHRITIS

EFFECTS rash has blisters filled with pus. A from the urine of infected rats in West
The rape victim may suffer a variety of butterfly rash is a skin eruption across Africa. Rats also carry the viral infection
physical injuries. Severe injury to the the cheeks with a narrow connecting lymphocytic chorio-meningitis, as well
genitals is rare, but there may be band across the nose; it is characteristic as the bacterial infection tularaemia.
swelling of the labia (folds of skin), of systemic lupus erythematosus.
bruising of the vaginal walls or cervix, CAUSES Raynaud’s disease
and possibly tearing of the anus or the Rashes are the main sign of many infec- A disorder of the blood vessels in which
perineum (the area between the geni- tious diseases, such as chickenpox, and exposure to cold causes the small arter-
tals and the anus). are a feature of many skin disorders, such ies supplying the fingers and toes to
The psychological effects of rape are as eczema and psoriasis. A rash may also contract suddenly. This action cuts off
often severe and may include significant indicate an underlying medical prob- blood flow to the digits, which become
anxiety, depression, or post-traumatic stress lem, such as the rashes of scurvy or pale. The fingers are more frequently
disorder. Nightmares or flashbacks of pellagra, which are caused by vitamin affected than the toes. The cause of Ray-
the event may also occur. deficiency. The rashes that are character- naud’s disease is unknown, but young
FORENSIC TESTS istic of urticaria (nettle rash) or contact women are most commonly affected.
Physical examination of a rape victim dermatitis may be caused by an allergic Symptoms develop with no known
involves noting signs of bruising or reaction (see allergy). Drug reactions, cause. On exposure to cold, the digits
injury, particularly to the genital area, particularly those to antibiotic drugs, are turn white due to lack of blood. As
and visual inspection of the vaginal another common cause. sluggish blood flow returns, the digits
canal. The doctor collects swabs from DIAGNOSIS AND TREATMENT become blue; when they are warmed
suspected bite marks, soiled areas of the Diagnosis is based on the appearance and normal blood flow returns, they
body, and the vagina, anus, or throat, as and distribution of the rash, the pres- turn red. During an attack, there is often
well as fingernail scrapings or clippings ence of any accompanying symptoms, tingling, numbness, or a burning feel-
and any loose strands of hair. Such spec- and the possibility of allergy (for exam- ing in the affected fingers or toes. In
imens are analysed in a laboratory and ple, to drugs). rare cases, the artery walls gradually
DNA tests are performed on them. The Any underlying cause of the rash is thicken, permanently reducing blood
results of these tests may be compared treated where possible. An itching rash flow, leading to painful ulceration or
with test results on samples that are may be relieved by a soothing lotion, even gangrene (tissue death) at the tips
taken from a suspect. such as calamine, or an antihistamine of the affected digits.
TREATMENT drug. (See also meningococcal rash.) Diagnosis is made from the patient’s
Physical injuries are treated as required. history. Treatment involves keeping the
Emergency contraception (see contra- RAST hands and feet as warm as possible.
ception, emergency) may be prescribed. An abbreviation for radioallergosorbent Vasodilator drugs or calcium channel block-
Treatment for sexually transmitted infec- test. RAST is a type of radioimmunoassay ers may be prescribed in severe cases.
tions may be necessary in some cases. used to detect antibodies (proteins (See also Raynaud’s phenomenon).
In the treatment of psychological manufactured by the immune system)
trauma, counselling can be beneficial. In to specific antigens (substances that can Raynaud’s phenomenon
some cases, psychiatric help may also trigger an immune response). A circulatory disorder affecting the fin-
be required. Many victims are now gers and toes that shares the mechanism,
helped by local rape support groups. rats, diseases from symptoms, and signs of Raynaud’s dis-
Rats are rodents that live close to ease but which results from a known
rash
A group of spots or an area of red,
human habitation. They damage and
contaminate crops and food stores and
underlying disorder.
Possible causes of Raynaud’s phe-
R
inflamed skin. A rash is usually tempo- can spread disease. nomenon include arterial diseases, such
rary and is only rarely a sign of a serious The organisms responsible for plague as atherosclerosis (fat deposits on the
underlying problem. A rash may be and one type of typhus are transmitted artery walls); connective tissue diseases,
accompanied by itching or fever. to humans by the bites of rat fleas. Lep- such as rheumatoid arthritis; and various
TYPES tospirosis (Weil’s disease) is caused by drugs, such as beta-blocker drugs. The
Rashes are classified according to contact with anything contaminated disorder is a recognized occupational
whether they are localized (affecting a with rat’s urine. disorder of people who use pneumatic
small area of skin) or generalized (cov- Rat-bite fever is a rare infection trans- drills, chain saws, or other vibrating
ering the entire body) and also by the mitted directly by a rat bite. There are machinery, and other people whose fin-
type of spots present. two types of rat-bite fever, each caused gers suffer repeated trauma.
A macular rash consists of spots that by different bacteria. Symptoms include Treatment is the same as for Ray-
are level with the surrounding skin and inflammation at the site of the bite and naud’s disease, along with treatment of
discernible from it only by a difference in nearby lymph nodes and vessels; bouts the underlying disorder.
in colour or texture. Nodular and papu- of fever; a rash; and, in one type,
lar rashes are composed of small, raised painful joint inflammation. Treatment reactive arthritis
bumps, which may or may not be the for both types is with antibiotic drugs. Inflammation of the joints due to an
same colour as the surrounding skin. A The rabies virus can be transmitted by abnormal immune response (the body’s
bullous rash has large blisters, a vesicu- the bites of infected rats. Lassa fever, defensive response to foreign sub-
lar rash has small blisters, and a pustular another viral disease, may be contracted stances) that occurs after an infection of

649
 REACTIVE DEPRESSION

the genital tract, such as chlamydial infec- reactive hypoglycaemia reboxetine

tion, or of the intestinal tract, such as A form of hypoglycaemia (low blood An antidepressant drug that blocks the
gastroenteritis. If there is additional in- glucose levels) that occurs within a few reuptake of noradrenaline (norepineph-
flammation elsewhere in the body, such hours of eating foods that are rich in rine) within the nervous system. Side
as in the eyes, the condition is known as glucose. In reactive hypoglycaemia, the effects of reboxetine include insomnia,
Reiter’s syndrome. body overreacts to the sudden rise in sweating, and dizziness on standing.
blood sugar by releasing large amounts
reactive depression of insulin. This results in a rapid and receding chin
A term that was formerly used to excessive drop in the blood sugar level Underdevelopment of the lower jaw.
describe a type of depression (feelings causing hypoglycaemic symptoms. The condition can be corrected by the
of sadness, hopelessness, and a lack of use of orthodontic appliances if used in
interest in life) resulting from a stressful reagent the growth spurt at adolescence or by
or emotional event or period of life. In A term that is used for any chemical cosmetic surgery.
contrast, another type of depression substance that takes part in a chemical
known as “endogenous depression” reaction. The term usually refers to a receding gums
was seen to originate from biological chemical or a mixture of chemicals that Withdrawal of the gums from around
factors within an individual. In the are used in chemical analysis (see analy- the teeth, resulting in the exposure of
majority of cases, however, depression sis, chemical) or used to detect a bio- part of the roots. The teeth may become
is a combination of these two types. logical substance. sensitive to hot and cold substances and

TYPES OF RECEPTOR

Stimuli are detected by the free endings of sensory nerve cells or by special structures
forming the endings of these cells. These respond to specific stimuli (such as light of HOW CELL SURFACE OR
a certain wavelength) and send a signal indicating the presence of the stimulus to CHEMICAL RECEPTORS WORK
the spinal cord and/or the brain. Cell surface or chemical receptors (right) are tiny
structures on the outer surface of a cell. They allow certain chemicals to bind to the Most cells have many surface
cell and trigger some change within it. receptors (only one is shown
below). Their existence allows the
Hair shaft activity of the cell to be influenced
Skin receptors
from outside.
The skin contains many Merkel’s disc
types of receptor that Nucleus Cell Receptor
respond to stimuli such as area
pressure, cold, heat, and Meissner’s
hair movement, allowing corpuscle
the sensations of touch, Pacinian
temperature, and pain. corpuscle
They include such
structures as pacinian Organ of Ruffini Other
corpuscles and Merkel’s chemicals
discs and are all special
types of nerve cell ending. Subcutaneous fat Other Hormone
chemicals molecule
R Receptors in tongue Receptors in eye
Each taste-bud (below)
consists of many receptor
The retina, located at the
back of the eye, contains
1or aAchemical
receptor allows only one specific
(which may be a hormone
neurotransmitter substance) to
cells. Each has surface receptor cells, called rods bind to it. The chemical must have a
receptors that respond and cones, which are configuration that “fits” the receptor.
to chemicals in food. responsive to light.
Supporting Taste Taste Tongue Vitreous humour
cell pore hair surface
Nerve fibres

Ganglion cell

Change Binding of
effected hormone
in cell
Bipolar cell

The binding of chemical to receptor

Cone
2triggers
alters the outer cell membrane and
a change, such as contraction by
Rod a muscle cell or increased activity in an
Nerve
enzyme-producing cell.
Receptor cells fibres

650
 RECTAL BLEEDING

the attachment of the tooth in the sock- reconstructive surgery rectal bleeding
et may weaken, causing the tooth to See arterial reconstructive surgery; plastic The passage of blood from the rectum or
become loose. Severe cases of receding surgery. anus.The blood may range in colour from
gums are usually a sign of gum disease bright red to dark brown or black. It may
(see gingivitis; periodontitis). recovery position be mixed with, or on the surface of, faeces
The position in which to place an or passed separately. Rectal bleeding may
receding hairline unconscious, breathing casualty, while or may not be accompanied by pain.
A feature that is characteristic of male- waiting for medical help to arrive. Haemorrhoids (swollen veins in the
pattern baldness (see alopecia). The body is placed on its side with lining of the anus) are the most com-
the upper leg bent at a right angle; the mon cause of rectal bleeding. Small
receptor lower leg is kept straight. The lower arm amounts of bright red blood appear on
A general term for any sensory nerve is bent at a right angle; the upper arm is the surface of faeces or on toilet paper.
cell (one that converts stimuli into bent with the back of the hand placed Anal fissure (an ulcer or tear at the mar-
nerve impulses). The term receptor is against the lower cheek to support the gin of the anus), anal fistula (an abnormal
also used to refer to specific structures head, which is tilted back to keep the anal channel), proctitis (inflammation of
that occur on the surface of a cell (see airway open. Casualties with suspected the rectum), or rectal prolapse (protru-
Types of receptor box, left) that allow spinal injuries should not be placed in sion of the rectal lining) may also cause
chemicals to bind with the cell in order the recovery position. rectal bleeding.
to exert their effects. Cancer of the colon (see colon, cancer
recovery room of) or the rectum (see rectum, cancer of)
recessive A hospital unit situated near operating or polyps (grape-like growths) can also
A term used in genetics to describe theatres and delivery rooms that con- cause bleeding. Disorders of the colon,
one of the ways by which a gene is tains specialized equipment and staff such as diverticular disease, may cause
passed from parent to offspring. Many who have been trained in the monitor- dark red faeces. Black faeces (see melae-
characteristics are determined by a sin- ing and care of postoperative patients na) may be due to bleeding from high
gle pair of genes, one of each pair and women who have recently given in the digestive tract. Bloody diarrhoea
being inherited from each parent. A birth. Patients leave the recovery room may be caused by ulcerative colitis, amoe-
recessive gene is overridden by an to return to general nursing care as biasis, or shigellosis.
equivalent dominant gene. For example, soon as they are considered to be in a Diagnosis may be made from a rectal
the gene for blue eye colour is reces- sufficiently safe and stable condition. examination, proctoscopy, sigmoidoscopy, or
sive; therefore, if a child inherits the (See also intensive care unit.) colonoscopy (internal examination using a
gene for brown eyes from one parent
and the gene for blue eyes from the
other, the “blue eye” gene is overrid- RECOMBINANT DNA AND GENETICALLY ENGINEERED INSULIN
den by the “brown eye” gene, and the
Genetic engineering can force bacteria to produce human insulin. The insulin gene
child ends up with brown eyes. The is obtained (by removing it from human DNA, then purifying it) and spliced into the
child must inherit the recessive blue DNA of a bacterium, causing it to produce human insulin. The bacterium is then
eye gene from both parents in order to cultured for large-scale insulin extraction.
develop blue eyes.
Many genetic disorders are deter- Bacterial Gene for insulin
mined by a recessive gene. Examples cell synthesized
include cystic fibrosis and sickle cell
anaemia. The child will only have the
R
disease if he or she inherits the gene
from both parents.
recombinant DNA Bacterial DNA
Synthetic gene
A section of DNA (genetic material) inserted into
from one organism that has been artifi- bacterial DNA.
Bacterium then
cially spliced into the DNA of another produces
organism, often that of a viral or bacte- Bacterium insulin.
multiplies
rial cell. This procedure may be carried
out in order to make the recipient cell
produce a substance that it would not
normally be able to produce. An exam-
ple of this technique is the addition of
a DNA section containing the genetic
code for the hormone insulin into a
recipient cell. If this cell can be en- Insulin
couraged to replicate, it is possible for extracted
large amounts of the hormone to be
obtained. (See also genetic engineering.)

651
 RECTAL EXAMINATION

rigid or flexible viewing instrument), rectum, cancer of

or a double-contrast barium X-ray exami- STRUCTURE OF THE RECTUM A malignant tumour in the rectum (the
nation. Rectal bleeding in anyone over muscular tube that forms the last part of
The rectum is about 12 cm long; its
the age of 40 should be carefully inves- wall consists mainly of longitudinal the large intestine). There may be a
tigated to rule out the possibility of and circular muscle. An inner, genetic basis for some types of rectal
colorectal cancer. mucous layer provides lubrication. cancer. In particular, an inherited disor-
der called familial adenomatous polyposis
rectal examination Ampulla of Sigmoid Transverse Muscular (in which large numbers of polyps
rectum colon rectal fold support
Examination of the anus and rectum, develop in the large intestine) increases
which may be performed as part of a the risk. In most cases, however, the
general physical examination. A rectal precise cause is unknown. Dietary fac-
examination is usually used to assess Lymphoid tors, such as eating a lot of meat and
symptoms of pain, changes in bowel follicle fatty foods and not enough fibre, may
habits, the size of the prostate gland, or also increase the risk. Cancer of the rec-
to check for the presence of tumours of tum is most common between the ages
the rectum or prostate gland. of 50 and 70.
SYMPTOMS
rectal prolapse Early symptoms of cancer of the rectum
Protrusion outside the anus of the lin- are rectal bleeding during defaecation
ing of the rectum, usually brought on by and diarrhoea or constipation. Later,
straining to defaecate. The condition pain may occur. Left untreated, the can-
commonly causes discomfort, a mucus cer may eventually cause severe bleed-
discharge, and rectal bleeding. ing and pain and block the intestine,
Rectal prolapse is usually temporary preventing the passage of faeces. The
Anus Fat
in young children, but it is often per- Muscular External cancer may also spread to other organs.
layer Mucous layer sphincter Skin
manent in elderly people due to a DIAGNOSIS AND TREATMENT
weakening of the tissues that support the Rectal cancer may be suspected from a
perineum (the area between the anus positive result in a faecal occult blood test,
and the external genitals). In cases in FUNCTION which is used to check for hidden
which the prolapse is large, leakage of The rectum collects faeces that have blood in the faeces. It may also be
faeces may occur. formed in the alimentary tract (the detected during a rectal examination and
Treatment is with a fibre-rich diet. tube-like structure that extends from confirmed using proctoscopy or sigmoid-
Surgery may also be performed, espe- the mouth to the anus). Pressure on the oscopy (internal examination using a
cially on older people. rectal wall causes nerve impulses to pass rigid or flexible viewing instrument)
to the brain; the urge to defaecate and a biopsy (removal of a small sample
rectocele occurs when the collected faeces dis- of tissue for microscopic analysis).
A bulging inwards and downwards of tend (stretch) the rectum. Treatment is usually with surgery. For a
the back wall of the vagina, which DISORDERS tumour in the upper rectum, the affected
occurs as a result of the rectum pushing Rarely, a baby is born with no rectum or area and the last part of the colon are
against weakened tissues in the vaginal anus (see anus, imperforate). removed and the two free ends of the
wall. A rectocele is usually associated There are a number of diseases and intestine are sewn together. To promote
R with a cystocele (protrusion of the blad-
der into the front wall of the vagina) or a
disorders that affect the rectum; these
include proctitis (inflammation), polyps
healing, a temporary colostomy (which
diverts faeces through a surgical open-
prolapsed uterus (see uterus, prolapse of). (grapelike growths), and cancer (see ing in the abdomen) may be made. For
There may be no symptoms or the rectum, cancer of). a growth in the lower rectum, the entire
rectocele may cause constipation. Pelvic The rectum can become obstructed as rectum and anus are removed. Because
floor exercises may help to relieve symp- a result of narrowing, which may be there is no outlet for faeces, a perma-
toms. If they do not, an operation to caused by radiotherapy, granuloma inguin- nent colostomy is created.
tighten the tissues at the back of the ale (a sexually transmitted infection), or Radiotherapy and anticancer drugs may
vagina may be recommended. a pelvic infection. In rare cases, an ulcer be used in addition to, or instead of,
develops in the rectum, causing bleed- surgery. The outlook depends on how
rectum ing and a discharge. widespread the cancer is at the time
A short, muscular tube that forms the Rectal prolapse occurs when the lining treatment is commenced.
lowest part of the large intestine and of the rectum protrudes outside the
connects it to the anus. anus. In a rectocele, the rectum and rear recurrent pregnancy loss
STRUCTURE wall of the vagina bulge downwards Another term for habitual abortion.
The first part of the rectum consists of into the vagina.
four layers: an outermost serous layer; a Rectal disorders are usually diag- red blood cell
muscular layer; a submucous layer; and nosed by means of rectal examination Also known as an erythrocyte, a blood
an innermost mucous layer that lubri- and proctoscopy or sigmoidoscopy (in- cell containing the red, oxygen-carrying
cates the rectum. There is no serous ternal examination using a rigid or pigment haemoglobin. The main function
layer in the last third of the rectum. flexible viewing instrument). of a red blood cell is that of transporting

652
 REFSUM’S DISEASE

oxygen around the body. A mature red Spinal cord Sensory neuron Motor few months after birth. Primitive reflex-
neuron
blood cell is a biconcave disc shape and es are believed to represent actions that
does not possess a nucleus. (See also may have been important for survival in
white blood cell.) earlier stages of human evolution.
Primitive reflexes include the grasp
red-eye reflex, which occurs when something
Another name for conjunctivitis. is placed in the baby’s hand, and the
rooting reflex, which enables a baby to
reduction find the nipple (see Types of primitive
The process of manipulating a displaced reflex box, overleaf).
part of the body back into its original Primitive reflexes are tested after
position. Reduction may be carried out Interneuron birth to give an indication of the condi-
to realign fractured bone ends (see frac- tion of an infant’s nervous system. Their
Tendon hammer
ture), to replace a dislocated joint in its persistence beyond the expected stage
socket (see dislocation, joint), or to treat of development may point to a disorder
an abdominal hernia by pushing the of the developing brain.
protruding intestine back through the
abdominal wall. reflux
An abnormal backflow of fluid in a
Reference Nutrient Intake (RNI) body passage, which may result from
Figures, based on the needs of a healthy failure of the passage’s exit to close
individual, that establish the minimum properly. A common type of reflux is
daily requirements of vitamins and min- the regurgitation of acidic fluid from the
erals. Requirements of certain vitamins Simple knee-jerk reflex stomach into the oesophagus (see acid
and minerals may differ according to fac- A tap with a rubber hammer just below the reflux). (See also vesicoureteric reflux.)
tors such as age, gender, and stage of life. kneecap stretches a tendon of one of the thigh
muscles. A signal passes via a sensory neuron reflux oesophagitis
(nerve cell) to the spinal cord, activating a motor
referred pain neuron, which contracts the muscle, jerking the A type of oesophagitis (inflammation of
Pain felt in a part of the body at some lower leg upwards. the oesophagus) that is caused by poor
distance from its cause. Referred pain functioning of the muscles in the lower
occurs because some remote parts of the grasp reflex that occurs when an oesophagus, leading to acid reflux.
the body are served by the same nerve adult’s finger is placed in the baby’s
or group of nerves. Occasionally, nerve palm. Inborn reflexes include those that reflux, vesicoureteric
impulses that reach the brain from one control basic body functions, such as See vesicoureteric reflux.
of these areas may be misinterpreted as contraction of the bladder after it has
coming from another. filled beyond a certain point. Such refraction
Common examples of referred pain inborn reflexes are managed by the The bending of light rays as they pass
are sciatica and the pain down the autonomic nervous system. from one substance to another. Refrac-
inside of the left arm caused by angina Conditioned reflexes are acquired tion provides the mechanism by which
pectoris (chest pain due to impaired through experience in a process called images are focused on the retina in the
blood supply to the heart muscle) or a conditioning. For example, a person may eye, thereby permitting vision.
myocardial infarction (heart attack). follow a familiar route home from work
without making a conscious effort. Refsum’s disease R
reflex Several simple reflexes, such as the A rare genetic disorder that affects lipid
An action that occurs automatically and knee-jerk reflex and constriction of the metabolism (the processing of fats by
predictably in response to a particular pupil in response to light, are tested in a the body). Refsum’s disease causes
stimulus; a reflex is independent of the physical examination. Changes in reflexes excessively high levels of phytanic acid,
will of the individual. may indicate damage to the nervous sys- a fatty acid, in the body.
In the simplest reflex, a sensory nerve tem. The examination of vital reflexes One major symptom is polyneuritis
cell reacts to a stimulus, such as heat or controlled by the brainstem is the basis (inflammation of nerves around the
pressure, and sends a signal along its for diagnosing brain death. body). This may result in weakness and
nerve fibre to the central nervous system numbness, often affecting the limbs.
(the brain and spinal cord). There, reflexology Other common features of the condi-
another nerve cell becomes stimulated A form of complementary medicine in tion are a visual defect called retinitis
and causes a muscle to contract or a which the practitioner massages parts of pigmentosa and ataxia, an unsteady gait
gland to increase its secretory activity. the patient’s feet in an attempt to treat caused by damage to the brain’s cerebel-
The passage of the nerve signal from disorders affecting other areas of the body. lum. Symptoms usually appear before
original sensation to final action is the age of 20.The disease is progressive,
known as a reflex arc. reflex, primitive although there are periods of remission.
Reflexes may be inborn or condi- An automatic movement in response to Phytanic acid may be obtained from
tioned. Some inborn reflexes occur only a stimulus that is present in newborn the diet. Therefore, people with Ref-
in babies (see reflex, primitive), such as infants but disappears during the first sum’s disease are advised to avoid all

653
 REGAINE

drug dependence. Treatment may include

TYPES OF PRIMITIVE REFLEX physiotherapy, occupational therapy, psy-
chotherapy, or speech therapy.
Grasping reflex
Certain automatic reflexes are present early In a rehabilitation centre, a person’s
in life before the baby becomes capable disabilityor dependence is assessed by a
of voluntary movement. These reflexes doctor who specializes in rehabilitation
disappear as the nervous system matures. For medicine, and a treatment programme
about the first four months, any object placed
in the infant’s palm will be firmly grasped.
is developed. Industrial rehabilitation
centres provide retraining for those who
cannot return to their previous job.
Tonic neck reflex Drug and alcohol rehabilitation centres
When the young baby turns the head, the arm, and help people through withdrawal and pro-
leg of that side are stretched out while on the other
side the arm and leg bend. This reflex normally
vide psychological support to reduce
disappears after the first few months except in the risk of a relapse (the recurrence of a
premature babies. A strong reflex, persisting for condition after apparent recovery).
longer than three months, suggests brain damage.
rehydration, oral
Walking reflex See rehydration therapy.
When the baby is held upright with a foot
touching the ground, a forward stepping rehydration therapy
movement is made by each leg as the weight is
placed on the other foot. This occurs during the The treatment of dehydration by admin-
first two months of life and is then lost. istering fluids, salts, and sugars usually
by mouth (oral rehydration) or by intra-
venous infusion. The amount of fluid
needed depends on the patient’s age and
weight and the degree of dehydration.
Moro reflex Mild dehydration, which occurs in
If the baby’s head is momentarily left many young children with diarrhoea,
unsupported, the arms will be swung outwards can usually be treated with oral solu-
and then brought together in an embracing tions, which are available as an effer-
movement. At the same time the legs are
extended and the baby cries. This symmetrical vescent tablet or powder to be made up
reflex disappears two or three months at home. In severe dehydration, or if the
after birth. patient cannot take fluids by mouth
because of nausea or vomiting, an intra-
venous infusion of saline and/or glucose
solution may be given in hospital.
Rooting reflex
This reflex enables the baby to find the nipple. It reimplantation, dental
is evoked by touching the baby’s cheek near the The replacement of a tooth in its socket
corner of the mouth. The baby’s head turns and after an accident so that it can become
the mouth opens. The reflex is best shown if reattached to supporting tissues. The
tried when the baby is hungry.
R front teeth are those that are most com-
monly reimplanted.
The tooth needs to be reimplanted
soon after the accident; it is then main-
tained with the help of a splint (see
foods containing this substance. The regurgitation splinting, dental) while healing takes
main sources of phytanic acid are meat A backflow of fluid. In medicine, the place. Keeping the tooth sterile and
from animals that feed on grass (cows, term is commonly used to describe the moist (with saliva or milk, for example)
sheep, and goats) and dairy products. return of swallowed food or drink from increases the chances of success. Heal-
the stomach into the oesophagus and ing may take several weeks.
Regaine mouth. The term is also used to
A brand name for minoxidil. Regaine is describe the backflow of blood through Reiter’s syndrome
used as a topical (applied to the skin) a heart valve that does not close fully A condition in which there is a com-
lotion in the treatment of male-pattern because of a disorder such as mitral bination of urethritis, reactive arthritis,
baldness (see alopecia). incompetence. (See also reflux.) and conjunctivitis. There may also be
uveitis. Reiter’s syndrome is more com-
regression rehabilitation mon in men than in women.
A term that is used in psychoanalytic the- Treatment aimed at enabling a person Reiter’s syndrome is caused by an
ory to describe the process of returning to live an independent life following immune response and usually develops
to a childhood level of behaviour, such injury (such as spinal injury), illness only in people with a genetic predispo-
as thumb-sucking. (See also fixation.) (such as a stroke), alcohol dependence, or sition. Most patients have the HLA-B27

654
 RENIN

tissue type (see histocompatability anti- relationship counselling nates with non-REM (NREM) sleep dur-
gens). The syndrome’s development is Formerly known as marriage guidance, ing the course of the night.
induced by infection: usually by non- relationship counselling is a type of
gonococcal urethritis, but sometimes by professional therapy for established part- renal
bacillary dysentery. ners aimed at resolving the problems Related to the kidney.
Reiter’s syndrome usually starts with within their relationship. The couple
a urethral discharge, followed by con- attends regular sessions together in renal biopsy
junctivitis, and then arthritis. The which the counsellor promotes commu- See kidney biopsy.
arthritis usually affects one or two joints nication and attempts to help resolve
(generally the knee and/or ankle) and differences. Relationship counselling is renal calculus
is often associated with fever and with largely based on the ideas and methods A kidney stone (see calculus, urinary
malaise. Attacks can last for several of behaviour therapy. If some of the cou- tract).
months. Tendons, ligaments, and tissue in ple’s problems are sexual, the counsellor
the soles of the feet may also become may also refer them for sex therapy. renal cell carcinoma
inflamed. Skin rashes are common. The most common type of kidney cancer.
Diagnosis is from the symptoms. relaxation techniques
Analgesic drugs (painkillers) and nonster- Methods of consciously releasing mus- renal colic
oidal anti-inflammatory drugs (NSAIDs) cular tension to achieve a state of mental Spasms of severe pain on one side of the
relieve pain and inflammation but may calm. Relaxation techniques can assist back, extending down to the groin, that
have to be taken long term. Relapses people with symptoms of anxiety, help to are usually caused by a kidney stone (see
occur in about one third of cases. reduce hypertension (high blood pres- calculus, urinary tract) passing down the
sure), and relieve stress.They may also be ureter (a tube that carries urine from the
rejection used to help pregnant women to cope kidney to the bladder). There may also
An immune response that is aimed at with labour pains (see childbirth, natural). be nausea, vomiting, sweating, and
destroying organisms or substances rec- Active relaxation consists of tensing blood in the urine.
ognized as foreign by the body’s immune and relaxing each of the body’s muscles The treatment of renal colic usually
system. Rejection also refers to nonaccep- in turn. Passive relaxation involves clear- consists of bed rest and plenty of fluids.
tance of tissue grafts (see grafting) or ing the mind and concentrating on a Injections of a strong analgesic drug
organ transplants (see transplant surgery). single phrase or sound. Breathing exercis- (painkiller), such as diclofenac or pethi-
To avoid rejection, donor tissues are es help to prevent hyperventilation (rapid, dine, help to ease the pain.
closely matched to recipient ones (see shallow breathing), which often brings
tissue-typing). Immunosuppressant drugs, on or worsens anxiety. Traditional con- renal failure
such as corticosteroid drugs and ciclosporin, centration methods, such as yoga and See kidney failure.
are given to organ transplant recipients to meditation, employ similar techniques.
suppress rejection by damping down the renal transplant
activity of the immune system. releasing factors See kidney transplant.
A group of hormones produced by the
relapse hypothalamus in the brain that stimulate renal tubular acidosis
The recurrence of a disease after an the release of other hormones. Luteinizing A condition in which the kidneys are
apparent recovery, or the return of hormone-releasing hormone is one such unable to excrete normal amounts of
symptoms after a period of remission. releasing factor. acid made by the body. In renal tubular
relapsing fever Relenza
acidosis, the blood is more acidic than
normal, and the urine less acidic.
R
An illness that is caused by infection The brand name for zanamivir, an anti- Possible causes of renal tubular acido-
with spirochaetes (spiral-shaped bacte- used to treat at-risk people
viral drug sis include kidney damage that may be
ria). Relapsing fever is transmitted to who develop influenza. due to disease, drugs, or a genetic disor-
humans by ticks or lice and is character- der. However, in many cases the cause
ized by high fever. The condition does rem of the condition is unknown.
not occur in the UK. An outdated unit of absorbed radiation The acidosis may result in osteomal-
A high fever of up to 40°C suddenly dose, now superseded by the sievert. acia (softening of the bones), kidney
develops, with shivering, headache, (See also radiation unit.) stones (see calculus, urinary tract), nephro-
muscle pains, nausea, and vomiting. The calcinosis (calcification of the kidney),
symptoms persist for three to six days, remission and hypokalaemia (an abnormally low
culminating in a crisis with a risk of col- Temporary disappearance or reduction level of potassium in the blood).
lapse and death. The affected person in severity of the symptoms of a disease,
then seems to recover but suffers anoth- or the period during which this occurs. renin
er attack seven to ten days later. If the An enzyme that is involved in the regula-
fever is tick-borne, there may be several REM sleep tion of blood pressure. When the blood
such relapses, each progressively milder. The abbreviation for rapid eye move- pressure falls, the kidneys release renin,
The spirochaetes can be seen in a ment sleep, the period of sleep during which changes a substance called angio-
blood film and they can be eliminated which the brain is more active and tensinogen into angiotensin I. This is
with antibiotic drugs. dreaming takes place. REM sleep alter- rapidly converted into angiotensin II,

655
 RENOGRAPHY

which acts to increase blood pressure Repaglinide stimulates the release of reproductive system, female
by constricting (narrowing) blood ves- insulin (a hormone that regulates the The female organs involved in ovulation,
sels and stimulating the release of level of glucose in the blood). Side sexual intercourse, nourishing a fertilized
aldosterone, a hormone that causes the effects of repaglinide may include abdo- ovum (egg) until it has developed into a
kidneys to retain sodium in the body. minal pain, diarrhoea or constipation, full-grown fetus, and childbirth. With the
Blood pressure can be lowered by drugs nausea, and vomiting. exception of the vulva (the external
that affect the renin–angiotensin system, genitalia that protects the opening of
such as beta-blocker drugs, which inhibit repetitive strain injury (RSI) the vagina), these organs lie within the
the production of renin, and ACE inhibitor An overuse injury that affects people who pelvic cavity.
drugs, which interfere with the conversion do repetitive movements for long peri- An ovum is released each month
of angiotensin I to angiotensin II. ods, such as keyboard workers and from one of the two ovaries, which also
musicians, causing pain and weakness secrete oestrogen hormones and proges-
renography in the wrists, fingers, or arms. RSI can terone hormones – hormones that are
A technique, also known as renal become chronic, with continuous pain involved in the control of the reproduc-
scintigraphy, that uses a radioactive sub- that does not cease when the causative tive cycle, together with follicle-stimulating
stance to measure kidney function. activity is stopped. hormone and luteinizing hormone. The
Renography is quick and painless and is ovum travels through the fallopian tubes
used, for example, when obstruction of repression to the uterus (womb). Fertilization takes
the passage of urine is suspected. A term used in psychoanalysis to refer to place if a sperm that has been released
The radioactive substance is injected the burial of an unacceptable idea or into the vagina during sexual intercourse
into the bloodstream and passes via the memory deep from an individual’s con- or artificial insemination travels through
kidneys into the urine. Radiation counts sciousness. The data that has been the cervix and uterus to penetrate the
are taken continually throughout the repressed is generally out of the reach ovum while it is in the fallopian tube.
procedure and both kidneys are exam- of voluntary recall. One of the aims of The normal functioning of the fe-
ined simultaneously to compare their psychoanalysis is to return repressed male reproductive system begins at
function. Normally, the radiation count material to conscious awareness in puberty with the onset of menstruation;
rises and then falls as the substance order that it can be accepted and there- the potential for reproduction ends at
passes into the bladder. If an obstruction fore dealt with in a rational manner. the time of the menopause.
is present, the substance accumulates in
the kidneys and the count continues to reproduction, sexual reproductive system, male
rise. (See also kidney imaging.) The process of producing offspring by The male organs involved in the pro-
the fusion of two cells from different duction of sperm and in sexual inter-
repaglinide individuals; this is achieved in humans course. Sperm and male sex hormones
An oral hypoglycaemic drug (see hypo- by the fusion of one sperm and one (see androgen hormones) are produced in
glycaemics, oral) that is used either alone ovum. This fusion (which is known as the testes (see testis), which are suspend-
or in combination with metformin in the fertilization) may be achieved by sexual ed in the scrotum. From each testis,
treatment of type 2 diabetes mellitus. intercourse or artificial insemination. sperm pass into an epididymis (a long
coiled tube behind the testis), where
they mature and are stored. Shortly
FEMALE REPRODUCTIVE SYSTEM before ejaculation, sperm are propelled
into a duct called the vas deferens,
Each month an ovum from one ovary is carried along the fallopian tube. If fertilized,
R it begins to divide and implants into the endometrium (lining of the uterus) to
which carries them to the seminal vesi-
cles behind the bladder. These two sacs
develop into an embryo. If the ovum is not fertilized, the endometrium is shed in
the form of menstrual bleeding. produce seminal fluid, which is added to
the sperm to produce semen.
Semen travels along two ducts to the
urethra (a tube that acts as a passage for
urine and semen). The two ducts pass
through the prostate gland, which pro-
duces secretions that are added to the
semen. At orgasm, semen is ejaculated
Fimbriae Fallopian tube from the urethra through the erect
penis, which is placed in the woman’s
vagina during sexual intercourse. (See
Ovary
Uterus also fertilization.)
rescue breathing
Cervix Vagina
The forced introduction of air into the
lungs of someone who has stopped
breathing (see respiratory arrest) or who
has inadequate breathing. Rescue breath-
ing was known as artificial respiration.

656
 RESPIRATORY ARREST

External resorption is part of the

MALE REPRODUCTIVE SYSTEM process by which primary teeth are lost
and is thought to be activated by pres-
Sperm made in the testes pass via the vas deferens to the seminal vesicle.
Secretions from the prostate increase the volume of the semen, which is
sure from the underlying permanent
ejaculated from the penis via the urethra during orgasm. teeth as they erupt (see eruption of teeth).
Some degree of external resorption also
Ureter occurs as part of the aging process and
may also be due to injury, inflammation
Bladder of surrounding tissues (see periodontitis),